Sunscreens Part 2: Regulation and Safety.

The second part of this CME article discusses sunscreen regulation and safety considerations for humans and the environment. First, we provide an overview of the history of the United States Food and Drug Administration's regulation of sunscreen. Recent Food and Drug Administration studies clearly demonstrate that organic ultraviolet filters are systemically absorbed during routine sunscreen use, but to date there is no evidence of associated negative health effects. We also review the current evidence of sunscreen's association with vitamin D levels and frontal fibrosing alopecia, and recent concerns regarding benzene contamination. Finally, we review the possible environmental effects of ultraviolet filters, particularly coral bleaching. While climate change has been shown to be the primary driver of coral bleaching, laboratory-based studies suggest that organic ultraviolet filters represent an additional contributing factor, which led several localities to ban certain organic filters.

Distribution of CARES Act Provider Relief Funding to Psychiatric Care Organizations.

More than $100 billion in Coronavirus Aid, Relief, and Economic Security (CARES) Act funding was intended to support financially stressed health care providers during the COVID-19 pandemic. The distribution of the CARES Act's Provider Relief Fund among psychiatrists is poorly understood. Analyzing funding received by 2,593 psychiatric care organizations (PCOs), the authors found that funding was more equally distributed across care organizations of different sizes in psychiatry versus other specialties. Substantially less relief funding was received by PCOs per provider relative to other specialties. This disparity in relief funding is surprising given that specific earmarks of the CARES Act were intended to improve U.S. mental health care capacity, meriting further attention.

Participation in the CARES Act Provider Relief Fund policy by dentists in South Carolina's safety net.

OBJECTIVES: The Coronavirus Aid, Relief, and Economic Security (CARES) Act appropriated $100 billion to the Provider Relief Fund, allowing for direct payments to health care providers due to COVID-19. Few studies have evaluated participation in the Provider Relief Fund (PRF), and none have specifically looked at dental providers in the safety net. METHODS: We conducted a retrospective, secondary data analysis using a quasi-experimental cohort design of South Carolina dentists who received PRF payments, comparing those who did and did not participate in the safety net. Safety net practice was operationalized as those participating in Medicaid, and whether they provided care in dental health professional shortage areas, or rural communities. RESULTS: Of the 628 dental providers in South Carolina who received PRF payments, 34% were identified as Medicaid providers while 66% did not participate in Medicaid; we found no statistical difference between payments to Medicaid versus non-Medicaid dental providers. Of PRF payments to dental providers participating in South Carolina's Medicaid program, we found no difference between payments to rural and urban providers but did find that practices offering services in dental care shortage areas received less than providers practicing in counties not designated as a shortage area. CONCLUSIONS: The PRF achieved its goal of distributing financial support to providers affected by the COVID-19 pandemic. But without policy imperatives linked to need-based allocations or incentives for PRF recipients to serve safety net populations, we may later learn this was a missed opportunity for PRF.

Public sentiment and opinion regarding the CARES Act.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act was the largest stimulus package in US history. In this paper, I look into whether public sentiment improved in response to the CARES Act, and analyze public opinion regarding the CARES Act, implementing a Latent Dirichlet Allocation (LDA) model. The sentiment analysis results indicate a significant improvement of public sentiment following the announcement of the CARES Act, which fades away after a week but improves again as the date to receive the first stimulus check approaches. The topic modeling results highlight support toward certain programs and some criticism of the CARES Act.

Single borrowers versus coborrowers in the pandemic: Mortgage forbearance take-up and performance.

Early in the COVID-19 pandemic, policymakers initiated a forbearance program-that allowed borrowers to pause their mortgage payments-to prevent a large-scale foreclosure crisis. Using detailed loan-level performance data, we study forbearance take-up and subsequent performance among two distinct group of mortgage borrowers: single borrowers versus coborrowers. We provide stylized facts that compared to coborrowers, single borrowers have lower incomes, lower credit scores, higher loan-to-value ratios and higher debt-to-income ratios and are hence more financially vulnerable. We find that single borrowers are more apt to elect forbearance, all else constant. We further find that forbearance had a stronger positive effect on helping single borrowers avoid or recover and exit delinquency than coborrowers.

Ultraviolet filters in the United States and European Union: A review of safety and implications for the future of US sunscreens.

BACKGROUND: Availability of new UV filters in the United States lags behind the European Union (EU), partly due to differing approval processes. OBJECTIVE: To review available human safety data of all US- and EU-approved UV filters. METHODS: Data from Food and Drug Administration and EU regulatory guidelines, federal governmental documentation, databases, reviews, and opinions for approval and ongoing safety evaluation were analyzed. RESULTS: Currently, there are 17 US UV filters and 29 EU UV filters (18 EU-approved only filters). Almost all US filters possessed sensitization data (94%, 16/17) with the majority (76%, 13/17) showing minimal skin sensitization. The minority of EU-approved only filters (33%, 6/18) possessed sensitization data, all showing no sensitization. Some filters possessed dermal absorption data (US: 76%, 13/17; EU: 44%, 8/18). Oxybenzone, octinoxate, octisalate, homosalate, and octocrylene, approved in the US and EU, were shown to have plasma levels exceeding the Food and Drug Administration exposure threshold. LIMITATIONS: Proprietary manufacturer human data were unavailable. CONCLUSIONS: Many new UV filters are available in the EU, but not yet in the United States. Rigorous US and EU guidelines ensure that UV filters provide adequate photoprotection assuming consumers follow American Academy of Dermatology SPF (sun protection factor) and broad-spectrum recommendations. Human data are limited, but known human risks of sunscreen appear minimal.

Perceptions and Concerns of SUD Treatment Organizations Regarding the CARES Act's Alterations to Patient Confidentiality Regulations.

Objectives: Learn how substance use disorder (SUD) treatment organizations view and respond to changes in confidentiality and disclosure law following adoption of CARES Act Sec. 3221 and prior to promulgation of revised implementing regulations. Methods: Online survey followed by informal interviews. Representatives of SUD organizations reported their degree of awareness of Sec. 3221 provisions and their organizations' views on amendments to disclosure practices; current and future changes of organizational policies; difficulties anticipated in implementing new rules; and preferences for resources. Results: Forty informant surveys on 30 organizations completed. Participants (62.5 percent) indicated being somewhat knowledgeable about Sec. 3221. Evenly divided positive and concerned views on Sec. 3221 reflect tension between preserving confidentiality of patient records and improving coordination of care. Most (76.7 percent) reported organizational discussions on Sec. 3221. Some (30 percent) identified changes to make in near future. Over a third expected few or no barriers to implementing changes to privacy and disclosure practices, while most (64.7 percent) expected hindrances including complexity and tensions in the law, staff education, cost, technological adjustments, and changes in the ways SUD organizations interact with external organizations and individuals. To overcome barriers noted, participants expressed desire (66.7 percent) for teaching tools such as webinars and templates to follow. Conclusions: SUD treatment organizations began thinking of and planning for proposed changes well before expected implementation of Sec. 3221. Their concerns reflected practicalities of implementation, determining content of law, and wondering about the extent to which it solves problems (improving coordination of care among various providers) or endangered other goals (protecting confidentiality of SUD patient records).

Airline market exit after a shock event: Insights from the COVID-19 pandemic.

During the COVID-19 pandemic, passenger demand for air transportation declined drastically. In the Unites States (U.S.), the Coronavirus Aid, Relief, and Economic Security (CARES) Act provided financial assistance. In return, commercial passenger airlines were given minimum service obligations, which allowed airlines to remove markets (flights between origin and destination airport pairs) from their networks as long as they continued operating in all cities that they serviced pre-pandemic. A binary logit methodology is used to model airline-market level decisions to continue operating in a market or to exit it. Two time periods are modeled: during normal operating conditions (before the pandemic) and after a major shock event (after the beginning of the pandemic). Results show that after the pandemic, 8.4 times more airline markets are exited as compared to before. Interestingly, the probability of exit is found to vary widely across markets, airports, and airlines. Some market characteristics have a high probability of exit both before and after the pandemic, including low passenger revenue per available seat mile, low flight frequencies, and flights to/from multi-airport cities. In contrast, other market characteristics impact airlines' market exit decisions in only one time period rather than both. For example, during normal operating conditions, airport size does not impact market exit. However, after the pandemic, the probability of exit is 1.8 to 2.2 times higher for the larger hub airports as compared to the smallest airports (non-hubs), a result that is explained within the context of the CARES Act minimum service obligations.

Paycheck Protection Program (PPP) COVID-19 relief funding for veteran-, minority-, and women- owned dental businesses: A cross-sectional study.

Background: The Covid-19 pandemic exacerbated dental staffing shortages, which impact care delivery and ultimately oral health equity. Federal funding efforts like the Paycheck Protection Program (PPP) sought to aid traditionally underserved businesses including those owned by veterans, minority racial and ethnic groups, and women. Objectives: (1) To examine differences in PPP funding between veteran- and nonveteran-owned dental care delivery businesses and organizations and (2) to analyze other relevant factors associated with variation in PPP funding levels for dental businesses. Methods: Using publicly available PPP data, we ran unadjusted bivariable and adjusted multivariable linear regression models to estimate associations between loan approval amount and forgiveness amount, veteran status, and relevant covariates. Results: Minority racial and ethnic groups and women received less PPP funding and less loan forgiveness, on average, compared with non-minority groups. In the adjusted model with no missing self-reported demographic observations at p < 0.10, veterans received more PPP funding and loan forgiveness, on average, compared to non-veterans. Conclusion: To our knowledge, this is the first comprehensive analysis of all dental recipients of PPP funding throughout the United States. Despite PPP program intentions and strategies, traditionally underserved dental businesses did not receive increased funding to support employment.

Racialized minorities, trust, and crisis: Muslim-American nonprofits, their leadership and government relations during COVID-19.

The COVID-19 pandemic disproportionately affects already-vulnerable minorities, highlighting the need for strong, trusting relationships between governments and minority nonprofits for everyone's benefit. The current scholarship suggests minority members often lack trust in government. This study contributes to the field by examining trust levels Muslim-American nonprofits have for federal, state, and local government. Nearly two-thirds (65%) of Muslim nonprofit leaders believe that they may be discriminated against in the award of CARES Act funding, but on racial rather than religious ones. Moreover, partisanship affects trust levels. Muslim nonprofits in Republican "red" states show less trust in government compared with those in Democratic "blue" states. This study finds evidence that past relationships with the government strengthen trust. Past awards of government grants correlated positively with higher trust at both federal and local levels.

The Psychology of COVID-19 Economic Impact Payment Use.

This study investigates how American adults' personality and financial self-efficacy (FSE) beliefs contributed to how they used their COVID-19 CARES Act Economic Impact Payment (EIP) for spending needs, spending wants, and financial transactions (save, invest, debt repayment). The results from a sample of 1172 Amazon MTurk users collected in July 2020 suggest that both personality traits and FSE beliefs were associated with EIP use. Specifically, this study finds that FSE and conscientiousness emerged as the most robust predictors of EIP use across all categories of financial behavior with a greater allocation of EIP funds to saving and less to spending needs and debt repayment. Additionally, greater FSE is associated with investing, while greater conscientiousness is connected to more spending on wants. The results suggest that saving habits associated with personality and FSE persist in a crisis environment, and pre-crisis preparedness may allow for greater spending flexibility on wants. Significant relationships were also found for openness, extraversion, agreeableness, and neuroticism. The findings highlight how people use unexpected financial windfalls during crises and uncertainty and how personal characteristics contribute to this decision making. Supplementary Information: The online version contains supplementary material available at 10.1007/s10834-021-09804-1.

Reducing Strategic Forbearance under the CARES Act: an Experimental Approach Utilizing Recourse Attestation.

The Coronavirus Aid, Relief, and Economic Security (CARES) Act was passed in response to both the global pandemic's immediate negative and expected long-lasting impacts on the economy. Under the Act, mortgage borrowers are allowed to cease making payments if their income was negatively impacted by Covid-19. Importantly, borrowers were not required to demonstrate proof of impaction, either currently or retrospectively. Exploring the economic implications of this policy, this study uses an experimental design to first identify strategic forbearance incidence, and then to quantify where the forborne mortgage payment dollars were spent. Our results suggest strategic mortgage forbearance can be significantly reduced, saving taxpayers billions of dollars in potential losses, simply by requiring a 1-page attestation with lender recourse for borrowers wishing to engage in COVID-19 related mortgage payment cessation programs. Additionally, we demonstrate the use of these forborne mortgage payments range from enhancing the financial safety net for distressed borrowers by increasing precautionary savings, to buying necessities, to equity investing and debt consolidation.

This time is really different: The multiplier effect of the Paycheck Protection Program (PPP) on small business bank loans.

In response to the COVID-19 crisis, the U.S. government passed the Coronavirus Aid, Relief, and Economic Security (CARES) Act on March 27, 2020, creating the Paycheck Protection Program (PPP), among others, to aid small businesses and their employees. Most PPP loans were administered by commercial banks in return for fees, and the banks bore little monitoring costs or risks, since PPP loans were forgivable by the government. I analyze if PPP loans of up to $1 million were net substitutes or complements for conventional small business loans of the same size for the PPP-issuing banks. The $1 million upper bound roughly corresponds to credits to the smallest firms that are often financially constrained. Using Call Report data through 2020:Q4, I find significant net complementarities. An additional dollar of PPP credit of up to $1 million had multiplier effects on conventional loans to the smallest firms of about an extra dollar.

Measuring the COVID-19 Financial Threat to Hospital Markets.

Many hospitals have been straining under the financial stress of treating COVID-19 patients. Those experiencing the greatest strain are in markets burdened with high levels of debt and uncompensated care. We propose a new measure of financial risk in a hospital market, combining both pre-existing financial vulnerability and COVID-19 severity. It reveals the highest concentrations of risk in counties with high poverty, low population density, and high shares of foreign-born and non-White populations. The CARES Act Provider Relief Fund helped many of the hospitals in these regions, but it left many markets with the same overall vulnerability to financial strain from the next health crisis.

Care Ethics versus the CARES Act.

One of the biggest policy interventions during the last year of the COVID-19 pandemic was the Coronavirus Aid, Relief, and Economic Securities Act, instituting a novel form of economic relief similar to a universal basic income. The economic impact payments, colloquially known as "stimulus checks," were distributed based on the socioeconomic status of American citizens and legal residents and provided much-needed financial aid. However, the distribution of these payments paid little attention to other important factors that might determine the economic security of said individuals, such as race and gender. This article calls for policy-makers to pay particular attention to how structural inequity and discrimination based on identity could affect the efficacy of proposed policies and demonstrate an ethic of care informed by an understanding of intersectionality.

Advocacy for School Nurses and Student Health and Safety: Highlighting National and State Efforts.

Annually, the National Association of School Nurses (NASN) sets advocacy goals. The goals include legislative and policy priorities. The COVID-19 pandemic brought attention to the need to heighten advocacy efforts, specifically to provide for additional school nurses and supplies necessary to meet the challenge of safely returning students to school. While advocating at the national level, NASN also encouraged advocacy at the state and local levels. This article provides a brief summary of NASN's advocacy efforts as well as providing examples from two different state associations demonstrating the importance of collaboration in advocacy efforts in areas related to the pandemic and in general areas related to school nursing.

Unsanitized and Unfair: How COVID-19 Bailout Funds Refuel Inequity in the US Health Care System.

CONTEXT: The CARES Act of 2020 allocated provider relief funds to hospitals and other providers. We investigate whether these funds were distributed in a way that responded fairly to COVID-19-related medical and financial need. The US health care system is bifurcated into the "haves" and "have nots." The health care safety net hospitals, which were already financially weak, cared for the bulk of COVID-19 cases. In contrast, the "have" hospitals suffered financially because their most profitable procedures are elective and were postponed during the COVID-19 outbreak. METHODS: To obtain relief fund data for each hospital in the United States, we started with data from the HHS website. We use the RAND Hospital Data tool to analyze how fund distributions are associated with hospital characteristics. FINDINGS: Our analysis reveals that the "have" hospitals with the most days of cash on hand received more funding per bed than hospitals with fewer than 50 days of cash on hand (the "have nots"). CONCLUSIONS: Despite extreme racial inequities, which COVID-19 exposed early in the pandemic, the federal government rewards those hospitals that cater to the most privileged in the United States, leaving hospitals that predominantly serve low-income people of color with less.

Arthroplasty During COVID-19: Surveillance of AAHKS Members in the First Year of the Pandemic.

BACKGROUND: The COVID-19 pandemic has had a severe impact on the practices of adult reconstruction surgeons, primarily due to the elective nature of hip and knee arthroplasty. METHODS: To capture the impact of COVID-19 on its members, the American Association of Hip and Knee Surgeons sent 6 surveys over a span of 7 months from late March until September of 2020 querying its members regarding the effects of COVID on the health and well-being of their personal, financial, and clinical practice. RESULTS: Ninety-two percent of surgeons reported a cessation of elective inpatient cases during the height of the crisis. The reduction was greatest for surgeries performed in hospital-based sites of care. Ninety-one percent reported a drop in clinic volume. At the final surveys, these numbers where 7% and 59%, respectively. In addition, there was a widespread increase in the use of telemedicine during this period. Only a small number of orthopedic practices permanently closed because of COVID-19; 68% of surgeons, however, sought federal funding to offset their loss of revenue because of the restrictions placed on elective surgeries. Finally, once elective surgeries were reinstated, most surgeons reported no restrictions with surgical cases and that they believed they were adapting to the challenges of COVID successfully. CONCLUSIONS: The impact of COVID-19 in 2020 on the practice of arthroplasty resulted in nearly universal loss of volume and significant financial stress. Recovery has been consistent but incomplete for most practices. Continued monitoring of the members of American Association of Hip and Knee Surgeons will be needed in 2021 to measure the strength of the demonstrated adaptive recovery of 2020.

Fiscal policy during a pandemic.

I study the effects of the 2020 coronavirus outbreak in the United States and subsequent fiscal policy response in a nonlinear DSGE model. The pandemic is a shock to the utility of contact-intensive services that propagates to other sectors via general equilibrium, triggering a deep recession. I use a calibrated version of the model that matches the path of the US unemployment rate in 2020 to analyze different types of fiscal policies. I find that the pandemic shock changes the ranking of policy multipliers. Unemployment benefits are the most effective tool to stabilize income for borrowers, who are the hardest hit during a pandemic, while liquidity assistance programs are the most effective if the policy objective is to stabilize employment in the affected sector. I also study the effects of the $2.2 trillion CARES Act of 2020.