Prolonged loneliness is a major yet underappreciated determinant of health, 1 placing individuals at greater risk of premature death than obesity, inadequate physical activity, or air pollution. 2 With more adults than ever before living alone 3 and a large proportion of older adults without access to online connectivity tools, the US has a dangerously fertile environment for an epidemic of loneliness caused by coronavirus disease 2019 (COVID-19) social distancing strategies. Groups at especially high risk include older adults, low-income individuals, and those with preexisting mental illness. Although social distancing is critical to mitigating COVID-19 transmission, the health care system should play a leading role in identifying, preventing, and alleviating loneliness and associated health risks during the pandemic. Loneliness Is a Core Determinant of HealthLoneliness is the subjective perception of a deficit in social connection; social isolation, in contrast, is an objective measure based on social network size or frequency of social interactions. Left unchecked, loneliness can become a potent risk to physical and mental health. In a 2015 meta-analysis of 70 cohort studies, lonely individuals had a 26% increased likelihood of nonsuicide death over a mean follow-up of 7 years. 4 This association is likely mediated by factors such as hypothalamic-pituitary-adrenocortical activation, impairments in sleep quality, and increases in systolic blood pressure. 5 Large cross-sectional studies have linked loneliness to higher rates of anxiety, depression, and suicidal ideation, although the causal direction of this association remains unclear. 6 In older adults, loneliness and cognitive decline are closely related. 5 Potential Effect of the COVID-19 Pandemic on LonelinessThe COVID-19 pandemic is likely exacerbating loneliness by drastically reducing routine and intimate interactions and substituting face-to-face contact with modes of communication that may increase loneliness, such as social media. 5 Several populations are at increased risk. Older adults may have less access to, or facility with, videoconferencing tools that assist in maintaining social contact. To protect vulnerable residents from COVID-19, nursing homes have implemented Centers for Disease Control and Prevention guidelines to restrict visitation and cancel group activities and communal dining. Such social restrictions in nursing homes will likely be among the last to be lifted.Loneliness also is more prevalent among low-income individuals, 6 who are less able to work remotely and thus more likely to lose employment. Unemployment, in turn, may worsen loneliness through a variety of mechanisms, from the loss of workplace social ties to shame induced by losing one's source of income and social role. Those with mental illness already experience higher loneliness rates, 6 and these rates may increase further owing to loss of routines, feelings of powerlessness and anxiety, and diminished access to mental health services.

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The International Health Regulation—State Party Annual Reporting (IHR-SPAR) and the Global Health Security Index (GHSI)) have been developed to aid in strengthening national capacities for pandemic preparedness. We examine the relationship between country-level rankings on these two indices, along with two additional indices (the Universal Health Coverage Service Coverage Index and World Bank Worldwide Governance Indicator (n = 195)) and compared them to the country-level reported COVID-19 cases and deaths (Johns Hopkins University (JHU) COVID-19 Dashboard) through 17 June 2020. Ordinary least squares regression models were used to compare weekly reported COVID-19 case and death rates per million in the first 12 weeks of the pandemic between countries classified as low, middle, and high ranking on each index, while controlling for country socio-demographic information. Countries with higher GHSI and IHR-SPAR index scores experienced fewer reported COVID-19 cases and deaths, but only for the first 8 weeks after the country’s first case. For the GHSI, this association was further limited to countries with populations below 69.4 million. For both the GHSI and IHR-SPAR, countries with a higher sub-index score in human resources for pandemic preparedness reported fewer COVID-19 cases and deaths in the first 8 weeks after the country’s first reported case. The UHC-SCI and WGI country-level rankings were not associated with COVID-19 outcomes. The associations between GHSI and IHR-SPAR scores and COVID-19 outcomes observed in this study demonstrate that these two indices, although imperfect, may have value, especially in countries with a population under 69.4 million people for the GHSI. Preparedness indices may have value; however, they should continue to be evaluated as policymakers seek to better prepare for future global public health crises.

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6503 Background: High-deductible health plans (HDHPs) have grown rapidly in recent years, and now cover over one-half of U.S. workers. Patients in HDHPs are liable for the costs of all cancer-related care until their annual deductible is met, with the exception of screening tests such as colonoscopy and mammography. Due to increased out-of-pocket obligations, patients may postpone presenting for concerning symptoms or diagnostic testing, leading to delayed diagnosis. We therefore assessed the impacts of HDHPs on the timing of metastatic cancer detection. Methods: Using a nationally representative cohort of privately insured members in a national commercial and Medicare Advantage database (2003-2017), we studied 345,401 individuals age 18-64 years whose employers mandated a switch from a low-deductible (≤$500) plan to a high-deductible (≥$1,000) plan. Our control group consisted of 1,654,775 contemporaneous individuals whose employers offered only low-deductible plans. Both groups had a 1-year baseline period when all members were enrolled in low-deductible plans, and we followed members for a maximum of 13.5 years. Participants were matched with respect to age, gender, race/ethnicity, morbidity (ACG) score, poverty level, geographic region, employer size, baseline primary cancer, baseline medical and pharmacy costs, and follow-up duration. We used a validated claims-based algorithm to detect incident metastatic cancer diagnoses. We assessed time to metastatic cancer diagnosis in the baseline period (pre-HDHP switch) and follow-up period (post-HDHP switch) using a weighted Cox proportional hazards model. Results: After matching, there were no systematic differences between the HDHP and control groups with regard to observable baseline characteristics (standardized differences < 0.1). The mean age of participants was 42 years and the mean ACG score was 0.75. 49% were female, 48% lived in low-income neighborhoods, and 62% were White. We detected 1,668 metastatic events over a mean follow-up period of 38 months. There were no differences in time to metastatic diagnosis in the baseline year, prior to the HDHP switch (HR 0.96, p = 0.67). After employer-mandated HDHP switch, HDHP participants had lower odds of metastatic cancer diagnosis (HR 0.88, p = 0.01), indicative of delayed detection relative to the control group. Conclusions: Compared with conventional health plans, HDHPs are associated with delayed detection of metastatic cancer. These findings imply that patients postpone seeking care for concerning symptoms or defer diagnostic testing when exposed to high cost-sharing. Given recent advances that have improved survival of patients with advanced-stage cancers, future research efforts should investigate the impacts of HDHPs on quality of life, engagement in palliative care, and use of treatments in this patient population.