FY23 Omnibus signed into law
President Biden signed on December 29, 2022 the FY23 Omnibus bill, which provided for appropriations for all 12 annual spending bills and numerous authorizations and pieces of legislation that Congress had been unable to pass before the end of their session. You can find a summary of the Labor, Health and Human Services, and Education (Labor-HHS) funding here, the bill text here, the report language here, and community projects (formerly “earmarks”) here.
The Agency for Healthcare Research and Quality (AHRQ) was funded at $373.5 million, an increase of $23.1 million (6.6 percent) over FY22. This is the highest nominal funding for the agency in over a decade, and is a testament to the hard work of health service researchers in highlighting the importance of the agency to Congress. Within this funding level, AHRQ is directed to pursue specific reports and priorities:
- 10 million for health services research on how to best deliver care to patients with Long Covid
- $2 million for the Center for Primary Care Research.
- $20 million to fund research, testing, and solutions to avoid diagnostic error and to support Diagnostic Safety Centers of Excellence to disseminate related findings.
- $1 million to fund an evidence review and technical expert panel to assess the feasibility of developing consensus-based quality standards for high quality bereavement and grief care.
- $750,000 for AHRQ to work with stakeholders to develop a research agenda and report for dissemination on health promotion, disease prevention, and intervention strategies for people with disabilities.
- $750,000 for AHRQ to conduct a comprehensive set of studies that calculate the morbidity, readmissions, and mortality related to sepsis with respect to pediatrics, maternal sepsis, nursing home care, and rehabilitation, and the association of pandemic-related changes in the healthcare system on the burden of sepsis.
- Calls on AHRQ to study the evidence for lipid control and cardiovascular event reduction, including the costs and benefits of angioplasties.
- Directs AHRQ to work with other agencies in HHS to brief Congress on the status of antimicrobial resistance.
In addition to AHRQ, other notable funding levels include:
- $120.7 billion for HHS, an increase of $9.9 billion above the fiscal year 2022 enacted level.
- $1.5 billion for ARPA-H, an increase of $500 million.
- $47.5 billion for NIH, an increase of $2.5 billion.
- $9.2 billion for CDC, an increase of $760 million.
- $9.7 billion for HRSA, an increase of $852 million.
- $4.1 billion for CMS administrative expenses, an increase of $100 million.
ARPA-H authorized by Congress within the NIH
Congress authorized the Advanced Research Projects Agency for Health (ARPA-H) in the FY23 omnibus. With this authorization, the new agency was placed in NIH, which was a point of contention among congressional authorizers and the Biden Administration. As a compromise to keep the new agency independent, the authorization prohibits it from being based on the NIH campus in Bethesda, Maryland and for HHS to publish specific exemptions from NIH policies for ARPA-H.
Biden Administration plans an end of the public health emergency
Senior Biden officials are targeting an end to the emergency designation for Covid as soon as the spring, after debating doing so last summer and taking a pass. Should they do so, such a move would represent a major pivot point in the country’s battle with the pandemic. The decision, which has not yet been finalized amid more immediate efforts to manage a recent spike in Covid cases, would trigger a complex restructuring of major elements of the federal response — and set the stage for the eventual shifting of greater responsibility for vaccines and treatments to the private market. It would kickstart a transition away from the White House-led crisis operation and toward treating the virus as a continuous long-term threat. The Administration has said that it will provide a 60 day notice before termination of the PHE.
MedPAC recommends increasing payments to hospitals and physicians, cutting for home health agencies
The Medicare Payment Advisory Commission (MedPAC) voted to recommend that Congress update Medicare payment rates for hospital inpatient and outpatient services by the current law amount plus 1 percent for 2024, and distribute an additional $2 billion to safety-net hospitals by transitioning to a safety-net index policy. They also recommended reducing payment rates for home health agencies by 7 percent and skilled nursing facilities by 3 percent.
Rural hospital closures are worsening health care with Mississippi at risk of losing most of its hospitals
Rural hospitals have struggled to remain open across the country. This is especially the case in Mississippi, which is the poorest state in the country with some of the worst health outcomes. Mississippi’s State Health Office has warned that 38 of Mississippi’s rural hospitals, or about 54%, could close. One of the leading causes in Mississippi is the state’s repeated refusal to accept $10 billion from the federal government to expand Medicaid as part of the Affordable Care Act. The American Hospital Association has found that while less than a quarter of the country refused to expand Medicaid, those states account for 74 percent of all rural hospital closures between 2010 and 2021.
Operation Warp Speed Chief Science Officer stepping down
Dr. David Kessler, chief science officer for the Biden Administration’s COVID-19 response, is stepping down as another sign that the pandemic is no longer a front and center priority for the White House. Dr. Kessler’s departure signals the end of Operation Warp Speed, which was started by the Trump administration to develop and distribute coronavirus vaccines. Although the Biden administration dropped the name, the mission of the program under Dr. Kessler remained the same. Now the Biden administration is working to shift Covid vaccination from a government-run effort to one that will be handled by the private sector.
What I’m reading
An editorial in Nature argues for a fundamental reform in PhD training programs. Early-career researchers constantly report concerns about a chronic lack of support and poor-quality supervision, with senior researchers rarely trained in mentorship. Racism and discrimination are systemic in academic culture in many places. Furthermore, PhD candidates are inadequately prepared for the cross-disciplinary working and large teams that characterize cutting-edge science today. This is especially true for careers outside academic research, where the overwhelming majority of PhD candidates will be heading.
Factors outside of teaching performance, such as gender, race, and even attractiveness, have been shown to bias teaching evaluations, which then are used in making decisions about tenure and promotions. New research is finding that being in the gender minority of one’s academic department has negative implications for student evaluations. For example, women teaching in predominately male departments tend to fare worse in student evaluations, and the same is true for men in predominately female departments.
An underground market of fraudulent authorships for prestigious journals is rocking the publishing world. Research-integrity groups have uncovered hundreds of advertisements that offer the chance to buy authorship on research papers that are published in reputable journals. Prices range from hundreds to thousands of US dollars depending on the research area and the journal’s prestige. Publishers are investigating the claims, and have retracted dozens of articles over suspicions that people have paid to be named as authors, despite not participating in the research. Integrity specialists warn that the problem is growing, and say that other retractions are likely to follow.
As risks to researchers grows, an association of Dutch universities created SafeScience, a website where researchers can report threats and harassment with an emergency number to call. Scientists can call the hotline if there is an incident and someone needs immediate assistance, including in identifying if the risk is serious. The hotline is answered 24/7 by a safety consultant. After the pandemic was declared in March 2020, the threats online became more intimidating and more common — especially for COVID-19 researchers, but also for those in other fields.
Researchers Park et al wrote in Nature about a curious phenomenon where despite the skyrocketing number of research papers published in recent decades that the “disruptiveness” of those papers has dropped. Their research found that date from millions of manuscripts found that they were much more likely to push science forward incrementally than to veer off in a new direction and render previous work obsolete. Although the proportion of disruptive research dropped significantly between 1945 and 2010, the number of highly disruptive studies has remained about the same.
Research is trying to fill in the gaps of what we know about the COVID-19 pandemic on the mental health of communities. Danielson et al wrote in Nature about cases of self-injury, suicidality, and eating disorders in young adults following COVID-19 lockdowns in Denmark. Interestingly, they found that following periods of pandemic lockdowns that there was no increase in any of these cases or their severity.
Hospital privatization has been shown to increase the growth and profitability of public firms, but there is less research on how privatization affects access to care for historically underserved populations. Duggan et al seek to answer this question in NBER. They used national data across all hospitals and patients, we study 258 hospital privatizations over the 2000–2018 period. Private operators improve profitability so that hospitals generate a modest surplus, primarily by increasing mean revenue per patient. However, this is partly achieved by differentially reducing the intake of low-income Medicaid patients, who are typically less profitable than other groups due to lower reimbursement rates. Medicaid patients experience an aggregate decline in utilization at the market-level, which is a proxy for access to care. This was seen most in areas with concentrated hospital markets.
A driving force in America’s high infant and maternal mortality rates is a lack of access to health care professionals. Sonenberg et al wrote in JAMA about the rising maternity care deserts in the US. They noted that nationwide, more than 400 maternity services closed between 2006 and 2020. Between March and June 2022 alone, 11 health systems announced they were closing their obstetric services, citing low birth volumes and staffing challenges. As birthing units close, obstetricians and nurse-midwives are more likely to leave the area, exacerbating “maternity care deserts.” They discuss policy solutions to consider, including child birthing centers and supporting the midwifery and doula workforces.
The Commonwealth Fund released a report on which states and metropolitan areas have the most consolidated Medicare hospital spending. Previous research has found that highly concentrated hospital markets can lead to worse health outcomes, higher readmission rates, and higher per capita Medicare spending than less-concentrated markets. They found that in 258 of the 306 hospital referral regions (HRRs), there were two hospital systems that accounted for more than half of traditional Medicare inpatient hospital spending. In 10 states plus the District of Columbia, two hospital systems account for the majority of Medicare inpatient hospital spending in the state. In Utah, Rhode Island, and Vermont, two-thirds of Medicare inpatient hospital spending is attributable to two health systems.