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Depressed? Anxious? Air Pollution May Be a Factor By Jim Robbins APRIL 25, 2023

In the 1990s, residents of Mexico City noticed their dogs acting strangely — some didn’t recognize their owners, and the animals’ sleep patterns had changed.

At the time, the sprawling, mountain-ringed city of more than 15 million people was known as the most polluted in the world, with a thick, constant haze of fossil fuel pollution trapped by thermal inversions.

In 2002, toxicologist and neuropathologist Lilian Calderón-Garcidueñas, who is affiliated with both Universidad del Valle de México in Mexico City and the University of Montana, examined brain tissue from 40 dogs that had lived in the city and 40 others from a nearby rural area with cleaner air. She discovered the brains of the city dogs showed signs of neurodegeneration while the rural dogs had far healthier brains.

Calderón-Garcidueñas went on to study the brains of 203 human residents of Mexico City, only one of which did not show signs of neurodegeneration. That led to the conclusion that chronic exposure to air pollution can negatively affect people’s olfactory systems at a young age and may make them more susceptible to neurodegenerative diseases such as Alzheimer’s and Parkinson’s.

The pollutant that plays the “big role” is particulate matter, said Calderón-Garcidueñas. “Not the big ones, but the tiny ones that can cross barriers. We can detect nanoparticles inside neurons, inside glial cells, inside epithelial cells. We also see things that shouldn’t be there at all — titanium, iron, and copper.”

The work the Mexican scientist is doing is feeding a burgeoning body of evidence that shows breathing polluted air not only causes heart and lung damage but also neurodegeneration and mental health problems.

It’s well established that air pollution takes a serious toll on the human body, affecting almost every organ. Asthma, cardiovascular disease, cancer, premature death, and stroke are among a long list of problems that can be caused by exposure to air pollution, which, according to the World Health Organization, sits atop the list of health threats globally, causing 7 million deaths a year. Children and infants are especially susceptible.

Sussing out the impact of air pollution on the brain has been more difficult than for other organs because of its inaccessibility, so it has not been researched as thoroughly, according to researchers. Whether air pollution may cause or contribute to Alzheimer’s or Parkinson’s is not settled science. But Calderón-Garcidueñas’ work is at the leading edge of showing that air pollution goes directly into the brain through the air we breathe, and has serious impacts.


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Some psychotherapists report seeing patients with symptoms stemming from air pollution. Not only does the pollution appear to cause symptoms or make them worse; it also takes away forms of relief.

“If we exercise and spend time in nature we become extra resilient,” said Kristen Greenwald, an environmental social worker and adjunct professor at the University of Denver. “A lot of folks do that outside. That’s their coping mechanism; it’s soothing to the nervous system.”

On polluted days a lot of her clients “can’t go outside without feeling they are making themselves more sick or distressed.”

Megan Herting, who researches air pollution’s impact on the brain at the University of Southern California, said environmental factors should be incorporated in doctors’ assessments these days, especially in places like Southern California and Colorado’s Front Range, where high levels of air pollution are a chronic problem.

“When I go into a medical clinic, they rarely ask me where I live and what is my home environment like,” she said. “Where are we living, what we are exposed to, is important in thinking about prevention and treatment.”

In the last two decades, with new technologies, research on air pollution and its impact on the human nervous system has grown by leaps and bounds.

Research shows tiny particles bypass the body’s filtering systems as they are breathed in through the nose and mouth and travel directly into the brain. Fine and ultrafine particles, which come from diesel exhaust, soot, dust, and wildfire smoke, among other sources, often contain metals that hitchhike a ride, worsening their impact.

A changing climate is likely to exacerbate the effects of air pollution on the brain and mental health. Warmer temperatures react with tailpipe emissions from cars to create more ozone than is generated when it’s cooler. And more and larger forest fires are expected to mean more days of smoky skies.

Ozone has been linked to neurodegeneration, decline in cerebral plasticity, the death of neurons, and learning and memory impairment. Ozone levels are extremely high in Los Angeles and the mountain valleys of the West, including the Front Range of Colorado, Phoenix, and Salt Lake City.

Air pollution also causes damage from chronic inflammation. As air pollution particles enter the brain, they are mistaken for germs and attacked by microglia, a component of the brain’s immune system, and they stay activated.

“Your body doesn’t like to be exposed to air pollution and it produces an inflammatory response,” said Patrick Ryan, a researcher at Cincinnati Children’s Hospital, in an email. “Your brain doesn’t like it either. There’s more than 10 years of toxicological science and epidemiologic studies that show air pollution causes neuro-inflammation.”

Much of the current research focuses on how pollution causes mental health problems.

Damage to the brain is especially pernicious because it is the master control panel for the body, and pollution damage can cause a range of neuropsychiatric disorders. A primary focus of research these days is how pollution-caused damage affects areas of the brain that regulate emotions — such as the amygdala, prefrontal cortex, and hippocampus. The amygdala, for example, governs the processing of fearful experiences, and its impairment can cause anxiety and depression. In one recent review, 95% of studies looking at both physical and functional changes to areas of the brain that regulate emotion showed an impact from air pollution.

A very large study published in February in JAMA Psychiatry, by researchers from the universities of Oxford and Peking and Imperial College London, tracked the incidence of anxiety and depression in nearly 400,000 adults in the United Kingdom over a median length of 11 years and found that long-term exposure even to low levels of a combination of air pollutants — particulate matter, nitrogen dioxide, and nitric oxide — increased the occurrence of depression and anxiety.

Another recent study, by Erika Manczak at the University of Denver, found adolescents exposed to ozone predicted “for steeper increases in depressive symptoms across adolescent development.”

But the epidemiological research has shortcomings because of confounding factors that are difficult to account for. Some people may be genetically predisposed to susceptibility and others not. Some may experience chronic stress or be very young or very old, which can increase their susceptibility. People who reside near a lot of green space, which reduces anxiety, may be less susceptible.

“Folks living in areas where there is greater exposure to pollutants tend to be areas under-resourced in many ways and grappling with a lot of systemic problems. There are bigger reports of stress and depression and anxiety,” said Manczak. “Given that those areas have been marginalized for a lot of reasons, it’s a little hard to say this is due to air pollution exposure.”

The best way to tell for sure would be to conduct clinical trials, but that comes with ethical problems. “We can’t randomly expose kids to air pollution,” Ryan said.

What Happens to Health Programs if the Federal Government Shuts Down? By Julie Rovner SEPTEMBER 27, 2023

What Happens to Health Programs if the Federal Government Shuts Down?

By Julie Rovner  SEPTEMBER 27, 2023

For the first time since 2019, congressional gridlock is poised to at least temporarily shut down big parts of the federal government — including many health programs.

If it happens, some government functions would stop completely and some in part, while others wouldn’t be immediately affected — including Medicare, Medicaid, and health plans sold under the Affordable Care Act. But a shutdown could complicate the lives of everyone who interacts with any federal health program, as well as the people who work at the agencies administering them.

Here are five things to know about the potential impact to health programs:

1. Not all federal health spending is the same.

“Mandatory” spending programs, like Medicare, have permanent funding and don’t need Congress to act periodically to keep them running. But the Department of Health and Human Services is full of “discretionary” programs — including at the National Institutes of Health, Centers for Disease Control and Prevention, community health centers, and HIV/AIDS initiatives — that must be specifically funded by Congress through annual appropriations bills.

The appropriations bills (there are 12 of them, each covering various departments and agencies) are supposed to be passed by both chambers of Congress and signed by the president before the start of the federal fiscal year, Oct. 1. This almost never happens. In fact, according to the Pew Research Center, Congress has passed all the appropriations bills in time for the start of the fiscal year only four times since the modern budget process was adopted in the 1970s; the last time was in 1997.

Congress usually keeps the lights on for the government by passing short-term funding bills, known as “continuing resolutions,” or CRs, until lawmakers can resolve their differences on longer-term spending.

This year, however, a handful of conservative Republicans in the House have said they won’t vote for any CR, in an attempt to force deeper spending cuts than those agreed to this spring in a bipartisan bill to raise the nation’s borrowing authority. House Speaker Kevin McCarthy and his allies could join with Democrats to keep the government running, but that would almost certainly cost McCarthy his speakership. Several of the rebellious conservatives are already threatening to force a vote to oust him.

2. The Biden administration decides what stays open.

The White House Office of Management and Budget is responsible for drawing up contingency plans in case of a government shutdown and publishes one for each federal department. The plan for Health and Human Services estimates that 42% of its staff would be furloughed in a shutdown and 58% retained.

The general rule is that two types of activities may continue absent annual spending authority from Congress. One is activities needed “for safety of human life or the protection of property.” At HHS, that would include caring for patients at the hospital on the campus of the National Institutes of Health — though new patients generally would not be admitted — as well as the agency’s laboratory animals, and CDC investigations of disease outbreaks.

Other activities that may continue are those with funding sources that aren’t dependent on annual appropriations. Medicare and Social Security, for example, are entitlements funded by taxes and premiums. Drug approvals at the FDA are largely funded by user fees paid by drugmakers, so approvals in process could continue, but questions remain about whether new approval processes could start.

Also unaffected are programs that have been funded in advance by Congress. For example, the Indian Health Service is already funded through the 2024 fiscal year.

3. What happens to enrollment in Medicare and Affordable Care Act plans?

It depends on how long the shutdown lasts. In the short term, mandatory spending programs would be mostly, but not completely, unaffected by a government shutdown. Benefits would continue under programs like Medicare, Medicaid, and the Affordable Care Act, and doctors and hospitals could continue to submit bills and get paid. But federal staffers not considered “essential” would be furloughed.

That means initial Medicare enrollment could be temporarily stopped. According to the Committee for a Responsible Federal Budget, an independent group that tracks federal spending, during the 1995-96 federal shutdown, “more than 10,000 Medicare applicants were temporarily turned away every day of the shutdown.”

A shutdown shouldn’t much affect Medicare’s annual open enrollment period, which starts Oct. 15 and allows current beneficiaries to join or change private Medicare Advantage or prescription drug plans. That’s because much of the funding to help seniors and other beneficiaries choose or change Medicare health plans has already been allocated.

Rebecca Kinney, who runs the HHS office that oversees the federal program that counsels Medicare beneficiaries about their myriad choices, said Sept. 22 that funding for both the 1-800-MEDICARE hotline and federally funded state counseling agencies has already been distributed for this year, so neither would be affected, at least in the short run.

The same is true for Affordable Care Act plans, which open for enrollment Nov. 1. The HHS contingency documents say the Centers for Medicare & Medicaid Services, which oversees the federal health exchange, healthcare.gov, “will continue Federal Exchange activities, such as eligibility verification,” using fees paid by insurers left over from the previous year.

Still, about half of CMS staffers would be furloughed in a shutdown. That could complicate a lot of other activities there, starting with drug price negotiations set to begin Oct. 1. HHS Secretary Xavier Becerra told reporters at the White House last week that a shutdown would likely push back the timeline for negotiations.

A shutdown would also threaten HHS oversight of the Medicaid “unwinding” process, as states reevaluate the eligibility of those enrolled in the program for low-income people. State workers would be unaffected, according to the Georgetown University Center for Children and Families, so eligibility reviews would continue regardless. But because of federal furloughs, “technical assistance to help states address unwinding problems and adopt mitigation strategies could cease,” wrote the center’s Kelly Whitener and Edwin Park. “Efforts to determine if there are further renewal processes that are out of compliance with federal requirements could be limited or ended.”

4. What if the shutdown is prolonged?

More programs could be affected. For example, the HHS shutdown contingency document says that “CMS will have sufficient funding for Medicaid to fund the first quarter” of fiscal year 2024. The government has never been shut down long enough to know what would happen after that. The 2013 shutdown, which included HHS, lasted just over two weeks. Most of the agency wasn’t affected by the 2018-19 shutdown because its annual appropriations bill had already been signed into law. (The FDA is funded under the appropriations bill that covers the Agriculture Department rather than the one that funds HHS.)

5. Do federal employees get paid during a shutdown?

It depends. Employees whose programs are funded continue to work and be paid. Those considered “essential” but whose programs are not funded would continue to work, but they wouldn’t get paid until after the shutdown ends. A 2019 law now requires federal workers to get back pay when funding resumes, which was not always the case. However, federal contractors, including those who work in food service or maintenance jobs, have no such guarantee.

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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New Medicare Advantage Plans Tailor Offerings to Asian Americans, Latinos, and LGBTQ+


By Stephanie Stephens

As Medicare Advantage continues to gain popularity among seniors, three Southern California companies are pioneering new types of plans that target cultural and ethnic communities with special offerings and native-language practitioners.

Clever Care Health Plan, based in Huntington Beach, and Alignment Health, based in nearby Orange, both have plans aimed at Asian Americans, with extra benefits including coverage for Eastern medicines and treatments such as cupping and tui na massage. Alignment also has an offering targeting Latinos, while Long Beach-based SCAN Health Plan has a product aimed at the LGBTQ+ community. All of them have launched since 2020.

While many Medicare Advantage providers target various communities with their advertising, this trio of companies appear to be among the first in the nation to create plans with provider networks and benefits designed for specific cultural cohorts. Medicare Advantage is typically cheaper than traditional Medicare but generally requires patients to use in-network providers.

“This fits me better,” said Clever Care member Tam Pham, 78, a Vietnamese American from Westminster, California. Speaking to KFF Health News via an interpreter, she said she appreciates the dental care and herbal supplement benefits included in her plan, and especially the access to a Vietnamese-speaking doctor.

“I can always get help when I call, without an interpreter,” she said.

Proponents of these new culturally targeted plans say they can offer not only trusted providers who understand their patients’ unique context and speak their language, but also special products and services designed for their needs. Asian Americans may want coverage for traditional Eastern treatments, while LGBTQ+ patients might be especially concerned with HIV prevention or management, for example.

Health policy researchers note that Medicare Advantage tends to be lucrative for insurers but can be a mixed bag for patients, who often have a limited choice of providers — and that targeted plans would not necessarily solve that problem. Some also worry that the approach could end up being a new vector for discrimination.

“It’s strange to think about commodifying and profiting off people’s racial and ethnic identities,” said Naomi Zewde, an assistant professor at the UCLA Fielding School of Public Health. “We should do so with care and proceed carefully, so as not to be exploitive.”

Still, there’s plenty of evidence that patients can benefit from care that is targeted to their race, ethnicity, or sexual orientation.

A November 2020 study of almost 118,000 patient surveys, published in JAMA Network Open, underscored the need for a connection between physician and patient, finding that patients with the same racial or ethnic background as their physicians are more likely to rate the latter highly. A 2022 survey of 11,500 people around the world by the pharmaceutical company Sanofi showed a legacy of distrust in health care systems among marginalized groups, such as ethnic minorities, LGBTQ+ people, and people with disabilities.

Clever Care, founded by Korean American health care executive Myong Lee, aimed from the start to create Medicare Advantage plans for underserved Asian communities, said Peter Winston, the senior vice president and general manager of community and provider development at the company. “When we started enrollments, we realized there is no one ‘Asian,’ but there is Korean, Chinese, Vietnamese, Filipino, and Japanese,” Winston added.

The company has separate customer service lines by language and gives members flexibility on how and where to spend their allowances for benefits like fitness programs.

Winston said the plan began with 500 members in January 2021 and is now up to 14,000 (still very small compared with mainstream plans). Herbal supplement benefit dollars vary by plan, but more than 200 products traditionally used by Asian clients are on offer, with coverage of up to several hundred dollars per quarter.

Sachin Jain, a physician and the CEO of SCAN Group, said its LGBTQ+ plan serves 600 members.

“This is a group of people who, for much of their lives, lived in the shadows,” Jain added. “There is an opportunity for us as a company to help affirm them, to provide them with a special set of benefits that address unmet needs.”

SCAN has run into bias issues itself, with some of its employees posting hate speech and one longtime provider refusing to participate in the plan, Jain recounted.

Alignment Health offers a plan targeting Asian Americans in six California counties, with benefits such as traditional wellness services, a grocery allowance for Asian stores, nonemergency medical transportation, and even pet care in the event a member has a hospital procedure or emergency and needs to be away from home.

Alignment also has an offering aimed at Latinos, dubbed el Único, in parts of Arizona, Nevada, Texas, Florida, and California. The California product, an HMO co-branded with Rite Aid, is available in six counties, while in Florida and Nevada, it’s a so-called special needs plan for Medicare beneficiaries who also qualify for Medicaid. All offer a Spanish-speaking provider network.

Todd Macaluso, the chief growth officer for Alignment, declined to share specific numbers but said California membership in Harmony — its plan tailored to Asian Americans — and el Único together has grown 80% year over year since 2021.

Alignment’s marketing efforts, which include visiting places where prospective members may shop or socialize, are about more than just signing up customers, Macaluso said.

“Being present there means we can see what works, what’s needed, and build it out. The Medicare-eligible population in Fresno looks very different from one in Ventura.”

“Just having materials in the same language is important, as is identifying the caller and routing them properly,” Macaluso added.

Blacks, Latinos, and Asians overall are significantly more likely than white beneficiaries to choose Medicare Advantage plans, according to recent research conducted for Better Medicare Alliance, a nonprofit funded by health insurers. (Latino people can be of any race or combination of races.) But it’s not clear to what extent that will translate into the growth of targeted networks: Big insurers’ Medicare Advantage marketing efforts often target specific racial or ethnic cohorts, but the plans don’t usually include any special features for those groups.

Utibe Essien, an assistant professor of medicine at UCLA, noted the historical underserving of the Black community, and that the shortage of Black physicians could make it hard to build a targeted offering for that population. Similarly, many parts of the country don’t have a high enough concentration of specific groups to support a dedicated network.

Still, all three companies are optimistic about expansion among groups that haven’t always been treated well by the health care system. “If you treat them with respect, and bring care to them the way they expect it, they will come,” Winston said.

This article was produced by KFF Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation. 

KFF Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about KFF.

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Seven intimate Egon Schiele artworks, looted by Nazis from Jewish art collector, returned to his heirs


Seven intimate Egon Schiele artworks, looted by the Nazis from a Jewish art collector, are returned to his heirs

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