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Eat Your Fruits and Vegetables

There are a number of factors that interact with one another to shape an individual’s fruit and vegetable access and intake. These factors include public policies regarding food availability and nutrition programs; community factors, such as geography and cultural norms; institutional guidelines for schools, food retailers and producers. Interpersonal relationships created by household food norms and peer support; and certain individual characteristics. The CDC states that just 1 in 10 adults meet their fruit and vegetable recommendations. A lack of appropriate fruit and vegetable consumption puts people at risk for chronic diseases because of insufficient vitamins, minerals and fiber. The CDC recommends a number of strategies that may increase access to fruit and vegetables, including but not limited to, the expansion of farm-to-institution programs, improved access to stores that sell high quality produce, and ensured access to fresh produce in cafeterias and food service venues.

Healthy People 2030 sets data-driven national objectives to improve health and well-being over the next decade. The program includes 355 objectives, that are distributed among 42 topic areas. One of these topic areas is Nutrition and Weight Status, which documents and highlights the practical application of law and policy to improve health.

According to the CDC, in the United States 18.5% of children aged 2-19 years are obese. Children that were obese during childhood are more likely to suffer from high blood pressure and high cholesterol, type 2 diabetes, breathing problems, joint problems, psychological problems like anxiety and depression, low self-esteem, and bullying. Furthermore, children who are obese are more likely to become adults who are obese, which is associated with increased risk of heart disease, type 2 diabetes, and cancer. Healthy eating in early childhood is critical to establishing lifelong healthy eating patterns, and the law can influence healthy eating habits in children, by setting strong and specific nutrition standards to increase the availability of fruits and vegetables.

Starting healthy habits young and improving access to fruits and vegetables in schools is only the beginning. There are a number of laws and policies that can be used to influence health behaviors. Taxing certain food items creates an incentive to purchase the items that are taxed lower. Accordingly, eliminating or reducing tax on healthy foods, or implementing a higher tax on foods with “minimal-to-no nutritional value” would motivate consumers to purchase the healthier options. Local governments may also set stocking requirements, so stores would have to have, at least, minimal healthy food options. Local communities could adopt ordinances to prevent property owners from restricting development of grocery stores in order to make grocery stores more accessible in every community. Additionally, in terms of accessibility, states and localities can allow SNAP benefits to be used on fresh produce or at farmer’s markets. Restaurants can also lend their assistance, by requiring caloric information to be posted on menus, thereby allowing individuals to make informed decisions about what to eat when dining out. Lastly, but certainly not least, local governments can decrease regulations when they act as a barrier to health. For example, land use and zoning codes often require costly permits to sell homegrown produce, so updating or removing these restrictions would encourage more people to grow their own produce, which would lower the cost of their grocery store visits.

Each of these laws and policies would move the general population one step closer to improving its cumulative health, and in so doing, improve its overall well-being. Healthy People 2030 uses evidence based policy solutions that can be used in nearly all communities to achieve their objectives, and provides guidance for how to apply the program in your own life.

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A Summer without Pride: Public Health Efforts to Reduce the Spread of HIV During COVID-19

Across the United States, Pride festivals provide opportunities for members of the LGBTQ community to celebrate their identities, receive free HIV testing, and other HIV prevention resources. This past summer, the COVID-19 pandemic had forced many cities in the United States to cancel their pride celebrations to reduce the spread of the coronavirus. While these state and municipal stay-at-home orders were needed to protect the public from COVID-19, the resulting loss of Pride events that provide the public with free HIV testing and PrEP advocacy may contribute to a potential increase in HIV cases.

HIV disproportionally affects members of the LGBTQ community in the United States, especially Black and Latinx members. According to the Centers for Disease Control and Prevention (CDC), one in six of all gay or bisexual men in the United States will contract HIV in their lifetime. When looking at the health risks by race, the CDC estimates that 1 in 2 Black men, one in four Latinx men, and one in eleven white men who identify as gay or bisexual will contract HIV in their lifetime. For transgender women,  the CDC estimates that 14% of all transgender women in the United States live with HIV. When analyzing the data by race, the CDC approximates that 44% of Black transgender women, 26% of Latinx transgender women, and 7% of white transgender women live with HIV.

Free HIV testing at Pride events have been shown to be an important strategy to promote HIV prevention in LGBTQ community, especially for those who lack access to healthcare. A study conducted by the CDC surveyed participants who were getting tested for HIV at Pride events held in thirteen separate cities in the United States. Among the participants tested at the Pride events, 11.9% had never been tested for HIV and 21.7% had not been tested for HIV for more than twelve months prior to the event. When analyzing the participants who tested positive for HIV, 84.4% stated that they were unaware of their HIV infection. Overall, the study found that free HIV testing in nonclinical settings like Pride events are an extremely useful strategy to promote HIV prevention among groups who lack access to healthcare and/ or fear societal stigma.

Some public health organizations have emphasized the importance of at-home HIV testing and prevention during the COVID-19 pandemic. For example, the non-profit organization Greater Than AIDS created an online platform to link people with participating local health agencies and community-based organizations in order to obtain free or reduced cost at-home HIV tests. Other efforts include the U.S. Department of Health and Human Service’s (HHS) Ready Set PrEP program. Pre-Exposure Prophylaxis (PrEP) is a daily pill that studies have shown to reduce the risk of contracting HIV by more than 90%. The Ready Set PrEP program works to provide free PrEP medication from participating pharmacies or by mail to individuals without insurance.

COVID-19 is a pressing public health issue in the United states. The total reported COVID-19 cases in the United States have reached the millions and the total reported COVID-19 related deaths are nearing 250,000. Yet, COVID-19 is not the only public health crisis that the United States faces. In 2018, an estimated 36,400 new HIV infections occurred in the United States. Currently, 1.2 million Americans live with HIV and about 14% of those people do not know they have the virus and need testing. While HIV prevention outreach like Pride events have been limited during the COVID-19 pandemic, public health organizations are trying to work around this obstacle. By expanding access to free at-home HIV testing and distribution of PrEP, public health officials may continue to be effective at reducing the spread of HIV.

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In the Shadow of the COVID-19 Pandemic, A Looming Mental Health Crisis

As most Americans fixate on the surging COVID-19 cases and deaths, health care experts are growing weary of “an imminent mental health surge” in the United States. Over the past nine months, COVID-19 has affected Americans of all ages in every facet of daily life disrupting employment, education, religious practices, recreational activities and relationships. The staggering amount of death experienced in the nine months since the World Health Organization declared the virus a pandemic is devastating. In the United States, the number of deaths currently attributed to COVID-19 is nearly 4 times the deaths of Americans killed during the entirety of the Vietnam War which spanned two decades. This magnitude of death combined with an upheaval of normal grieving processes due to social distancing measures has significantly altered the ways in which individuals and families cope with grief, compounding their already disrupted daily lives. 

A recent study, conducted this year by scientists at the Journal of Affective Disorders, showed a global increase in the prevalence and severity of anxiety and depression and increases in post-traumatic stress disorder and substance abuse. Of central concern is the transformation of normal grief and distress into prolonged grief and major depressive order and symptoms of post-traumatic stress disorder. Indicators of prolonged grief disorder include at least six months of intense longing, preoccupation, or both with the deceased, emotional pain, loneliness, difficulty reengaging in life, avoidance, feeling life is meaningless, and increased suicide risk. These conditions, once established, could become chronic and may lead to substance use disorders. While prolonged grief affects approximately 10% of bereaved individuals, experts believe is an underestimate for grief related to deaths from COVID-19. Measurements estimate that each COVID-19 death leaves an estimated nine family members bereaved. This approximation projects over two million bereaved individuals at the current COVID-19 death count. Mental health experts warn this level of  bereavement, triggering new mental health disorders and intensifying existing mental health disorders, has the potential to overwhelm the American healthcare system beyond its capacity. 

America’s infrastructure for mental health and addiction services was fragmented, overburdened, and underfunded even before the COVID-19 crisis. An online survey of 880 organizations that provide behavioral-health services revealed that the pandemic has forced practices to reduce services, provide care to patients without sufficient protective equipment, lay off and furlough employees, and risk untimely closures. This reduction in services further burdens individuals with serious mental illness from receiving treatment and/or medication for their conditions, including those who are experiencing such symptoms for the first time. Alarmingly, mirroring COVID-19 itself, experts anticipate that a mental health surge will disproportionately affect Black and Hispanic individuals, older individuals, lower socio-economic groups of all races and ethnicities, and health care workers. 

Each day, as the United States continues to report record breaking COVID-19 cases, mental health care experts are certain the second wave of the COVID-19 pandemic is imminent. Experts suggest immediate emergent funding for mental health programs; widespread screening to identify those at the highest risk; availability of primary care clinicians and mental health professionals trained to treat those with prolonged grief, depression, traumatic stress, and substance abuse; and a diligent focus on families and communities to creatively restore the approaches by which they have managed tragedy and loss over generations. To further mitigate the threats of a mental health care disaster, states like Connecticut, are reaching out to the Centers for Disease Control and Prevention for grants to support expanded mental health resources after experiencing increases in both the use of the state’s suicide hotline and suicide rate amid the COVID-19 pandemic. 

Even as mental health care experts rush to mitigate the potential devastation of a second wave, it is clear that the havoc from COVID-19 will be felt for generations to come. The tremendous loss of life and the disruptions to all aspects of everyone’s lives reminds us of our fragility and how important it is and it will be to provide adequate mental health protections as an integral part of the healing process.

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Are Physicians and Hospitals Profiting from Over-Reporting COVID-19 Deaths?

Currently, there are over 11.8 million active cases and 253,600 COVID-19 related deaths in the United States. Since the onset of the pandemic, the Trump Administration has repeatedly downplayed COVID-19, denounced mask-wearing mandates, and refused to order a nationwide shutdown. Moreover, the current administration has been criticized for false claims that physicians are financially benefiting from the increase in COVID-19 cases. For instance, at a Michigan rally, President Trump stated that “our doctors get more money if somebody dies from COVID.” He then criticized the United States’ method of reporting COVID-19 deaths by stating deaths are characterized differently in other countries if a patient has multiple causes of death. However, this is misleading because the World Health Organization dictates that COVID-19 deaths should “not be attributed to another disease (i.e. cancer) and should be counted independently of preexisting conditions that are suspected of triggering a severe course of COVID-19.”

The interpretation of the administration’s unsubstantiated statements is that physicians and hospitals are incentivized to over-report COVID-19 deaths in order to receive additional federal funding supplied by the Coronavirus Aid, Relief, and Economic Security Act (CARES). The term “upcoding” is used when providers fraudulently request reimbursements for services they did not provide to patients. Upcoding violates the False Claims Act (“FCA”) which prohibits providers from intentionally making false claims to federal healthcare programs. Penalties for violating the FCA include fines triple the amount of the claim plus $11,000, criminal prosecution, and imprisonment.

Unjustified claims against COVID-19 reporting reveal a general misunderstanding of how the U.S. healthcare billing system functions. Insurance companies and payor systems, including Medicare, require physicians to bill for various services provided to the patient throughout their treatment. Therefore, providers are compensated for treating COVID-19 related symptoms regardless if the patient dies from a pre-existing condition. Since reimbursements are not increased based on cause of death, providers have no financial incentive to over-report COVID-19 deaths.

The CARES Act increased physician and hospital reimbursements by 20% in an effort to assist hospitals with the increased costs related to COVID-19. Medicare has estimated the cost of treatment for an inpatient with COVID-19 to be around $13,000. If the patient requires a ventilator, the cost of treatment increases to roughly $39,000. The reimbursements that insurance companies pay out is split between the physicians and hospitals. Physicians are reimbursed for services rendered to patients, while hospitals are reimbursed for the use of equipment, nurse and staffing salary, laboratory services, and various treatment related services. Although hospitals stand to receive additional financial compensation, these institutions are not “financially benefiting”. The additional funds are allocated to cover the increased cost of resources needed for treating COVID-19 patients in addition to providing personal protective equipment (PPE) to employees. The additional money from the CARES Act also allows hospitals to hire additional nurses and staff. Furthermore, while the federal government has provided aid in supplying expensive medical equipment, the increase in cases have left many hospitals needing to purchase additional ventilators. The CARES Act reimbursement enables hospitals to purchase additional necessary equipment required to treat COVID-19 patients and PPE to protect hospital staff from contracting the virus.

Although data shows reimbursement rates for COVID-19 patients are higher, there is no evidence suggesting provider upcoding or other fraudulent over-reporting of COVID-19 deaths. Unsubstantiated claims against physicians and other providers gravely undermines the ethics and hard work of many American frontline workers and lends itself to the fear that surrounds the impact of COVID-19 in the US.


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Airline COVID-19 Health Standards Remain Grounded While Holiday Travel Season Looms

The start of the holiday season—the busiest travel period in the United States—is just weeks away. Though the number of Americans taking to the skies this Thanksgiving is sure to be less than the 26 million travelers who passed through Transportation Security Administration checkpoints last year, passenger volume is nonetheless expected to surge.

However, potential travelers will have to weigh the risks of a COVID-19 resurgence against the range of travel options in an industry that remains largely outside the scope of any federally mandated COVID-19 safety regulations. The reticence to issue firm federal regulations to keep both passengers and workers safe has been a familiar narrative during this health crisis, and the airline industry has arguably been one of the most scrutinized segments of travel.

This unprecedented public health crisis begs the question: who is responsible for regulating passenger safety on airplanes as it pertains to COVID-19?

This is not a novel question. On March 14, 2020, in the early stages of the COVID-19 outbreak in the U.S., the Director of the Centers for Disease Control and Prevention (CDC) Dr. Robert Redfield issued a No Sail Order for all cruise ships operating within the United States, effectively shutting down cruise lines until further notice. In the No Sail Order, the Director rooted his decision in scientific information about the transmission of COVID-19 and on the powers granted to him as the CDC Director in 42 CFR § 71.32(b). Dr. Redfield justified issuing this federal mandate as he determined that the scope of this pandemic “cannot be controlled sufficiently by the cruise ship industry or individual state or local health authorities.”

However, the federal government has enacted no other substantive regulatory measures on other sectors of the travel industry during the course of the COVID-19 crisis. Instead, the CDC has opted for issuing non-binding COVID-19 safety guidelines for different industries, leaving sectors, such as the airline industry, to individually self-regulate.

The result of this recommended guidelines approach is a wide array of safety policies that differ between airlines with no legal mechanism for enforcement, meaning that the repercussions for consumer noncompliance extend only as far as what is within the company’s power to implement (e.g. denying service, customer banning, etc.). Furthermore, this range of options forces the consumer to compare health and safety measures between available choices or settle for the only option available to them.

Opponents to national standards often cite a disdain for government regulations as a driving factor for inaction. The Department of Transportation (DOT) recently denied a petition requesting the implementation of a nationwide mask policy for airports and air travel under their rule making powers found in 5 U.S.C. § 553(b)(3)(B). In DOT’s response, General Counsel Steven Bradbury stated his reasons for the denial being that guidelines recommending masks already exist, most air carriers have enacted mask policies, and DOT “embraces the notion that there should be no more regulations than necessary.”

Similarly, the New York Times reported that the CDC drafted a mandate last month that would require masks on all commercial and private transportation. The mandate was rooted in the CDC’s quarantine powers found in 42 USC § 264, 268, and was backed by the Secretary of Health and Human Services (HHS) Alex Azar II. However, the White House reportedly blocked the mandate, instead deferring to state and local authorities to issue their own guidance; Vice President Pence “declined to even discuss [the mandate]” with the White House Coronavirus Task Force.

This vacuum of federal safety regulation has led to a patchwork of self-regulation between industries and state officials attempting to establish legal standards to allow for enforcement of these standards. Some states, such as Virginia, have taken it upon themselves to codify CDC guidelines to provide legal standards for businesses and individuals alike whereas other states continue to pass the responsibility of public safety off to industries and individuals.

For interstate industries such as airlines, differing state and company standards are not sufficient to effectively manage the risks COVID-19 presents. Yet, a path toward the creation of national safety standards and a means of enforcement does exist. The CDC, DOT, HHS, and the president are provided various statutory powers while Congress has the ability to pass legislation—similar to some legislation passed at the state level—to create a national set of safety standards for certain industries.

As we approach the 2020 holiday travel season amidst the backdrop of a global pandemic, it is abundantly clear that the airline industry and the American people would be better served by a set of national safety regulations for air travel. The implementation of national safety regulations will provide the airline industry with means of legal enforcement for noncompliance, restore confidence in air travel, and provide airlines the best guidance from health experts to ensure consumer safety.

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