Thirty-five years ago, Jerry Gurwitz was among the first physicians in the United States to be credentialed as a geriatrician — a doctor who specializes in the care of older adults.
"I understood the demographic imperative and the issues facing older patients," Gurwitz, 67 and chief of geriatric medicine at the University of Massachusetts Chan Medical School, told me. "I felt this field presented tremendous opportunities."
But today, Gurwitz fears geriatric medicine is on the decline. Despite the surging older population, there are fewer geriatricians now (just over 7,400) than in 2000 (10,270), he noted in a recent piece in JAMA. (In those two decades, the population 65 and older expanded by more than 60%.) Research suggests each geriatrician should care for no more than 700 patients; the current ratio of providers to older patients is 1 to 10,000.
What's more, medical schools aren't required to teach students about geriatrics, and fewer than half mandate any geriatrics-specific skills training or clinical experience. And the pipeline of doctors who complete a one-year fellowship required for specialization in geriatrics is narrow. Of 411 geriatric fellowship positions available in 2022-23, 30% went unfilled.
The implications are stark: Geriatricians will be unable to meet soaring demand for their services as the aged U.S. population swells for decades to come. There are just too few of them. "Sadly, our health system and its workforce are wholly unprepared to deal with an imminent surge of multimorbidity, functional impairment, dementia and frailty," Gurwitz warned in his JAMA piece.
This is far from a new concern. Fifteen years ago, a report from the National Academies of Sciences, Engineering, and Medicine concluded: "Unless action is taken immediately, the health care workforce will lack the capacity (in both size and ability) to meet the needs of older patients in the future." According to the American Geriatrics Society, 30,000 geriatricians will be needed by 2030 to care for frail, medically complex seniors.
There's no possibility this goal will be met.
What's hobbled progress? Gurwitz and fellow physicians cite a number of factors: low Medicare reimbursement for services, low earnings compared with other medical specialties, a lack of prestige, and the belief that older patients are unappealing, too difficult, or not worth the effort.
"There's still tremendous ageism in the health care system and society," said geriatrician Gregg Warshaw, a professor at the University of North Carolina School of Medicine.
But this negative perspective isn't the full story. In some respects, geriatrics has been remarkably successful in disseminating principles and practices meant to improve the care of older adults.
"What we're really trying to do is broaden the tent and train a health care workforce where everybody has some degree of geriatrics expertise," said Michael Harper, board chair of the American Geriatrics Society and a professor of medicine at the University of California-San Francisco.
Among the principles geriatricians have championed: Older adults' priorities should guide plans for their care. Doctors should consider how treatments will affect seniors' functioning and independence. Regardless of age, frailty affects how older patients respond to illness and therapies. Interdisciplinary teams are best at meeting older adults' often complex medical, social, and emotional needs.
Medications need to be reevaluated regularly, and de-prescribing is often warranted. Getting up and around after illness is important to preserve mobility. Nonmedical interventions such as paid help in the home or training for family caregivers are often as important as, or more important than, medical interventions. A holistic understanding of older adults' physical and social circumstances is essential.
The list of innovations geriatricians have spearheaded is long. A few notable examples:
Hospital-at-home. Seniors often suffer setbacks during hospital stays as they remain in bed, lose sleep, and eat poorly. Under this model, older adults with acute but non-life-threatening illnesses get care at home, managed closely by nurses and doctors. At the end of August, 296 hospitals and 125 health systems — a fraction of the total — in 37 states were authorized to offer hospital-at-home programs.
Age-friendly health systems. Focus on four key priorities (known as the "4Ms") is key to this wide-ranging effort: safeguarding brain health (mentation), carefully managing medications, preserving or advancing mobility, and attending to what matters most to older adults. More than 3,400 hospitals, nursing homes, and urgent care clinics are part of the age-friendly health system movement.
Geriatrics-focused surgery standards. In July 2019, the American College of Surgeons created a program with 32 standards designed to improve the care of older adults. Hobbled by the covid-19 pandemic, it got a slow start, and only five hospitals have received accreditation. But as many as 20 are expected to apply next year, said Thomas Robinson, co-chair of the American Geriatrics Society's Geriatrics for Specialists Initiative.
Geriatric emergency departments. The bright lights, noise, and harried atmosphere in hospital emergency rooms can disorient older adults. Geriatric emergency departments address this with staffers trained in caring for seniors and a calmer environment. More than 400 geriatric emergency departments have received accreditation from the American College of Emergency Physicians.
New dementia care models. This summer, the Centers for Medicare & Medicaid Services announced plans to test a new model of care for people with dementia. It builds on programs developed over the past several decades by geriatricians at UCLA, Indiana University, Johns Hopkins University, and UCSF.
A new frontier is artificial intelligence, with geriatricians being consulted by entrepreneurs and engineers developing a range of products to help older adults live independently at home. "For me, that is a great opportunity," said Lisa Walke, chief of geriatric medicine at Penn Medicine, affiliated with the University of Pennsylvania.
The bottom line: After decades of geriatrics-focused research and innovation, "we now have a very good idea of what works to improve care for older adults," said Harper, of the American Geriatrics Society. The challenge is to build on that and invest significant resources in expanding programs' reach. Given competing priorities in medical education and practice, there's no guarantee this will happen.
But it's where geriatrics and the rest of the health care system need to go.
We're eager to hear from readers about questions you'd like answered, problems you've been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.
Last year, Jennifer Reisz's college-age daughter, Megan, was kicked in the chest multiple times by the family's horse. Megan fell to the ground, unable to move or speak. Though she was alone, her Apple Watch detected her distress and called 911.
She was taken to a hospital in Clovis, a city in Fresno County, near where the Reisz family lives. But the severity of Megan's injuries — four broken ribs and a partially collapsed lung — prompted doctors to transport her 12 miles by ambulance to the Level I trauma center at Community Regional Medical Center in Fresno.
While Megan was still recovering at home from her injuries, she received a $2,400 bill from the ambulance company — after the family's health plan had paid nearly $2,200.
"When we received the bill, I thought our insurance company was processing the claim incorrectly," says Jennifer Reisz. An attorney, Reisz says she then spent hours on the phone with the health plan, the ambulance company, and a few consumer advocates. She learned that the ambulance company was not in the health plan's network and was permitted to bill patients for any uncovered portion of its charges — a practice known as balance billing.
Starting Jan. 1, ground ambulance operators will be barred from doing that because of a new law signed by Democratic Gov. Gavin Newsom. California is the 14th state to provide some protection against balance billing for ground ambulance rides.
Both the federal law, which took effect in 2022, and a California law that predates it largely banned balance billing for hospital care and air ambulance services, but not ground ambulance services.
And that is hardly fair, since patients have zero control in a medical emergency over which ambulance company responds, whether it is in network, or how much it will charge.
In California, nearly three-quarters of emergency ground ambulance rides result in out-of-network bills. The average surprise bill for a ground ambulance ride in California is $1,209, the highest in the nation, according to a December study.
The new law, which applies to about 14 million Californians enrolled in state-regulated commercial health plans, limits how much a non-network ambulance operator can charge patients to the amount they would pay for an in-network ambulance.
The law also caps bills for uninsured people, stipulating they can't be charged more than the Medi-Cal or Medicare rate, whichever is greater. (Medi-Cal is California's Medicaid program, providing coverage to people with low incomes or disabilities.) And it prohibits ambulance operators and debt collectors from reporting patients to a credit rating agency or taking legal action against them for at least 12 months after the initial bill.
Under current law, people in distress sometimes decline to call an ambulance for fear of a huge bill, putting themselves or a loved one at risk, says Katie Van Deynze, policy and legislative advocate for Health Access California, which sponsored the legislation. With the new law, she says, "they will have peace of mind."
Existing laws already protect Medicare and Medi-Cal beneficiaries from surprise ground ambulance bills. The new law does not cover the nearly 6 million Californians enrolled in the subset of employer-sponsored health plans that are federally regulated.
The advisory committee working on a federal fix agreed last week on nonbinding proposals that would, among other things, prohibit balance billing for the vast majority of ambulance rides and cap patients' financial liability at $100. The committee plans to formally report its recommendations to Congress early next year for potential legislation.
Under California's new law, patients can expect to save an average of nearly $1,100 per emergency ambulance ride and over $800 per nonemergency ride in the first year, according to a legislative analysis conducted this year.
Health plans will be required to pay ambulance operators the rates set by county authorities, which the study said would increase the average amount insurers pay per ride by around $2,000.
Since ambulance rides account for a tiny percentage of overall health plan spending, those increases should not raise premiums by much.
But local authorities might be tempted to hike ambulance rates over time to increase revenue for publicly run ambulance operators, such as fire departments, says Loren Adler, associate director of the Brookings Schaeffer Initiative on Health Policy. That could prompt health plans to raise ambulance copays, offsetting some of the consumer savings from the new law, Adler says.
Jenn Engstrom, director of CalPIRG, an advocacy group that helped shepherd the law through the legislature, notes there will be built-in accountability, since the legislation requires public reporting of ambulance rates. "If we notice that things start to skyrocket, there will be a need for legislative action or local action," Engstrom says.
Reisz says the ambulance company that transported her daughter wrote off the bill after she made it clear she had no intention of paying it — and after her health plan ponied up a little more. But as she notes, not everyone is a lawyer adept at arguing their cause.
Even if you are no rhetorical wizard, you can take simple steps to protect yourself against errors or ambulance operators that disregard the new law.
Check your insurance policy to know your deductible and any copay or coinsurance should you ever need an ambulance. If you get an ambulance bill, don't pay it right away. Check your insurer's explanation of benefits to make sure what it says you owe matches what you think your cost-sharing amount should be. If the bill is higher, the ambulance company may be trying to pull a fast one. Call the ambulance company and tell them they need to knock the bill down. If they don't, file a complaint with your health plan and include a copy of the bill.
If you disagree with your plan's decision, or it takes more than 30 days for the plan to respond, take your complaint to the regulator.
The new law requires your insurer to tell you if your health plan is regulated by the state and thus subject to the statute. If it is, the regulator is likely to be the Department of Managed Health Care. You can contact that agency online (www.healthhelp.ca.gov) or by phone at 1-888-466-2219. If your health plan is regulated by the Department of Insurance, you can file a complaint online (www.insurance.ca.gov) or call 1-800-927-4357.
Another good resource is the Health Consumer Alliance, which offers free legal assistance in multiple languages. Call 1-888-804-3536.
More than two dozen people lined up outside a state public assistance office in Montana before it opened to ensure they didn't get cut off from Medicaid.
Callers in Missouri and Florida reported waiting on hold for more than two hours on hotlines to renew their Medicaid coverage.
The parents of a disabled man in Tennessee who had been on Medicaid for three decades fought with the state this summer to keep him enrolled as he lay dying from pneumonia in a hospital.
Seven months into what was predicted to be the biggest upheaval in the 58-year history of the government health insurance program for people with low incomes and disabilities, states have reviewed the eligibility of more than 28 million people and terminated coverage for over 10 million of them. Millions more are expected to lose Medicaid in the coming months.
The unprecedented enrollment drop comes after federal protections ended this spring that had prohibited states from removing people from Medicaid during the three pandemic years. Since March 2020, enrollment in Medicaid and the related Children's Health Insurance Program had surged by more than 22 million to reach 94 million people.
The process of reviewing all recipients' eligibility has been anything but smooth for many Medicaid enrollees. Some are losing coverage without understanding why. Some are struggling to prove they're still eligible. Recipients and patient advocates say Medicaid officials sent mandatory renewal forms to outdated addresses, miscalculated income levels, and offered clumsy translations of the documents. Attempting to process the cases of tens of millions of people at the same time also has exacerbated long-standing weaknesses in the bureaucratic system. Some suspect particular states have used the confusing system to discourage enrollment.
"It's not just bad, but worse than people can imagine," said Camille Richoux, health policy director for the nonprofit Arkansas Advocates for Children and Families. "This unwinding has not been about determining who is eligible by all possible means, but how we can kick people off by all possible means."
To be sure, some of the Medicaid recipients who signed on to the program when the U.S. unemployment rate soared amid covid-19 lockdowns have since gotten health insurance through new jobs as unemployment dropped back to pre-pandemic lows.
And some of the disenrolled are signing up for Affordable Care Act marketplace plans. Centene CEO Sarah London, for example, told investors on Oct. 24 that the health care giant expected as many as 2.4 million of its 15 million Medicaid managed care members to lose coverage from the unwinding, but more than 1 million customers had joined its exchange plans since the same time last year.
Still, it's anyone's guess how many former Medicaid beneficiaries remain uninsured. States don't track what happens to everyone after they're disenrolled. And the final tallies likely won't be known until 2025, after the unwinding finishes by next summer and federal officials survey Americans' insurance status.
Without Medicaid, Patients Miss Appointments
Trish Chastain, 35, of Springfield, Missouri, said her Medicaid coverage is scheduled to expire at the end of the year. Though her children are still covered, she no longer qualifies because her income is too high at $22 an hour. Chastain's employer, a rehab center, offers health insurance but her share of the premium would be $260 a month. "I can't afford that with my monthly budget," she said.
She said she did not know she might be eligible for a lower-cost plan on the Affordable Care Act marketplace. That still would mean new costs for her, though.
Gaps in coverage can jeopardize people's access to health services or their financial security if they get medical bills for care they cannot postpone.
"Any type of care that's put off — whether it's asthma, whether it's autism, whether it's something as simple as an earache — can just get worse if you wait," said Pam Shaw, a pediatrician in Kansas City, Kansas, who chairs the American Academy of Pediatrics' state government affairs committee.
Doctors and representatives of community health centers around the country said they have seen an uptick in cancellations and no-shows among patients without coverage — including children. Nationwide, states have already disenrolled at least 1.8 million children in the 20 states that provide the data by age. Children typically qualify more easily than adults, so child advocates believe many kids are being wrongly terminated based on their parents' being deemed no longer eligible. Meanwhile, enrollment in CHIP, which has higher income eligibility levels than Medicaid, has shown only a tiny increase.
Kids accounted for varying shares of those disenrolled in each state, ranging from 68% in Texas to 16% in Massachusetts, according to KFF. In September, President Joe Biden's administration said most states were conducting eligibility checks incorrectly and inappropriately disenrolling eligible children or household members. It ordered states to reinstate coverage for some 500,000 people.
Varying Timetables, Varying Rates of Disenrollment
Idaho, one of a few states that completed the unwind in six months, said it disenrolled 121,000 people of the 153,000 recipients it reviewed as of September because it suspected they were no longer eligible with the end of the public health emergency. Of those kicked off, about 13,600 signed up for private coverage on the state's ACA marketplace, said Pat Kelly, executive director of Your Health Idaho, the state's exchange. What happened to the rest, state officials say they don't know.
California, by contrast, started terminating recipients only this summer and is automatically transferring coverage from Medicaid to marketplace plans for those eligible.
The Medicaid disenrollment rates of people reviewed so far vary dramatically by state, largely along a blue-red political divide, from a low of 10% in Illinois to a high of 65% in Texas.
"I feel like Illinois is doing everything in their power to ensure that as few people lose coverage as possible," said Paula Campbell of the Illinois Primary Health Care Association, which represents dozens of community health centers.
Nationwide, about 71% of Medicaid enrollees terminated during the unwinding have been cut because of procedural issues, such as not responding to requests for information to verify their eligibility. It's unclear how many are actually still eligible.
State and local Medicaid officials say they have tried contacting enrollees in multiple ways — including through letters, phone calls, emails, and texts — to check their eligibility. Yet some Medicaid recipients lack consistent addresses or internet service, do not speak English, or are juggling more pressing needs.
"The unwinding effort continues to be very challenging and a significant lift for all states," said Kate McEvoy, executive director of the National Association of Medicaid Directors.
'People Are Not Getting Through'
In many states, that has meant enrollees have faced long waits to get help with renewals. The worst phone waits were in Missouri, according to a KFF Health News review of letters the Centers for Medicare & Medicaid Services sent to states in August. In the letter to Missouri's Medicaid program, CMS said it was concerned that the average wait time of 48 minutes and the 44% rate of Missourians abandoning those calls in May was "impeding equitable access" to assistance and patients' ability to maintain coverage.
Some people are waiting on hold more than three hours, said Sunni Johnson, an enrollment worker at Affinia Healthcare, which runs community health centers in the St. Louis area. That's a significant hurdle for a population in which many have limited cellphone minutes.
In Florida, which has removed over 730,000 people from the program since April, enrollees earlier this year were waiting almost 2½ hours on a Spanish-language call center, according to a report from UnidosUS, a civil rights advocacy group. The Spanish versions of the Medicaid application, renewal website, and other communications are also confusing, said Jared Nordlund, the Florida director for UnidosUS.
"They can barely get the Spanish translations right," he said.
Miguel Nevarez, press secretary for Florida's Department of Children and Families, which is managing the state's Medicaid redetermination process, criticized complaints about poor translations and long waits for the Spanish-language call center as a "false narrative." He said, "The data clearly shows Florida has executed a fair and effective plan for redeterminations."
In California, similarly jammed phone lines, crowded and understaffed county offices, and trouble downloading renewal applications electronically are all "compounding people's difficulty to renew" their Medicaid, said Skyler Rosellini, a senior attorney in the Los Angeles office of the National Health Law Program. "We do know, based on the cases we're getting, that people are not getting through."
Jasmine McClain, a 31-year-old medical assistant, said she tried everything before Montana ended Medicaid coverage for her kids, ages 3 and 5, in early October. She tried submitting paperwork online and over fax to prove they still qualified. She spent hours on hold with the state hotline. After her kids' coverage ended, she went to a state public assistance office in Missoula but couldn't get an appointment. One day in mid-October, roughly 30 people lined up outside the office starting as early as 6:40 a.m., before its doors opened.
After three weeks of her pleading for help while her kids were uninsured, the state restored her kids' coverage. She said a supervisor told her the family's paperwork submitted online wasn't processed initially.
"The phone call system was a mess. Callbacks were a week out to even talk to somebody," McClain said. "It just was just a lot of hurdles that I had to get through."
Spokespeople for the Montana, Florida, and Missouri Medicaid programs all said their states had reduced call wait times.
Some Medicaid recipients are seeking help through the courts. In a 2020 class-action lawsuit against Tennessee that seeks to pause the Medicaid eligibility review, parents of recipients describe spending hours on the phone or online with the state Medicaid program, trying to ensure their children's insurance coverage is not lost.
One of those parents, Donna Guyton, said in a court filing that Tennessee's Medicaid program, called TennCare, sent a June letter revoking the coverage of her 37-year-old son, Patrick, who had been eligible for Medicaid because of disabilities since he was 6. As Guyton made calls and filed appeals to protect her son's insurance, he was hospitalized with pneumonia, then spent weeks there before dying in late July.
"While Patrick was fighting for his life, TennCare was threatening to take away his health insurance coverage and the services he relied on," she said in a court filing. "Though we should have been able to focus on Patrick's care, our family was required to navigate a system that kept denying his eligibility and putting his health coverage at risk."
TennCare said in a court filing Patrick Guyton's Medicaid coverage was never actually revoked — the termination letter was sent to his family because of an "error."
Phil Galewitz in Washington, D.C., wrote this article. Daniel Chang in Hollywood, Florida; Katheryn Houghton in Missoula, Montana; Brett Kelman in Nashville, Tennessee; Samantha Liss and Bram Sable-Smith in St. Louis; and Bernard J. Wolfson in Los Angeles contributed to this report.
TAHLEQUAH, OK — Ashton Glover Gatewood decided to give medical school a second try after learning about a new campus designed for Indigenous students like herself.
Gatewood is now set to be part of the first graduating class at Oklahoma State University's College of Osteopathic Medicine at the Cherokee Nation. Leaders say the physician training program is the only one on a Native American reservation and affiliated with a tribal government.
"This is the school that is everything that I need to be successful," said Gatewood, a member of the Choctaw Nation who also has Cherokee and Chickasaw ancestry. "Literally, the campus, the curriculum, the staff — everything was built and hired and prepared and planned for you."
The program in Tahlequah, the capital of the Cherokee Nation, aims to increase the number of Cherokee and other Indigenous physicians. It's also focused on expanding the number of doctors from all backgrounds who serve rural or tribal communities.
Natasha Bray, an osteopathic physician and dean of the program, said most medical schools teach about barriers that can make it difficult for rural or Indigenous patients to get care and improve their health.
But she said students in Tahlequah get to see these barriers firsthand by studying on the Cherokee Reservation and doing rotations in tiny communities and within facilities run by the federal Indian Health Service.
"Unless you are living in that community, you're part of that community, you're seeing patients from that community — you can't begin to understand what those barriers to care are," said Bray, who is not Native American.
For example, Bray knows that one town on the reservation is a 50-minute drive to the nearest delivery room, and that some patients trying to eat healthier live far from supermarkets and settle for convenience store food.
Rural residents make up about 14% of the U.S. population but fewer than 5% of incoming medical students, according to a study of 2017 data. Native Americans are 3% of the population but represented only 0.2% of those accepted to medical school for the 2018-19 school year, according to the Association of American Medical Colleges.
Gatewood, 34, who grew up in a city between the Chickasaw Reservation and Oklahoma City, first attended medical school at the University of Missouri. She said it was a great program, but it didn't match her learning style. And with few Native American students, it left her feeling disconnected from her culture.
She ended up leaving after three semesters. Gatewood went on to become a nurse and earned a master's degree in public health.
Then, in 2019, six years after dropping out of the Missouri medical school, Gatewood learned about Oklahoma State's new campus in Tahlequah. She decided to once more pursue her dream of becoming a doctor. After taking classes in Oklahoma, she's now getting hands-on experience through a family medicine rotation in Baltimore.
Half the 202 medical students in Tahlequah are from rural areas, and nearly a quarter are Native American. Most of the Indigenous students are from Oklahoma tribes. Others come from tribes outside the state, including from Alaska and New Mexico.
Tahlequah has about 16,800 residents. It's more than an hour east of Tulsa, home to Oklahoma State's other osteopathic medicine campus.
Osteopathic physicians, or DOs, attend separate medical schools from allopathic doctors, or MDs. The schools have similar curricula, but osteopathic colleges also teach how to ease patient discomfort through physical manipulation of muscles and bones. Osteopathic schools graduate more students who decide to work in primary care and in rural areas.
The Cherokee Reservation spreads across roughly 7,000 square miles in eastern Oklahoma. It's home to about 150,000 Cherokee citizens, most of whom live in rural areas, said Principal Chief Chuck Hoskin Jr. Hoskin grew up in a small town that was once served by a doctor who traveled across the reservation, treating patients in a recreational vehicle.
The Cherokee Nation now operates 10 hospitals and clinics to ensure that all citizens live within a 30-minute drive of care. Hoskin said this means the reservation has better access to health care than much of rural America.
"There are not many communities in this country in which you would see that sort of investment," he said.
Still, access to care remains challenging for some rural residents on the reservation, Bray said. The reservation has significant poverty, and some people lack cars or cell or internet service. Cherokee residents have high rates of diabetes, obesity, addiction, and heart disease, Bray said.
The Cherokee Nation spent $40 million of its own revenue — including from casinos and federal contracts — to construct the college building on its medical campus, which includes a hospital and outpatient center. The tribe is responsible for maintenance, while Oklahoma State pays for the faculty and equipment.
The college building features large windows, Cherokee symbols etched into concrete, and orange accents — a shoutout to the university's colors. Inside, signs are written in both English and Cherokee.
On a recent afternoon, students practiced osteopathic manipulative therapy on one another inside a classroom. Down the hall in a simulation center, lifelike patient models lay with their mouths agape on hospital beds.
Next door at the hospital, medical student Mackenzie Hattabaugh checked on Chyna Chupco, who was recovering after giving birth to her first baby. Hattabaugh asked Chupco questions to make sure she was reaching recovery milestones and not showing signs of complications. She also felt Chupco's uterus to make sure it was healing properly.
Hattabaugh, who is not Native American, grew up in Muldrow, a town of about 3,300 on the reservation. The 24-year-old said the town sometimes had a doctor but never a hospital or urgent care clinic.
"I would like to go back to around my hometown and perhaps be a staple in my community, to become a physician and provide people health care who usually have to drive 30 minutes or more to get it," said Hattabaugh, a first-generation college student.
Students said studying at the Tahlequah campus prepares them to work in tribal and rural areas in ways that might not be possible at other medical schools.
Charlee Dawson, a 27-year-old medical student and citizen of the Cherokee Nation, said rotations within the Indian Health Service help students understand how the system's care and complex billing procedures differ from those of other health facilities.
The program helps students understand what health problems are more common among Native Americans, Gatewood said. She said her previous medical school taught students about the high rate of diabetes among Black patients, but not the rate for Native Americans, which is the highest of all U.S. racial groups.
The students also said they've learned to ask Indigenous patients not just what pharmaceutical drugs and supplements they're taking, but also whether they're using traditional medications or working with a healer.
This has led some Indigenous people to mistrust the health care system. But several of the Tahlequah students said they've bonded with patients who share similar backgrounds.
"It really comforts patients to know that someone like them is taking care of them," said Caitlin Cosby, a member of the Choctaw Nation.
Cosby, 24, said she once had a patient who asked, "‘Are you Native?' And I said, ‘I am!'"
For millions of Americans who buy their own health insurance through the Affordable Care Act marketplace, the end of the year brings a day of reckoning: It's time to compare benefits and prices and change to a new plan or enroll for the first time.
Open enrollment starts Nov. 1 for the ACA's federal and state exchanges. Consumers can go online, call, or seek help from a broker or other assister to learn their 2024 coverage options, calculate their potential subsidies, or change plans.
In most states, open enrollment lasts through Jan. 15, although some states have different time periods. California's, for example, is longer, open until Jan. 31, but Idaho's runs from Oct. 15 to Dec. 15. In most states enrollment must occur by Dec. 15 to get coverage that begins Jan. 1.
Health policy experts and brokers recommend all ACA policyholders at least look at next year's options, because prices — and the doctors and hospitals in plans' networks — may have changed.
It Could Be Another Record Year
ACA plans are now well entrenched — an estimated 16.3 million people signed up during open enrollment last year. This year may see even larger numbers. Enhanced subsidies first approved during the height of the covid pandemic remain available, and some states have boosted financial help in other ways.
In addition, millions of people nationwide are losing Medicaid coverage as states reassess their eligibility for the first time since early in the pandemic. Many of those ousted could be eligible for an ACA plan. They can sign up as soon as they know they're losing Medicaid coverage — even outside of the open enrollment season.
Another important caution: Don't wait until the last minute, especially if you are seeking help from a broker. Consumers this year will be asked to certify that they voluntarily agreed to brokers' assistance and that their income and other information provided by brokers is accurate.
It's a good protection for both parties, said broker Joshua Brooker, founder of PA Health Advocates in Pennsylvania. But brokers are concerned the requirement could cause delays, especially if clients wait until right before the end of open enrollment to apply.
"Brokers will need to stop what they are doing right at the end before they click 'submit' and wait for the consumer to sign a statement saying they reviewed the policy," Brooker said.
Premiums Are Changing
While some health plans are lowering premiums for next year, many are increasing them, often by 2% to 10%, according to a Peterson-KFF Health System Tracker initial review of rate requests. The median increase, based on a weighted average across its plans for each insurer, was 6%.
Premiums, and whether they go up or down, vary widely by region and insurer.
Experts say that's a big reason to log on to the federal website, healthcare.gov, in the 32 states that use it, or on to the insurance marketplace for one of the 18 states and the District of Columbia that run their own. Changing insurers might mean a lower premium.
"It's very localized," said Sabrina Corlette, research professor and co-director of the Center on Health Insurance Reforms at Georgetown University. "People should shop to maximize their premium tax credit, although that might require not only changing to a new insurance plan, but potentially also a new network of providers."
Most people buying their own coverage qualify for the tax credit, which is a subsidy to offset some, or even all, of their monthly premium. Subsidies are based partly on the premium of the second-lowest-priced silver-level plan in a region. When those go up or down, possibly from a new insurer entering the market with low initial rates, it affects the subsidy amount.
Household income is also a factor. Subsidies are on a sliding scale based on income.
Subsidies were enhanced during the pandemic, both to increase the amount enrollees could receive and to allow more families to qualify. Those enhancements were extended through 2025 by President Joe Biden's Inflation Reduction Act, passed last year.
In addition to the premium subsidies, most ACA enrollees qualify for reduced deductibles, copayments, and other types of cost sharing if their income is no more than 2.5 times the federal poverty level, or about $75,000 for a family of four or $36,450 for a single-person household.
ACA plans are grouped into colored tiers — bronze, silver, gold, and platinum — based largely on how much cost sharing they require. Bronze plans offer the lowest premiums but usually the highest copayments and deductibles. Platinum plans carry the highest premiums but the lowest out-of-pocket expenses for care.
Cost-sharing reductions are available only in silver-level plans and are more generous for those on the lower end of the income scale. New this year: To help more people qualify, the federal marketplace will automatically switch eligible people to a silver plan for next year if they are currently enrolled in a bronze plan, as long as the enrollee has not made an adjustment in coverage themselves.
There are safeguards built in, said insurance expert and broker Louise Norris, so that people are auto-enrolled in a plan with the same network of medical providers and a similar or lower premium. Additionally, nine of the states that run their own marketplaces — California, Colorado, Connecticut, Maryland, Massachusetts, New Jersey, New Mexico, Vermont, and Washington — have enhanced their cost-sharing reduction programs by extending eligibility or increasing benefits.
Some 26-Year-Olds Will Get to Stay on Parents' Plans Longer
Happy birthday! Existing federal marketplace rules allowing adult children to stay on their parents' plans though the calendar year in which they turn 26, rather than lose coverage on their 26th birthday, were codified into regulation.
States that run their own markets can set similar rules, and some already allow for longer periods on a parent's plan.
Networks May Still Be Small
Insurance plans often try to reduce premiums by partnering with a limited set of doctors, hospitals, and other providers. Those can change year to year, which is why insurance experts like Norris say enrollees should always check their plans during open enrollment to ensure their preferred physicians and medical centers are included in the network.
It's also a good idea, Norris said, to look closely for changes in prescription drug coverage or copayments.
"The general message is, don't assume anything and make sure you check to see who is in the network," Norris said.
Last year, the Biden administration set rules requiring health plans to have enough in-network providers to meet specific driving time and distance standards. A proposal to limit how long patients wait for a routine appointment has been delayed until 2025.
What We Still Don't Know
A few things remain uncertain as the end of the year approaches. For example, the Biden administration proposed this summer to reverse a Trump-era rule that allowed short-term insurance plans to be sold for coverage periods of up to a year.
Short-term plans are not ACA-compliant, and many have fewer benefits and can set restrictions on coverage, including barring people with health conditions from purchasing them. As a result, they are far less expensive than ACA plans. The Biden proposal would restrict them to coverage periods of four months, but the rule isn't final.
Also pending: a final rule that would allow people to sign up for ACA coverage if they were brought to the U.S. as children by parents lacking permanent legal status — a group known as "Dreamers."
Christine Rogers of Wake Forest, North Carolina, didn't hesitate when she was asked to fill out a routine mental health questionnaire during a checkup last November.
Her answers on the form led her primary care doctor to ask about depression and her mood, and Rogers said she answered honestly.
"It was a horrible year. I lost my mom," Rogers said she told her physician.
After what Rogers estimates was a five-minute conversation about depression, the visit wrapped up. She said her doctor did not recommend treatment nor refer her for counseling.
"It's not like anything I told her triggered, ‘Oh my goodness, I'm going to prescribe you medication,'" she said.
Then the bill came.
The Patient: Christine Rogers, 60, a public relations/communications worker who is insured by Cigna Healthcare through her job.
Medical Services: An annual wellness visit, which included typical blood tests, as well as a depression screening and discussion with a physician.
Service Provider: WakeMed Physician Practices, part of WakeMed Health & Hospitals, a Raleigh-based, tax-exempt system with three acute care hospitals, outpatient centers, and hundreds of physicians across a range of specialties.
Total Bill: $487, which included a $331 wellness visit and a separate $156 charge for what was billed as a 20- to 29-minute consultation with her physician. Her insurer paid $419.93, leaving Rogers with a $67.07 charge related to the consultation.
What Gives: Rogers said the bill came as a surprise because she knows annual wellness checks are typically covered without patient cost sharing as preventive care under the Affordable Care Act. And as part of an annual physical, patients routinely fill out a health questionnaire, which may cover mental health topics.
But there is a catch: Not all care that may be provided during a wellness visit counts as no-cost preventive care under federal guidelines. If a health issue arises during a checkup that prompts discussion or treatment — say, an unusual mole or heart palpitations — that consult can be billed separately, and the patient may owe a copayment or deductible charge for that part of the visit.
In Rogers' case, a brief chat with her doctor about mental health triggered an additional visit charge — and a bill she was expected to pay.
Rogers said she didn't broach the subject of depression during her checkup. She was asked when she checked in to fill out the questionnaire, she said — and then the doctor brought it up during her exam.
The Affordable Care Act requires insurers to cover a variety of preventive services without a patient paying out-of-pocket, with the idea that such care might prevent problems or find them early, when they are more treatable and less costly.
The federal government lists dozens of services that are classified as no-cost-sharing preventive care for adults and children, such as cancer screenings, certain vaccinations, and other services recommended by either of two federal agencies or the U.S. Preventive Services Task Force, an independent group of experts in disease prevention.
Depression screening is covered as preventive care for adults, including when they're pregnant or in the postpartum phase.
Rogers requested an itemized bill from her doctor's practice, which is part of WakeMed Physician Practices. It showed a charge for the wellness visit (free for her), as well as a separate charge for a 20- to 29-minute office visit. Earlier, Rogers said, she had discussed the initial bill with the office manager at her doctor's office, who told her the separate charge, roughly $67, was for discussing her questionnaire results with her doctor.
For Rogers, it wasn't so much about the $67 she owed for the visit, as it was a matter of principle. The separate change, she said, was "disingenuous" because she was specifically asked about her mental health.
Also, annual physicals are intended to nip health problems in the bud, which sometimes requires a few more minutes of attention — whether to discuss symptoms of depression or palpate an abdomen for digestive issues.
Sabrina Corlette, a research professor and co-director of the Center on Health Insurance Reforms at Georgetown University, agrees the charge seemed a bit over-the-top: Depression screening "is now a recommended part of the annual physical," she said. "Implicit in that is someone looks at answers and makes an assessment, and you should not be charged for that."
Beyond the confusion of being charged for what she thought would be free preventive care, Rogers wondered how the bill was calculated: Her conversation with her doctor about depression did not last that long, she said.
A 20- to 29-minute-visit billing code is commonly used in primary care, reflecting not just the time spent, but also the complexity of the condition or diagnosis, said Yalda Jabbarpour, a family physician in Washington, D.C. She also directs the Robert Graham Center for Policy Studies, which researches primary care in the U.S.
Billing codes exist for other, shorter time frames, though those are rarely used except for the most minimal of services, such as a quick question about a test result, she said.
Physicians said Rogers did the right thing, emphasizing that patients should be honest with their doctors during preventive visits — and not keep silent about issues because they are concerned about potential cost sharing.
"If you have a condition like depression, not only does it affect mental health, but it can have significant impact on your medical health overall," said Stephen Gillaspy, senior director for health and health care financing at the American Psychological Association.
The Resolution: Confused by getting billed for a visit she thought would have no charge, Rogers initially called her doctor's office and spoke with the office manager, who told her the claim submitted to her insurer was coded correctly for her visit. She then called her insurer to question whether a mistake had been made. She said her insurer said no, agreeing that the physician had billed properly.
Rogers paid the bill.
After being contacted by KFF Health News, and with Rogers' permission, the WakeMed health system investigated the bill and said it was handled correctly.
"We do split bills when a service is provided that is above and beyond the preventive components of a physical — in this case, beyond a positive screening for depression," WakeMed spokesperson Kristin Kelly said in an email.
By contrast, Cigna Healthcare, Rogers' insurer, sent her a new explanation of benefits statement after being contacted by KFF Health News. The EOB showed Cigna had zeroed out any cost to Rogers associated with the visit.
Cigna spokesperson Meaghan MacDonald, in a written statement, said the "wellness visit was initially billed incorrectly with two separate visit codes, and has now been resubmitted correctly so there is no cost-share for Ms. Rogers. We are working with the physician to ensure she is refunded appropriately."
The insurer's website says Cigna covers a variety of preventive services without copayment and encourages doctors to counsel patients about depression.
Not long after receiving the new EOB, Rogers said she received a refund of $67.07 from WakeMed.
The Takeaway: While many preventive services are covered under the ACA, the nuances of when a patient pays can be complicated and open to interpretation. So, it is not uncommon for medical practices to narrowly interpret the term "preventive service."
That creates a billing minefield for patients. If you respond on a questionnaire that you sometimes experience heartburn or headaches, most physicians will inquire about your responses to assess the need for treatment. But should that come with an extra charge? Other patients have written to KFF Health News and NPR expressing frustration over being billed for conversations during a checkup.
Additional time spent during a wellness exam discussing or diagnosing a condition or prescribing medication can be considered beyond preventive care and result in separate charges. But if you receive a bill for a preventive service that you expected would be free, request an itemized bill with billing codes. If something seems off, ask the physician's office.
If you're billed for time spent on extra consultation, question it. You know how long the provider spent discussing your health issue better than a billing representative does. Next, reach out to your insurer to protest.
Most important, be honest with your primary care provider during your annual physical.
Bill of the Month is a crowdsourced investigation by KFF Health News and NPR that dissects and explains medical bills. Do you have an interesting medical bill you want to share with us? Tell us about it!
The world is entering a new era of vaccines. Following the success of COVID-19 mRNA shots, scientists have a far greater capacity to tailor shots to a virus's structure, putting a host of new vaccines on the horizon.
The most recent arrivals — as anyone on the airwaves or social media knows — are several new immunizations against respiratory syncytial virus, or RSV.
These shots are welcome since RSV can be dangerous, even deadly, in the very old and very young. But the shots are also expensive — about $300 for those directed at adults, and up to $1,000 for one of the shots, a monoclonal antibody rather than a traditional vaccine, intended for babies. Many older vaccines cost pennies.
So their advent is forcing the United States to face anew questions it has long sidestepped: How much should an immunization that will possibly be given — maybe yearly — to millions of Americans cost to be truly valuable? Also, given the U.S. is one of two countries that permit direct advertising to consumers: How can we ensure the shots get into the arms of people who will truly benefit and not be given, at great expense, to those who will not?
Already, ads on televisions and social media show active retirees playing pickleball or going to art galleries whose lives are "cut short by RSV." This explains the lines for the shot at my local pharmacy.
But indiscriminate use of expensive shots could strain both public and private insurers' already tight budgets.
Other developed countries have deliberate strategies for deciding which vulnerable groups need a particular vaccine and how much to pay for it. The U.S. does not, and as specialized vaccines proliferate, public programs and private insurers will need to grapple with how to use and finance shots that can be hugely beneficial for some but will waste precious health dollars if taken by all.
A seasonal viral illness, RSV can cause hospitalization or, in rare cases, death in babies and in people age 75 or older, as well as those with serious underlying medical conditions such as heart disease or cancer. For most people who get RSV, it plays out as a cold; you've likely had RSV without knowing it.
But RSV puts about 2% of babies under age 1 in the hospital and kills between 100 and 300 of those under 6 months, because their immune systems are immature and their airways too narrow to tolerate the inflammation. Merely having a bad case of RSV in young childhood increases the risk of long-term asthma.
That's why Barney Graham, the scientist who spent decades at the government's National Institutes for Health perfecting the basic science that led to the current shots, said: "The most obvious use is in infants," not adults.
That's also why European countries trying to figure out how best to use these vaccines without breaking the bank focused first on babies and determining a sensible price. Though more of the very old may die of RSV, the years of life lost are much greater for the very young. (Babies can get the monoclonal antibody shot or gain protection through a traditional vaccine given to the mother near the end of pregnancy, conferring immunity through the womb.)
A consortium of European experts led by Philippe Beutels, a professor in health economics at the University of Antwerp in Belgium, calculated that the shots would only be “worth it” in terms of the lives saved and hospitalizations averted in infants if the price were under about $80, he said in a phone interview. That's because almost all babies make it through RSV with supportive care.
The calculation will be used by countries such as Belgium, England, Denmark, Finland, and the Netherlands to negotiate a set price for the two infant shots, followed by decisions on which version should be offered, depending partly on which is more affordable.
They have not yet considered how to distribute the vaccines to adults — considered less pressing — because studies show that RSV rarely causes severe disease in adults who live outside of care settings, such as a nursing home.
Why did the United States and Europe approach the problem from opposite directions?
In the U.S., there was a financial incentive: Roughly 3.7 million babies are born each year, while there are about 75 million Americans age 60 and older — the group for whom the two adult vaccines were approved. And about half of children get their vaccines through the Vaccines for Children program, which negotiates discounted prices.
Also, babies can get vaccinated only by their clinicians. Adults can walk into pharmacies for vaccinations, and pharmacies are only too happy to have the business.
But which older adults truly benefit from the shot? The two manufacturers of the adult vaccines, GSK and Pfizer, conducted their studies presented to the FDA for approval in a population of generally healthy people 60 and older, so that's the group to whom they may be marketed. And marketed they are, even though the studies didn't show the shots staved off hospitalization or death in people ages 60 to 75.
That led to what some have called a "narrow" endorsement from the Centers for Disease Control and Prevention's Advisory Committee on Immunization Practices for people 60 to 75: Patients in that age range could get the shot after "shared clinical decision-making" with a health provider.
It is likely that because of this fuzzy recommendation, some Americans 60 and over with commercial insurance are finding that their insurers won't cover it. Under Obamacare, insurers are generally required to cover at no cost vaccines that are recommended by the ACIP; however, if a provider recommends vaccination, then it must be covered by insurance.
There are better and more equitable ways to steer the shots into the arms of those who need it, rather than simply administering it to those who have the “right” insurance or, swayed by advertising, can pay. For example, insurers, including Medicare, could be required to cover only those ages 60 to 75 who have a prescription from a doctor, indicating shared decision-making has occurred.
Finally, during the pandemic emergency, the federal government purchased all COVID-19 vaccines in bulk at a negotiated price, initially below $20 a shot, and distributed them nationally. If, to protect public health, we want vaccines to get into the arms of all who benefit, that's a more cohesive strategy than the patchwork one used now.
Vaccines are miraculous, and it's great news that they now exist to prevent serious illness and death from RSV. But using such novel vaccines wisely — directing them to the people who need them at a price they can afford — will be key. Otherwise, the cost to the health system, and to patients, could undermine this big medical win.
With his company's health costs soaring and his workers struggling with high blood pressure and other medical conditions, Winston Griffin, CEO of Laurel Grocery Co., knew his company had to do something.
So the London, Kentucky, wholesaler opened a health clinic.
"Our margins are tiny, so every expense is important," Griffin said. The clinic, he said, has helped lower the company's health costs and reduce employee sick leave.
Large employers have run clinics for decades. At Laurel Grocery's in-house clinic, workers can get checkups, blood tests, and other primary care needs fulfilled free, without leaving the workplace. But Griffin's move is notable because of his company's size: only about 250 employees.
Nationwide, a modest number of small- and medium-size employers have set up their own health clinics at or near their workplaces, according to surveys and interviews with corporate vendors and consulting firms that help employers open such facilities.
Improving employee health and lowering health costs are among the main advantages employers cite for running clinics. But some companies also say they're helping to blunt the nation's shortage of primary care doctors and eliminate the hassle of finding and getting care.
"Why did we do this? So my employees would not drop dead on the floor," Griffin said. "We had such an unhealthy workforce, and drastic times called for drastic measures."
KFF's annual survey of workplace benefits this year found that about 20% of employers who offer health insurance and have 200 to 999 workers provide on-site or near-site clinics. That compares with 30% or better for employers with 1,000 or more workers.
Those figures have been relatively steady in recent years, surveys show.
And U.S. employers reported the biggest increase this year in annual family premiums for their sponsored health plans in a decade — an average jump of 7% to nearly $24,000, according to the KFF survey, released Oct. 18. That spike may intensify interest among business leaders in curbing underlying health costs, including by exploring delivering care at workplaces.
Employers don't require their workers to use their clinics but typically provide incentives such as free or reduced copayments. Griffin offered employees $150 to get a physical at the clinic; 90% took advantage of the deal, he said.
Employer clinics could alleviate the rising demand for primary care. A far lower proportion of U.S. doctors are generalists than in other advanced economies, according to data compiled by the Peterson Center on Healthcare and KFF.
For patients, frustrating wait times are one result. A recent survey by a physician staffing firm found it now takes an average of three weeks to get in to see a family doctor.
In 2022, Franklin International, a manufacturer of adhesives in Columbus, Ohio, began offering its 450 workers the option to use local primary care clinics managed by Marathon Health, one of about a dozen companies that set up on-site or near-site health centers for employers.
Franklin employees pay nothing at the clinics compared with a $50 copayment to see an outside doctor in their insurance network. So far about 30% of its workers use the Marathon clinics, said Doug Reys, Franklin's manager of compensation benefits.
"We heard about the difficulty employees had to get in to a doctor," he said. They would call providers who said they were accepting new patients but would still wait months for an appointment, he added.
At the Marathon clinics — which are shared by other employers — workers now can see a provider within a day, he said.
That's good for employees — and for the company's recruiting efforts. "It is a good benefit to say you can get free primary care," Reys said.
Not all employers that have explored opening their own clinics have seen the value. In 2020, the agency that oversees health benefits for Wisconsin state employees opted against the on-site model after a review of experiences by similar agencies in Indiana and Kentucky found it didn't save money or constrain health insurance premiums.
Kara Speer, national practice leader for consulting firm WTW, said potential cost savings from employer-run clinics can take years to accrue as employees shift from pricier hospital emergency rooms and urgent care clinics. And it can be difficult to measure whether clinics control costs by improving workers' health through preventive screenings and checkups, she said.
Kathy Vicars, a senior vice president at Marathon Health, said about 25% of its 250 clients are firms with fewer than 500 people. She said Marathon's clinics help drive down costs and help employees get easier access to doctors who spend more time with them during appointments. Her company helps employers manage workers with chronic diseases better and redirects care from urgent care centers and ERs, she said.
Hospitals have also sought to get into the business of running on-site clinics for employers, but some potential clients question whether those health systems have incentives to funnel workers to their own hospitals and specialists.
At Laurel Grocery, Griffin said he knows many of his employees don't regularly exercise and have poor diets — a reflection of the overall population in the region. Health screenings performed by a local hospital over the years found many residents with high cholesterol and high blood pressure. "Nothing tended to change," he said.
Laurel Grocery contracts with a local hospital for about $100,000 a year to manage its clinic, including having a physician assistant on-site three days a week. Laurel Grocery does not have access to any employee health records.
He said the clinic has saved money by reducing unnecessary ER use and reducing hospitalizations. "It's been way more successful than I thought it would" be, he said.
The clinic is about a three-minute walk from Kip Faulhaber's office. Faulhaber, a senior vice president at Laurel Grocer who is 73, said he goes in every week for a vitamin B12 shot to treat a deficiency. He also turns to the clinic for an annual physical, vaccinations, and when he has a sinus infection but doesn't want to wait several days to see his regular physician.
For the first time, people worried about their risk of Alzheimer's disease can go online, order a blood test, and receive results in the privacy of their homes.
This might seem appealing on the surface, but the development has Alzheimer's researchers and clinicians up in arms.
The Quest Diagnostics blood test, AD-Detect, measures elevated levels of amyloid-beta proteins, a signature characteristic of Alzheimer's. Introduced in late July, the test is targeted primarily at people 50 and older who suspect their memory and thinking might be impaired and people with a family history of Alzheimer's or genetic risks for the condition.
Given Alzheimer's is among the most feared of all medical conditions, along with cancer, this could be a sizable market, indeed. Nearly 7 million older adults in the U.S. have Alzheimer's, and that number is expected to double by 2060 if medical breakthroughs don't occur.
But Alzheimer's researchers and clinicians aren't convinced the Quest test is backed by sound scientific research. The possibility of false-positive results is high, as is the likelihood that older adults won't understand the significance of their results, they say. The test should be taken only under a physician's supervision, if at all, they advise. And, priced originally at $399 (recently discounted to $299) and not covered by insurance, it isn't cheap.
Though blood tests for Alzheimer's are likely to become common in the years ahead, the Alzheimer's Association said it's premature to offer a test of this kind directly to consumers.
For its part, Quest, which also sells direct-to-consumer tests for sexually transmitted diseases and various other conditions, suggests older adults can be trusted to respond responsibly to AD-Detect results. The test is not meant to diagnose Alzheimer's, the company stressed; instead, it's meant to help assess an individual's risk of developing the condition. But under a new, proposed biological definition of Alzheimer's, excess amyloid could automatically trigger a diagnosis of "preclinical" Alzheimer's.
Michael Racke, Quest's medical director of neurology, said individuals who test positive might be inspired to talk to their physicians about cognitive symptoms and seek comprehensive evaluations from dementia specialists. Others may just want to adopt behaviors associated with brain health, such as exercising more and maintaining healthy blood pressure, blood sugar, and cholesterol levels.
"People who do consumer-initiated testing are often very motivated to figure out what they can do to help reduce the risk of disease," he said.
To get the test, a person first needs to go to the AD-Detect test's website and report that they're experiencing mild cognitive decline and have at least one other risk factor. (Self-reported complaints of this kind are often unreliable, experts note.) The order then goes automatically to a doctor paid by Quest, who will order a blood test to be drawn at a Quest laboratory.
Results classifying a person as low, medium, or high risk will be provided on a secure patient portal. Post-test counseling isn't mandatory, but individuals can speak to a physician paid by Quest, if they like. (There is a separate $13 "physician service fee.")
A new poll from the University of Michigan confirms that older adults will take results seriously: Ninety-seven percent of seniors said they would take steps to improve brain health upon receiving a positive result from a blood test, while 77% said they would consider changes to financial or end-of-life plans.
But research scientists and clinicians worry that Quest hasn't published any peer-reviewed studies documenting the test's validity. The company's preliminary data released at the 2022 Alzheimer's Association International Conference in San Diego suggests there's a relatively high chance of false-positive results, said Suzanne Schindler, an associate professor of neurology at Washington University School of Medicine in St. Louis.
That's a significant problem because telling someone they have biological changes associated with Alzheimer's disease is a "big deal and you want to be as accurate as possible," Schindler noted.
Racke said at least three scientific studies giving more details about the AD-Detect test have been submitted to medical journals and might be published by the end of this year.
Experts also question the usefulness of the test since a positive result (indicating abnormal levels of amyloid in the blood) doesn't mean an individual will definitely develop Alzheimer's disease. Amyloid in the brain accumulates slowly over the course of decades, typically beginning in middle age, and becomes more common as people age.
"This test gives you a fuzzy answer. We don't know whether you're going to get dementia, or when symptoms might begin, or, really, how high the risk is for any individual," said Meera Sheffrin, medical director of the Senior Care clinic at Stanford Healthcare.
Also, cognitive symptoms that prompt someone to take the test might be due to a wide variety of other causes, including mini-strokes, sleep apnea, thyroid problems, vitamin B12 deficiency, or medication interactions. If an older adult becomes anxious, depressed, or hopeless upon learning they're at risk for Alzheimer's — another source of concern — "they may not go for further evaluation and seek appropriate care," said Rebecca Edelmayer, senior director of scientific engagement at the Alzheimer's Association.
The University of Michigan poll confirms the potential for misunderstanding. Upon receiving a positive result from a blood test, 74% of seniors said they would believe they were likely to develop Alzheimer's and 64% said they would be likely to experience significant distress.
Because the science behind blood tests for Alzheimer's is still developing and because "patients may not really understand the uncertainty of test results," Edelmayer said, the Alzheimer's Association "does not endorse the use of the AD-Detect test by consumers."
Quest's blood test is one of several developments altering the landscape of Alzheimer's care in the United States. In early July, the FDA granted full approval to Leqembi, an anti-amyloid therapy that slightly slows cognitive decline in people with mild cognitive impairment and early-stage Alzheimer's. Early detection of cognitive symptoms and diagnosis of cognitive dysfunction have assumed greater importance now that this disease-modifying drug is available.
Also in July, a work group convened by the National Institute on Aging and the Alzheimer's Association proposed a new definition of Alzheimer's disease to be used in clinical practice.
Previously, Alzheimer's could be diagnosed only when there was evidence of underlying brain pathology (amyloid plaques and tau tangles) as well as cognitive symptoms (memory loss, poor judgment, disorientation, among others) and accompanying impairments (difficulty with managing finances, wandering, problems with self-care, and more). Under the new definition, Alzheimer's would be defined purely on a biological basis, as a "continuum that is first evident with the appearance of brain pathologic changes" including amyloid accumulation, according to a draft of the work group's report.
That would mean "you can get a positive result from the Quest test and be diagnosed with Alzheimer's disease if these guidelines are adopted, even if you're cognitively normal," cautioned Eric Widera, a professor of medicine at the University of California-San Francisco.
Demand for follow-up evaluations by dementia specialists is likely to be high and contribute to already-long waits for care, he suggested.
Additional concerns about the test relate to safeguarding privacy and the potential for discrimination. No federal laws protect people who receive Alzheimer's biomarker results from discriminatory practices, such as employment discrimination or the denial of life, disability, or long-term care insurance. (The Genetic Information Nondiscrimination Act applies only to genetic tests.) And "laws that normally protect the privacy of health information do not apply in this space," said Emily Largent, an assistant professor of medical ethics and health policy at the University of Pennsylvania's Perelman School of Medicine.
Notably, HIPAA, the Health Insurance Portability and Accountability Act, doesn't extend to laboratory tests marketed directly to consumers.
The bottom line: Before taking a test, "older adults need to ask themselves, ‘Why do I want to know this? What will I do with the information? How will I react? What would I change in the future?'" said C. Munro Cullum, a neuropsychologist and distinguished professor of clinical psychology at the University of Texas Southwestern Medical Center. "This test needs to be used very cautiously and with great forethought."
We're eager to hear from readers about questions you'd like answered, problems you've been having with your care, and advice you need in dealing with the health care system. Visit kffhealthnews.org/columnists to submit your requests or tips.
SACRAMENTO, Calif. — California continues to burnish its reputation as a progressive state for health policy as Gov. Gavin Newsom signed bills expanding paid sick leave, adding bereavement leave for miscarriages, and boosting wages for health workers.
Newsom blessed a rare agreement between labor and the health industry to gradually phase in a nation-leading $25-an-hour statewide minimum wage for health workers. Estimates based on earlier versions of the bill found it would increase healthcare costs by billions of dollars each year and put pressure on the state's Medicaid program to raise reimbursement rates for long-term care to maintain patients' access to services. Other new laws aim to strengthen reproductive rights, as well as patient protections against errant doctors and pharmacists and surprise ambulance bills.
Still, in a possible sign of his national ambitions and experience as a businessperson and father, the Democrat tempered the bill-signing season by vetoing free condoms in schools and possession of psychedelic mushrooms.
He rejected decriminalizing such hallucinogens even as he supported their therapeutic potential as "an exciting frontier." He urged lawmakers to try again next year, this time adding specific treatment guidelines including recommended doses and protections for people with underlying psychoses. The bill's lead author, state Sen. Scott Wiener of San Francisco, had introduced the proposal amid successful decriminalization efforts in Colorado, Oregon, and some cities, saying veterans and others suffering from post-traumatic stress disorder and depression should not be penalized for seeking relief.
Newsom also shot down a $35 price cap for a 30-day supply of insulin in favor of his own price-cutting efforts, touting his administration's $50 million contract to begin sourcing its own insulin as early as next year. He argued this approach would avoid indirect price hikes for consumers that could come in the form of higher premiums to cover cheaper insulin.
The governor similarly showed caution in vetoing health and safety protections for domestic workers, arguing that "private households and families cannot be regulated in the exact same manner as traditional businesses."
The new laws will take effect in 2024 unless otherwise noted:
Sick Days
California workers will be entitled to five paid sick days a year under SB 616, by state Sen. Lena Gonzalez, a Democrat from Long Beach. That's up from the three days required in California since 2014, but short of the seven days Gonzalez originally sought. Advocates say workers shouldn't have to show up sick, potentially spreading illness, because they can't afford to stay home. But the California Chamber of Commerce included the bill on its annual job killer list and said it would harm struggling small businesses.
Miscarriage and Failed Adoption Leave
Parents who experience miscarriages, stillbirths, failed adoptions, or a breakdown in a surrogate pregnancy agreement will all be entitled to bereavement leave under SB 848. The bill, by state Sen. Susan Rubio, a Democrat from the San Gabriel Valley, will include unpaid reproductive loss leave under the state's existing law allowing up to five days of bereavement leave upon the death of a family member. She called reproductive losses "one of the most traumatizing events a person can experience," noting that Illinois and Utah enacted similar laws in 2022. The bill applies to companies with five or more employees.
Abortion Protections
A year after the U.S. Supreme Court overturned Roe v. Wade, Newsom signed nine abortion-related laws, adding to the strong protections for the procedure that California lawmakers adopted a year ago. Among them is SB 345, which increases protections for medical providers who live in California but mail abortion pills or gender-related medications to states where they are illegal. The bill's lead author, state Sen. Nancy Skinner, a Democrat from Berkeley, said in a statement that the laws strengthen California's position "as the national leader for reproductive freedom." Another bill, AB 1646, by Assembly member Stephanie Nguyen, a Democrat from Elk Grove, allows doctors from other states to receive abortion training in California without having to obtain a California medical license.
Behavioral Health Funding
Voters will get a direct say in March on Proposition 1, Newsom's key behavioral health initiative. Having signed a bipartisan package of bills, Newsom will ask voters to approve billions of dollars aimed at alleviating California's seemingly incorrigible homelessness crisis. He says that represents a paradigm shift in how California addresses the dilemma, but the proposition is opposed by those worried about expanding involuntary treatment and diverting funding from existing community-based programs. He also signed SB 43, expanding the state's conservatorship law to make it easier to force people into treatment for mental illness or addiction.
Medical Licensing Fees
The Medical Board of California will be required to follow new procedures while investigating complaints, while doctors will pay higher licensing fees to help fund those investigations. SB 815, by Sen. Richard Roth, a Riverside Democrat, mandates the new complaint procedures amid criticism of the board by patient advocates, who say bad doctors often escape sanction. It will gradually boost the license renewal fee to $1,255 every two years, up from $863 currently. It also repeals AB 2098, passed last year, that said it is unprofessional conduct for doctors to spread misinformation or disinformation related to COVID-19. The law was entangled in multiple lawsuits with conflicting rulings, including one by a federal judge who called it "unconstitutionally vague."
Pharmacy Errors
Medication errors harm at least 1.5 million Americans annually and are among the most common medical errors, according to the National Academy of Medicine. In California, they are the top violation resulting in a citation. AB 1286, by Assembly member Matt Haney, a Democrat from San Francisco, imposes what he said is a first-in-the-nation requirement that retail pharmacies report every error. It also gives the pharmacist in charge at each store the authority to increase staffing and the duty to inform the store's management of dangerous conditions. The California State Board of Pharmacy can close a pharmacy if the conditions aren't improved.
Surprise Ambulance Bills
Patients who call for an ambulance can sometimes receive "surprise bills" topping $1,000, according to Health Access California. AB 716, by Assembly member Tasha Boerner, a Democrat from Encinitas, protects consumers from being charged out-of-network costs for ambulance services and uninsured Californians from being charged what she calls inflated ambulance rates. An analysis by the California Health Benefits Review Program said that would require health plans and insurers to pay more for out-of-network services.
Lifesaving Medications
AB 1651, by Assembly member Kate Sanchez, a Republican from Rancho Santa Margarita, will require schools to have emergency epinephrine auto-injectors for use by school nurses or trained volunteers to treat life-threatening anaphylactic reactions. More than 15% of children with food allergies have had a reaction at school, according to the Latino Food Allergy Network, which sought the bill.
Food Safety
By 2027, California will become the first U.S. state to ban four chemicals widely used in processed food and drinks, following the lead of the European Union and other nations. AB 418, by Democratic Assembly members Jesse Gabriel and Buffy Wicks, initially drew headlines because it would have banned titanium dioxide, which is used in Skittles, but that chemical was dropped from the bill. Opponents said the U.S. and California already have sufficient food safety and food labeling requirements. Newsom and the bill's supporters chided the Food and Drug Administration for failing to take action.