Medicaid enrollment fell by 0.6 percent in 2018 — its first drop since 2007 — due to the strong economy and increased efforts in some states to verify eligibility, a new report finds.
But costs continue to go up. Total Medicaid spending rose 4.2 percent in 2018, same as a year ago, as a result of rising costs for drugs, long-term care and mental health services, according to the study released Thursday by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)
States expect total Medicaid spending growth to accelerate modestly to 5.3 percent in 2019 as enrollment increases by about 1 percent, according to the annual survey of state Medicaid directors.
About 73 million people were enrolled in Medicaid in August, according to a federal report released Wednesday.
Medicaid, the state-federal health insurance program for low-income Americans, has seen its rolls soar in the past decade — initially as a result of massive job losses during the Great Recession and in recent years when dozens of states expanded eligibility using federal financing provided by the Affordable Care Act. Thirty-three states expanded their programs to cover people with incomes under 138 percent of the federal poverty level, or an income of about $16,750 for an individual in 2018.
Medicaid spending and enrollment typically rise during economic downturns as more people lose jobs and health benefits. When the economy is humming, Medicaid enrollment flattens as more people get back to work and can get coverage at work or can afford to buy it on their own. The national unemployment rate was 3.7 percent in September, the lowest since 1969.
The falling unemployment rate is the main reason for the drop in Medicaid enrollment, but some states have reduced their rolls by requiring adults and families to verify their eligibility. Arkansas, for example, has cut thousands of people after instituting new steps to confirm eligibility.
The brightening economic outlook for states has led many to increase benefits to enrollees and payment rates for health providers.
"A total of 19 states expanded or enhanced covered benefits in fiscal 2018 and 24 states plan to add or enhance benefits for the current fiscal year, which for most states started in July," the Kaiser report said. "The most common benefit enhancements reported were for mental health and substance abuse services. A handful of states reported expansions related to dental services, telehealth, physical or occupational therapies and home visiting services for pregnant women."
A dozen states increased pay to dentists and 18 states added to primary care doctors' reimbursements for fiscal year 2019.
Medicaid covers about 20 percent of U.S. residents and accounts for nearly one-sixth of health care expenditures. Nearly half of enrollees are children.
Overall, the federal government pays about 62 percent of Medicaid costs with state's picking up the rest. Poorer states get a higher federal match rate.
Seventeen Republican-controlled states have not expanded Medicaid. For individuals accepted into the program as part of the ACA expansion, the federal government paid the full cost of coverage from 2014 through 2016. It will pay no less than 90 percent thereafter.
In 2018, the states' share of spending rose 4.9 percent. This was the first full year that states were responsible for part of the cost of the expansion. States expect their spending will grow about 3.5 percent in 2019.
Robin Rudowitz, one of the authors of the study and associate director of the Kaiser Commission on Medicaid and the Uninsured, said the survey found many states were using Medicaid to address the opioid crisis by expanding benefits for substance disorders and also by implementing tougher restrictions on prescriptions.
"Almost every governor wants to do something, and Medicaid is generally a large part of it," she said.
While the Trump administration's approval of work requirements for some adults on Medicaid has generated controversy over the past year, the report shows that states are making many other changes to the program, such as increasing benefits and changing how it pays providers to get better value.
Last year, nearly 60 percent of Maine residents voted to expand the state's Medicaid program — an option provided by the Affordable Care Act that would extend health insurance to tens of thousands of the state's low-income people.
But the state's Republican governor, Paul LePage, a longtime opponent of Medicaid expansion, has refused to implement the policy because he doesn't want to raise taxes to pay the state's share of the cost.
The impasse highlights how the intense political push and pull over Medicaid expansion persists even when voters bypass legislators and decide the issue directly at the ballot box. Nevertheless, four more states — Idaho, Montana, Nebraska and Utah — will give voters in November's elections the opportunity to resolve the dispute.
"It's always treacherous" for politicians to raise taxes, said Matt Salo, who heads the National Association of Medicaid Directors. "But there are ways around it. You can figure out ways that are politically palatable."
When the ACA's Medicaid expansion took effect in 2014, proponents say, it set up an enticing deal. It allowed states to cover people with incomes up to 138 percent of the federal poverty level, including childless single adults.
The federal government paid the entire cost of the new enrollees. In 2017, states were to take on 5 percent of those costs. By 2020, that amount will increase to 10 percent.
States that didn't pursue the expansion pay as much as half the cost of coverage. And, in 2018, median eligibility for a family of four was 43 percent of the poverty level, or about $10,800. No childless adults were eligible.
So far, 33 states plus the District of Columbia have opted to expand, extending coverage to almost 12 million Americans, according to federal estimates last year. In those states, the expense ranges from tens of millions of dollars to hundreds of millions.
Rather than being a cash drain, many health policy researchers and economists note, expansion has generally boosted state economies, with higher employment, reduced state spending on health care services for the uninsured and consumer spending elsewhere that would have gone to health care.
"The state savings are so significant, they make it much more manageable," said Adam Searing, an associate professor of practice at Georgetown University's Center for Children and Families. "The issue of how it gets paid for — it's still an important issue, but it's not as front and center."
Different approaches work for different states, Salo said, and all invite political complications.
In Montana, voters are considering Initiative 185, a ballot question that would continue the state's Medicaid expansion and fund it by increasing what is known as a "sin tax" on tobacco products, including electronic cigarettes.
It's a counterintuitive double whammy in such a conservative state: persuading voters first to favor an Obamacare policy, and second to finance it with a tax hike.
By taking on cigarettes, the campaign has incurred the wrath of Big Tobacco, which has put forth more than $12 million in contributions and expenditures to fight the measure.
"Anytime you go up against the tobacco industry, you are mainly going to have them as your opponent," said Amanda Cahill, who directs government relations for Montana's American Heart Association chapter and is part of the "Yes on I-185" campaign.
Voters can be skittish about a tax increase, she said, but many are receptive to the campaign's argument that it pays off in the long term.
New Hampshire took a parallel "sin tax"-type approach. It uses money from an alcohol tax to help fund expansion, a deal negotiated this year.
In Utah, voters will consider newly expanding Medicaid and funding it with a 0.15 percent increase to the state's sales tax, though the hike would exempt groceries. Current polling suggests strong voter support. Nebraska and Idaho also have Medicaid expansion on the ballot, though they would punt the funding question to state legislatures.
Other states have tried a different strategy: shielding consumers from direct taxes and instead financing expansion through taxes on industry players that benefit from Medicaid expansion. The most notable example: hospitals. For these facilities, reducing the number of uninsured, low-income people reduces the burden of uncompensated care and improves their bottom line. Research from states that have already expanded Medicaid supports this idea.
Virginia, Oregon and Colorado already have such taxes or fees in place. (Oregon voters in January approved a tax on both health insurance and hospitals to fund expansion.)
But it hasn't been easy. Virginia's legislature voted this summer to expand Medicaid eligibility after failing five times. During Statehouse debates, funding was a "very significant concern," said Michael Cassidy, president of the Commonwealth Institute for Fiscal Analysis, a Richmond-based think tank that has long supported the policy.
Proponents of expansion showed economic projections that Virginia would benefit financially, since fewer uninsured people would need state-funded health services, and the injection of federal cash would boost the state economy.
The legislature eventually approved a tax on hospitals, by garnering support from their trade group, the Virginia Hospital and Healthcare Association. But the path to approval was "quite contentious," Cassidy said. Critics argued the cost was too great and could drive up health care expenses.
Medicaid advocates haven't begun planning ballot initiatives for 2020 yet, but there are six states that haven't expanded eligibility where voters could take on the question directly: Florida, Mississippi, Missouri, Oklahoma, South Dakota and Wyoming.
As political analysts have long argued, the issue isn't entirely about funding. States can surmount that obstacle if there is political will.
"If you're talking about why did certain states not do the expansion, the fear of the cost — while a real issue — has never been within the top three of the actual reasons why they actually didn't do it," Salo said. "It all has been political and ideological."
Medicare-for-all means bringing all Americans under the government's insurance program now reserved for people 65 and over, while single-payer health care would have the government pay everyone's medical bills. But few politicians are speaking precisely.
After decades in the political wilderness, "Medicare-for-all" and single-payer health care are suddenly popular. The words appear in political advertisements and are cheered at campaign rallies — even in deep-red states. They are promoted by a growing number of high-profile Democratic candidates, like Alexandria Ocasio-Cortez in New York and Rep. Beto O'Rourke in Texas.
Republicans are concerned enough that this month President Donald Trump wrote a scathing op-ed essay that portrayed Medicare for all as a threat to older people and to American freedom.
It is not that. But what exactly these proposals mean to many of the people who say they support them remains unclear.
As a renegade candidate for the 2016 Democratic nomination for president, Sen. Bernie Sanders (I-Vt.) opened the door to such drastic reform. Now, with Republicans showing little aptitude for fixing an expensive, dysfunctional health system, more voters, doctors and politicians are walking through it.
More than 120 members of Congress have signed on as co-sponsors of a bill called the Expanded and Improved Medicare for All Act, up from 62 in 2016. And at least 70 have joined Capitol Hill's new Medicare for All Caucus.
But some worry the terms "Medicare-for-all" and "single-payer" are at risk of becoming empty campaign slogans. In precise terms, Medicare-for-all means bringing all Americans under the government's insurance program now reserved for people 65 and over, while single-payer health care would have the government pay everyone's medical bills. But few politicians are speaking precisely.
Celinda Lake, a Democratic pollster, said, "People read into 'Medicare-for-all' what they want to read into it."
For every candidate with a clear proposal in mind, another uses the phrases as a proxy for voter frustration. The risk, some critics say, is that "Medicare-for-all" could become a Democratic version of the Republican "repeal and replace" slogan — a vote-getter that does not translate to political action because there is neither agreement about what it means nor a viable plan.
"If you're on the left, you have to have something on health care to say at town halls," said David Blumenthal, president of the Commonwealth Fund. "So you say this and move on. That's part of the motivation."
Dr. Carol Paris, the president of Physicians for a National Health Program, an advocacy group, said she has fielded a number of calls from candidates asking for tutorials on Medicare-for-all.
"I'm heartened, but not persuaded" that all the high-profile talk will result in any action, she said. She worries about what she called "faux 'Medicare-for-all' plans" that don't live up to the mantra.
Polling highlights health care as a top voter concern, and pressure is building for politicians to take meaningful action that could redress the pain caused by personal health care costs that continue to rise faster than inflation.
Maybe that action would be negotiating lower drug prices or fixing flaws in the insurance system that allow for surprise medical bills and high out-of-pocket costs. Republican candidates mostly continue to bad-mouth "Obamacare" as the root of all problems in American health care (of course, it's not), and some still push to repeal it. They tend to offer only vague assurances that, for example, they will guarantee that people with preexisting conditions can find affordable insurance — proposals that do not withstand expert scrutiny.
But more and more voters seem to think the country needs more radical change.
Yet experts suggest voter support may not withstand warnings of tax increases or changes to employer-sponsored insurance. A 2017 poll from the Kaiser Family Foundation found that support for Medicare-for-all dropped when respondents were told that their taxes might increase or that the government might get "too much control over health care" — a common Republican talking point. (Kaiser Health News is an editorially independent program of the foundation.)
The broader goal — affordable, universal health care — could be achieved by a range of strategies. For models, we can look to nations that have generally achieved better health outcomes, for less money, than the United States.
Canada and Britain come particularly close to true single-payer. Their governments pay medical bills with money raised through taxes and have monopolistic negotiating power over prices. But after that, the systems differ.
In Canada, which is Sanders' inspiration, the government provides health insurance for most medical needs, with no out-of-pocket costs. People can, and often do, buy a second, private plan for any unmet health needs, such as prescription drugs.
Britain goes a step further. Its government owns hospitals and employs many specialists via the National Health Service. A small private system exists, catering mainly to wealthier people seeking faster access to elective procedures.
Other countries achieve universal health care (or nearly so), but without single-payer. France and Germany have kept an insurance system intact but heavily regulate health care, including by setting the prices for medical procedures and drugs, and requiring all citizens to purchase coverage.
These more incremental options have not captured the American imagination to the same extent as Medicare-for-all. But adopting such a system would require the biggest shift, with significant implications for taxes, patient choice, doctors' salaries and hospital revenue.
Enthusiastic politicians sometimes gloss over those consequences. For example, Liz Watson, a Democrat running in Indiana's 9th Congressional District, suggested the impact on doctors' income was not much of a concern, because they would see a "huge recovery" on expenses since they would no longer need to navigate the bureaucracy of insurance paperwork. But analysts across the board agree single-payer would cut revenue for doctors — many say by about 12 percent on average.
And many voters seem confused by the fundamentals. In polling by the Kaiser Family Foundation, about half of Americans said they believed they would be able to keep their current insurance under a single-payer plan, which is not the case.
Optimism without specifics carries risk, as President Barack Obama learned after promising that people wouldn't lose their doctors under the Affordable Care Act. That promise haunted the Obama administration — it was singled out as PolitiFact's "Lie of the Year" in 2013 and is still mocked by members of the Trump White House.
There's also the thorny issue of how Medicare-for-all would affect the thousands of jobs at private insurers. "We have an insurance industry in Omaha, and people say, 'I worry about those jobs,'" said Kara Eastman, a Democrat running on Medicare-for-all in Nebraska's 2nd Congressional District. She suggested people could be retrained, saying there would have to be "repurposing of positions."
Critics of Medicare-for-all, on the other hand, tend to exaggerate the costs of single-payer: "Denmark's top tax bracket is nearly 60 percent!" (True, although that's largely not because of health care.) "Doctors' incomes will drop 40 percent!" (True, specialists in private practice would probably see pay cuts, but primary care doctors could well see an increase.)
Canadians generally pay higher taxes than Americans do — specifically a goods and services tax, and higher taxes on the wealthy. In Germany, working people pay 7.5 percent of income as a contribution toward comprehensive insurance.
But many Americans pay far more than that when you count premiums, deductibles, copayments and out-of-network charges. Estimates of the tax increases required to support a Medicare-for-all or single-payer system are all over the map, depending on how the plan is structured, the prices paid to providers and drugmakers, and the generosity of benefits.
As a politician famously noted, "Nobody knew health care could be so complicated."
Some candidates do have clear proposals in mind. Ocasio-Cortez, for example, running for the House from New York's 14th District, is firm: a single, government-run health plan that covers everyone with no copayments or deductibles and perhaps allows Americans to buy supplemental private coverage. It's the Canadian approach, textbook single-payer.
But many who back Medicare-for-all are vague or open toincremental approaches, like a "public option" that maintains the current insurance structure while allowing people to buy into Medicare.
O'Rourke casts Medicare-for-all as a starting point for discussion. But he said that what matters most is "high-quality, guaranteed universal health care." Getting there, he added, "will inevitably require some compromise" — like a public option. Notably, he has not signed on as a co-sponsor of the Medicare-for-all bill because that plan does not allow for-profit providers to participate.
Jared Golden, a Democratic House candidate from Maine's 2nd District, says in his campaign materials that he favors "something like Medicare for all," but he clarified that at least initially, he would argue to lower the Medicare eligibility age, a change that wonks often call "Medicare for more."
And the Wisconsin Democrat Randy Bryce, who is running to replace Speaker Paul Ryan in the House, said he would support a public option or lowering the eligibility age for Medicare. "I don't want to say that there's only one way to go about it," Bryce said.
But many other candidates — both for Congress and for governorships — who are talking "Medicare-for-all" on the campaign trail either did not acknowledge or declined multiple requests to be interviewed on the subject. They include Andrew Gillum, who is running for governor in Florida; Gina Ortiz Jones of Texas’ 23rd District; the California candidate for governor Gavin Newsom; Massachusetts 7th District candidate Ayanna Pressley; and Pennsylvania 1st District candidate Scott Wallace.
Lake, the pollster, suggested that policy details simply aren't as relevant in a midterm year and that for now we shouldn't expect a candidate's support for Medicare-for-all to be anything more than a way to signal his or her values. But she suggested that will change in the run-up to 2020, adding, "When we head into the presidential election, people will probably be pickier and want more details."
That gives politicians and voters a few years to decide what they mean and what they want when they say they support Medicare-for-all or single-payer health care. For now, it's hard to read too much into promises.
Paris, who lives in Nashville, said she was surprised and excited to hear that her representative, Jim Cooper, a Blue Dog Democrat, had signed up as a co-sponsor of the Medicare for all bill.
As rates of sexually transmitted infections steadily rise nationwide, public health officials and experts say primary care doctors need to step up screening and treatment.
Julie Lopez, 21, has been tested regularly for sexually transmitted diseases since she was a teenager. But when Lopez first asked her primary care doctor about screening, he reacted with surprise, she said.
"He said people don't usually ask. But I did," said Lopez, a college student in Pasadena, Calif. "It's really important."
Lopez usually goes to Planned Parenthood instead for the tests because "they ask the questions that need to be asked," she said.
As rates of sexually transmitted infections steadily rise nationwide, public health officials and experts say primary care doctors need to step up screening and treatment.
"We know that doctors are not doing enough screening for STDs," said David Harvey, executive director at the National Coalition of STD Directors. The failure to screen routinely "is leading to an explosion in STD rates," he said, adding that cutbacks in funding and a lack of patient awareness about the risks make it worse.
The federal government's Centers for Disease Control and Prevention has set guidelines for annual screening for sexually active individuals. Among them: women under 25 should be tested for gonorrhea and chlamydia, and men who have sex with men should get tested for syphilis, chlamydia and gonorrhea.
However, testing does not always happen as recommended. For example, only about half of sexually active women ages 16 to 24 with private health plans or Medicaid were screened for chlamydia in 2015. The rate was slightly better in California.
Nationally, reported cases of chlamydia, gonorrhea and syphilis are at an all-time high, CDC data show. In one year, from 2016 to 2017, nationwide rates of chlamydia rose by 7 percent, gonorrhea by 19 percent and syphilis by 11 percent.
Rates of congenital syphilis, which passes from mother to baby during pregnancy or delivery, increased by 44 percent during that time. Nearly one-third of the congenital syphilis cases are from California. The state also saw a record number of STDs last year: more than 300,000 cases of gonorrhea, chlamydia and early syphilis among adults.
Because sexually transmitted infections are often asymptomatic, screening is essential. Untreated STDs can lead to serious health problems, such as chronic pain, infertility or even death.
"Providers and primary care providers play a crucial role in combating these rising STD rates," said Dr. Laura Bachmann, chief medical officer for the CDC division of STD prevention. "If providers don't ask the questions and don't apply the screening recommendations, the majority of STDs will be missed."
State governments don't have enough money to combat the rising number of cases, in part because federal STD funding for them has remained stagnant, Harvey said. Last year, he said, $152.3 million in federal funding was appropriated for prevention, the same as eight years earlier.
Experts cite several reasons primary care physicians don't routinely diagnose and treat STDs. They may worry that they won’t be compensated for providing STD services, or they may not be familiar with the most up-to-date recommendations about testing and treatment. For example, the CDC in 2015 updated the medications it recommends to treat gonorrhea.
Perhaps most commonly, many family physicians are reluctant to discuss sexual health with their patients. One study showed that one-third of adolescents had annual visits that didn't include any discussion about sexuality.
"We're in this situation with health care providers and patients — each waiting for the other to start [the conversation]," said Dr. Edward Hook, professor at the University of Alabama-Birmingham School of Medicine. "Doctors worry if they ask patients about their sexual history that it will somehow be offensive to them."
Dr. Michael Munger, president of the American Academy of Family Physicians, said he remembers that his conversations around sexual health were uncomfortable at first. "There are a lot of challenging conversations you can have with patients," he said. "But this is important. If we don't do it, who will?"
Rob Nolan, a writer from Los Angeles, said he gets tested every six months, but he prefers to do so at the Los Angeles LGBT Center rather than during visits with his regular doctor, who rarely asks about sexual health.
Nolan, who said he has had experience with STDs, considers the clinic's staff to be more knowledgeable about sexual health than those at a regular doctor's office. "They just seem specialized in it," he said. "And there is zero shame when you are in the clinic."
Physicians also may have other, more immediate health issues to address during the short time they have with patients. Taking a sexual history and talking about sexual health falls to the bottom of many doctors' priorities, said Dr. Leo Moore, acting medical director of the division of HIV and STD programs for the Los Angeles County Department of Public Health.
Julia Brewer, a nurse practitioner at Northeast Community Clinic in Hawthorne, Calif., said she screens for STDs as a regular part of women's health exams. But she said her colleagues frequently refer cases to her rather than having the conversations themselves. "The family providers are overwhelmed with diabetes and high blood pressure," she said. Sexual health, she said, can end up being an "afterthought."
The L.A. County public health department, which identified STDs as a key priority for the next five years, recently sent representatives to doctors' offices to teach providers how to address sexually transmitted infections. They distributed information detailing screening recommendations, sample sexual history questions and treatment guidelines.
The Los Angeles County Medical Association also plans to get the word out to doctors through social media and other efforts. "It's an epidemic and we have to treat it that way," said CEO Gustavo Friederichsen. "Doctors have to feel a sense of urgency."
Dr. Heidi Bauer, who heads the California Department of Public Health's STD control branch, said the state also is trying to educate doctors so they will screen more routinely. The department provides both in-person and online training for doctors to learn about STDs, and publishes downloadable information with current guidelines.
At the same time, Bauer urged the federal government to make its screening recommendations more comprehensive. Outside of pregnancy, for example, there are no recommendations for routine syphilis screening for women. "We are seeing this huge re-emergence of syphilis," she said. "We haven't been testing and syphilis is very challenging to diagnose."
The CDC plans to review the recommendations in the next year, Bachmann said.
This pattern of requests for taxpayers to help pay for major projects 'could leave children's hospitals with little incentive to control their costs,' a Johns Hopkins University Carey Business School professor said.
Back in 2004, California's children's hospitals asked voters to approve a $750 million bond measure to help fund construction and new medical equipment. In 2008, they asked for $980 million more. Now they're hoping voters will agree on Nov. 6 to cough up an additional $1.5 billion.
The state's 13 children's hospitals treat California's sickest kids — including those with leukemia, sickle cell disease, rare cancers and cystic fibrosis — so approving their fund-raising requests is an easy "yes" for many voters.
Despite the feel-good nature of the requests, some health care experts and election analysts question the hospitals' multiple appeals for taxpayer money — and are warning voters to review this year's proposal with a critical eye.
"I think it's a misuse of the initiative process for private groups to sponsor ballot measures that are intended to benefit them exclusively," said Elizabeth Ralston, a former president of the League of Women Voters of Los Angeles who analyzes state finance measures for the group. The league recommends a "no" vote on the measure.
Repeatedly asking taxpayers to pay for the construction of state-of-the-art facilities is not standard practice, according to critics who believe it raises questions about financial accountability — and whether the hospitals truly need some of the projects on their wish lists.
This pattern "could leave children's hospitals with little incentive to control their costs," said Ge Bai, a professor at the Johns Hopkins University Carey Business School, who added that each hospital should take care of itself.
The initiative, Proposition 4, needs a majority vote to pass. The 2004 and 2008 children's hospital bond measures passed with 58.3 percent and 55.3 percent of the vote, respectively.
The California Children's Hospital Association said its members can't afford to pay for their building and technology needs without help from the state's taxpayers, who would be on the hook to pay off $1.5 billion plus interest. The state Legislative Analyst's Office estimates that would come to $2.9 billion — or about $80 million a year over the next 35 years.
Private donations often aren't the answer because donors frequently specify how their money should be used, said Ann-Louise Kuhns, the association's CEO. The posh playrooms and gardens at some of these hospitals, for example, are completely funded by private donations, she said.
"We do fund-raise, we ask donors to make contributions and we issue our own debt," Kuhns said. "But it's hard to completely close that gap for what's needed … without a little bit of assistance."
The association, which sponsored the initiative, said the bond measure would help pay for construction, remodeling, equipment and seismic retrofitting at the state's eight private, nonprofit children's hospitals and the five that are part of the University of California medical system.
The California Health Facilities Financing Authority would have to approve the hospitals' use of the bond money. The agency weighs whether projects would expand access and improve patient care but does not determine whether a project is necessary or prudent.
That's up to the hospitals.
California Children's Hospitals
The state's 13 children's hospitals — eight private nonprofits and five that are part of the University of California medical system — are asking voters to approve a $1.5 billion bond measure on the Nov. 6 ballot to help them pay for construction and equipment. If the measure passes, the private hospitals will receive about three-quarters of the proceeds, or about $135 million each, regardless of their profits or losses.
The campaign in support of the bond measure — funded by the nonprofit hospitals themselves — has raised nearly $11 million this year, according to the California secretary of state’s office.
In their last financial reports audited by the state, six of the eight private, nonprofit hospitals reported annual profits ranging from $18 million to nearly $176 million. The bond issuance would provide each with $135 million, regardless of its profits or losses.
Almost three-quarters of the bond proceeds would go to the nonprofits because they have the most beds, but nonprofit hospitals already receive certain perks, Bai explained. For instance, they're exempt from paying property taxes, as well as state and federal income taxes.
Eighteen percent would be allotted to the UC system hospitals. And the proposal would offer 10 percent in competitive grants for approximately 150 hospitals that aren't classified as pediatric hospitals, but treat children nonetheless.
The hospitals argue they need to expand because they are facing greater demand for services, as general and community hospitals increasingly transfer their patients to them for specialized pediatric care.
Children's hospitals also rely heavily on Medi-Cal, the state's insurance program for low-income people, Kuhns said. Medi-Cal pays hospitals less than private insurance.
Nancy Kane, a professor in the department of health policy and management at the Harvard T.H. Chan School of Public Health, pointed out that nationwide "many children's hospitals have the same payer mix, but manage to do this anyway without the government paying for their capital."
Kuhns said that California hospitals also face deadlines to meet seismic safety mandates. By 2020, they must be ready to withstand a major earthquake, and by 2030, they must be deemed safe enough to continue operating after a quake.
About 28 percent of the beds in the eight nonprofit children's hospitals do not meet the 2030 seismic standards, so significant investments must be made, she said.
Tim Curley of Valley Children's Healthcare in Madera said the previous bond measures helped pay for a 60,000-square-foot expansion of operating rooms. If this year's bond measure is approved, the hospital would consider renovating its laboratories and pharmacy, he said.
At the end of last year, it had just under $28 million in funds remaining from the 2008 bond, a report by the financing authority said.
Loma Linda University Children's Hospital is still using its share of the 2008 bond to help with the construction of a nine-story tower that will house most departments and labs.
The new tower, expected to be completed by 2021, will help the children's hospital operate independently of the rest of the medical center — which serves adults — and meet the growing demand for space, said Scott Perryman, a senior administrator.
But Ralston, with the League of Women Voters, said Californians should consider whether the money could be better used elsewhere.
"You're committing state money," she said, "and that means that's money not spent on something else" like affordable housing or aging roads.
Should voters nonetheless approve this third bond measure, Bai wonders if and when the requests for taxpayer money will stop. "There are always new things to buy," she said.
Medicare often pays higher-than-necessary rates to doctors and hospitals and can't take steps used by private insurers to control costs, the CMS administrator said.
The Trump administration's top Medicare official Tuesday slammed the federal health program as riddled with problems that hinder care to beneficiaries, increase costs for taxpayers and escalate fraud and abuse.
Seema Verma, administrator of the Centers for Medicare & Medicaid Services (CMS), said those troubles underscore why she opposes calls by many Democrats for dramatically widening eligibility for Medicare, now serving 60 million seniors and people with disabilities, to tens of millions other people.
"We only have to look at some of Medicare's major problems to know it's a bad idea," Verma told health insurance executives at a meeting in Washington.
CMS lacks the authority from Congress to operate the program effectively, Verma said, which means it often pays higher-than-necessary rates to doctors and hospitals and can't take steps used by private insurers to control costs.
"We face tremendous barriers to supporting and bringing innovation to Medicare, and it literally takes an act of Congress to add new types of benefits for the Medicare population," she added.
Since Medicare was approved in 1965, Congress has held power over eligibility and benefits — largely to control spending. That has meant efforts to expand services can get weighed down by partisan politics and swayed by lobbying groups, which significantly delay changes. One example: Congress didn't add a pharmaceutical benefit to Medicare until 2003 — decades after drugs became a mainstay in most treatments.
Advocates for seniors have called for adding vision and dental benefits for many years, but the proposals have gotten little traction because of cost concerns.
Another problem, according to Verma, is that her agency reviews less than 0.2 percent of the more than 1 billion claims that Medicare receives from providers. "That is ridiculously low," she said.
Verma also lamented the traditional Medicare program's limited ability to require doctors and hospitals to get prior authorization from the federal government before performing certain procedures. That process — which has been routine for decades in the private sector — can lead to higher improper payments to doctors and more fraud and abuse, she said.
Jonathan Oberlander, a professor in the department of health policy and management at the University of North Carolina-Chapel Hill, agreed with Verma that "Medicare is not always nimble, particularly in adjusting benefits," and officials have long complained that Congress micromanages the program. Still, he added, "with a program as large and important to Americans as Medicare, it is perfectly appropriate for Congress to weigh in on the addition of new benefits, especially since taxpayers will bear the costs of those changes."
Verma for months has spoken out against the "Medicare-for-all" proposals pushed by Sen. Bernie Sanders (I-Vt.) and a growing chorus of Democrats. But her 35-minute address to the meeting of the trade group America's Health Insurance Plans marked the first time she listed the litany of problems with Medicare, which she has run since March 2017.
Proponents of "Medicare-for-all" are reacting to problems caused by the Affordable Care Act, she said, and should know expanding Medicare will worsen the program's existing challenges of controlling costs and improving care.
"But their solution is literally to do more of what's not working," she added. "It's like the man who has a pounding headache, who then takes a hammer to his head to make it go away."
Verma's comments, however, overlooked the key leadership role that Medicare plays in the health sector, which is often emulated by private insurers, Oberlander said.
"In payment reform, Medicare has a record of being a leader and innovator," he said. "For all of their supposed advantages, private insurers pay much higher prices than Medicare does for medical services. Verma ignores the fact that Medicare's price regulation has produced substantial savings."
Although Verma heavily criticized the traditional Medicare program, which covers two-thirds of enrollees, she boasted about how she and the Trump administration were running Medicare Advantage, the fast-growing alternative program that is operated by private insurers such as UnitedHealthcare and Humana.
More than 20 million Medicare beneficiaries are enrolled in these plans, which often cost members less than traditional Medicare and have additional benefits. But they generally require members to use only the plan's network of providers.
"Medicare Advantage represents value for our beneficiaries and taxpayers," Verma said.
She touted a 2019 CMS initiative that will for the first time allow the Advantage plans to offer supplemental health benefits that go beyond traditional dental and health services. These include adult day care, in home support services and meals.
It is "one of the most significant changes made to the Medicare program" and "will have a major impact" on improving health for plan members, she said.
But the private plans have taken a cautious approach to adding those benefits.
About 270 Medicare Advantage plans — or fewer than 10 percent of the total — agreed to offer these services next year.
At the AHIP conference on Monday, health insurance executives said they were still trying to figure out which of their members would most likely benefit from the new offerings.
"We are operating in a vacuum of good evidence," said William Shrank, chief medical officer of UPMC Health Plan in Pittsburgh. Nonetheless, Shrank said the opportunity to offer new benefits going beyond just health care could help beneficiaries stay out of the hospital and lead healthier lives.
Verma did not mention a report last month by the Department of Health and Human Services' inspector general that found many Advantage plans were improperly denying claims from patients and doctors.
Administration critics were quick to note that omission.
"Her intemperate attack on traditional Medicare — on which two-thirds of all beneficiaries rely and which millions value so highly" — is "striking," said Sara Rosenbaum, a professor of health law and policy at George Washington University. As is "her utter failure to acknowledge the serious challenges in making Medicare Advantage operate fairly, which her own inspector general underscored."
The influential Leapfrog Group, which grades nearly 2,000 U.S. hospitals, is launching a national survey to evaluate the safety and quality of up to 5,600 surgery centers that perform millions of outpatient procedures every year.
The group now issues hospitals an overall letter grade and evaluates how hospitals handle myriad problems, from infections to collapsed lungs to dangerous blood clots — helping patients decide where to seek care.
The new surgery center effort will focus on staffing, surgical outcomes and patient experience in facilities that are performing increasingly complex procedures and seeing more aging patients. The grades will also cover surgery centers' closest competitor, hospital outpatient departments.
Leah Binder, Leapfrog Group's chief executive, said she wants to fill gaps in information about same-day surgery, which employers and health plans have embraced for its lower costs.
Employers, she said, "don't have enough information on quality and safety of that care."
Binder said a recent Kaiser Health News/USA Today Network investigation highlighted the need for independent information about surgery centers. The investigation found that since 2013, more than 260 patients died after care at centers that lacked appropriate lifesaving equipment, operated on very fragile patients or sent people home before they fully recovered.
"Your reporting did highlight the real lack of information from the federal government and the need for us to have an independent means of reporting," Binder said. "People are going in for surgery, and our federal government doesn't think it's important to tell us how it's going. Maybe that was OK 30 years ago, but now it's not OK."
The news report was based on inspection reports, lawsuits and data from many states that tally patient deaths but which refuse to note where they occurred. Seventeen other states collect no data on deaths at all.
The new Leapfrog plan will start with a survey of 250 centers in 2019 and include up to 5,600 surgery centers in 2020. At that point, it will publish data on the outcomes of specific procedures, like total knee replacements, across the hospital outpatient departments and surgery centers nationwide.
The Leapfrog Group is funded by employers and health plans that cover the health care of the half of Americans who get health benefits through their job, Binder said. The organization was founded to shed light on health care quality and safety to help consumers pick high-value providers. It plans to disseminate the new surveys through its 40 business group members that steer millions in health spending.
Bill Prentice, chief executive of the Ambulatory Surgery Center Association, an industry trade group, said he supports the move toward greater transparency. However, he said the work to determine the specific measures is still underway, and "the devil is in the details."
Ty Tippets, administrator of St. George Surgical Center in Utah, said he welcomes what Leapfrog is doing.
"Anytime [data] is gathered and provided in a transparent, easily accessed forum — it helps empower patients," said Tippets, who recently testified before Congress about transparency in health care.
The Leapfrog Group announcement comes as Medicare is reviewing the data it will collect to gauge the quality of surgery centers.
The agency previously asked each surgery center to report its emergency transfer rate, or how often a patient 65 or older was sent from a center to the hospital. Yet the agency only required the centers to send data for half or more of its Medicare patients.
In the current rule-making period, Medicare declared the resulting data of little value, given the minimal differences among centers' scores. The agency proposed dropping the measure, but has not yet finalized the proposal.
Going forward, Medicare has said it will use its own billing data to report the percent of surgery center patients who seek care at a hospital in the week after a procedure.
Medicare recently announced plans to shine more light on the performance of accreditors, which play a key role in granting or denying health facilities approvals to operate. A recent KHN investigation into accreditor performance in California — the only state where the private bodies' inspection reports are public — showed repeated lapses in oversight.
A Medicare spokesman said new reports will show how well accreditors fare when state health officials inspect the same facilities. In recent years, Medicare has found that accreditors overlooked the majority of problems that government officials uncovered.
In September, the White House Office of Management and Budget approved another health agency's proposal to collect and report data about the "culture of safety" in surgery centers. The Agency for Healthcare Research and Quality will ask surgery center staff about issues such as whether staff feel comfortable speaking up about patient care concerns.
The plan says summary data — not facility-by-facility data — on the survey's results will be reported publicly.
That effort would add to the overall information the public has about surgery centers, said Dr. Ashish Jha, a patient safety expert at Harvard's School of Public Health.
"Places that do badly on safety culture surveys tend to have worse outcomes," Jha said. "But you can't bank on it."
He said the most useful data for the public would cover actual events — such as deaths after surgery, admissions to the hospital or functional status and pain three months after surgery.
"Those are the things that actually matter," he said.
Since 2010, enrollment in Medicare Advantage has doubled to more than 20 million enrollees, growing from a quarter of Medicare beneficiaries to more than a third.
Health care experts widely expected the Affordable Care Act to hobble Medicare Advantage, the government-funded private health plans that millions of seniors have chosen as an alternative to original Medicare.
To pay for expanding coverage to the uninsured, the 2010 law cut billions of dollars in federal payments to the plans. Government budget analysts predicted that would lead to a sharp drop in enrollment as insurers reduced benefits, exited states or left the business altogether.
But the dire projections proved wrong.
Since 2010, enrollment in Medicare Advantage has doubled to more than 20 million enrollees, growing from a quarter of Medicare beneficiaries to more than a third.
"The Affordable Care Act did not kill Medicare Advantage, and the program looks poised to continue to grow quite rapidly," said Bill Frack, managing director with L.E.K. Consulting, which advises health companies.
And as beneficiaries get set to shop for plans during open enrollment — which runs from Monday through Dec. 7 — they will find a greater choice of insurers.
Fourteen new companies have begun selling Medicare Advantage plans for 2019, several more than a typical year, according to a report out Monday from the Kaiser Family Foundation. (KHN is an editorially independent part of the foundation.)
Overall, Medicare beneficiaries can choose from about 3,700 plans for 2019, or 600 more than this year, according to the federal government's Centers for Medicare & Medicaid Services.
CMS expects Medicare Advantage enrollment to jump to nearly 23 million people in 2019, a 12 percent increase. Enrollees shopping for new plans this fall will likely find lower or no premiums and improved benefits, CMS officials say.
With about 10,000 baby boomers aging into Medicare range each day, the general view of the insurance industry, said Robert Berenson, a Medicare expert with the nonpartisan Urban Institute, "is that their future is Medicare and it's crazy not to pursue Medicare enrollees more actively."
Bright Health, Clover Health and Devoted Health, all for-profit companies, began offering Medicare Advantage plans for 2018 or will do so for 2019.
Mutual of Omaha, a company owned by its policyholders, is also moving into Medicare Advantage for the first time in two decades, providing plans in San Antonio and Cincinnati.
Some nonprofit hospitals are offering Medicare plans for the first time too, such as the BayCare Health system in the Tampa, Fla., area.
While Medicare beneficiaries in most counties have a choice of several plans, enrollment for years had been consolidated into several for-profit companies, primarily UnitedHealthcare, Humana and Aetna, which have accumulated just under half the national enrollment.
These insurance giants are also expanding into new markets for next year. Humana in 2019 will offer its Medicare HMO in 97 new counties in 14 states. UnitedHealthcare is moving into 130 new counties in 13 states, including for the first time Minnesota, its headquarters for the past four decades.
Extra Benefits
Seniors have long been attracted to Advantage plans because they often include benefits not available with government-run Medicare, such as vision and dental coverage. Many private plans save seniors money because their premiums, deductibles and other patient cost sharing are lower than what beneficiaries pay with original Medicare. But there is a trade-off: The private plans usually require seniors to use a restricted network of doctors and hospitals.
The federal government pays the plans to provide coverage for beneficiaries. When drafting the ACA, Democratic lawmakers targeted the Medicare Advantage plans because studies had shown that enrollees in the private plans cost the government 14 percent more than people in the original program.
Medicare plans weathered the billions in funding cuts in part by qualifying for new federal bonus payments available to those that score a "4" or better on a five-notch scale of quality and customer satisfaction.
Health plans also gained extra revenue by identifying illnesses and health risks of members that would entitle the companies to federal "risk-adjustment" payments. That has provided hundreds of billions in extra dollars to Medicare plans, though congressional analysts and federal investigators have raised concerns about insurers exaggerating how sick their members are.
A study last year found that those risk adjustments could add more than $200 billion to the cost of Medicare Advantage plans in the next decade, despite no change in enrollees' health.
For-profit Medicare Advantage insurers made a 5 percent profit margin in 2016 — twice the average of Medicare plans overall, according to the Medicare Payment Advisory Commission, which reports to Congress. That's slightly better than the health insurance industry's overall 4 percent margin reported by Standard & Poor's.
Those profit margins could expand. The Trump administration boosted payments to Medicare Advantage plans by 3.4 percent for 2019, 0.45 percentage points higher than the 2018 increase.
Betsy Seals, chief consulting officer for Gorman Health Group, a Washington company that advises Medicare Advantage plans, said many health plans hesitated to enter that market or expand after President Donald Trump was elected because they weren't sure the new administration would support the program. But such concerns were erased with the announcement on 2019 reimbursement rates.
"The administration's support of the Medicare Advantage program is clear," Seals said. "We have seen the downstream impact of this support with new entrants to the market — a trend we expect to see continue."
Getting Consumers To Switch
Since the 1960s, Mutual of Omaha has sold Medicare Supplement policies — coverage to help beneficiaries in government-run Medicare pay the portion of costs that program doesn't pick up. But the company only briefly entered the Medicare Advantage business once — in its home state of Nebraska in the 1990s.
"In the past 10 or 20 years it never seemed quite the right time," said Amber Rinehart, a senior vice president for the insurer. "The main hindrance was around the political environment and funding for Medicare Advantage."
Yet after watching Medicare Advantage enrollment soar and government funding increase, the insurer has decided now is the time to act. "We have seen a lot more stability of funding and the political tailwinds are there," she said.
One challenge for the new insurers will be attracting members from existing companies since beneficiaries tend to stick with the same insurer for many years.
Vivek Garipalli, CEO of Clover Health, said his San Francisco-based company hopes to gain members by offering low-cost plans with a large choice of hospitals and doctors and allowing members to see specialists in its network without prior approval from their primary care doctor. The company is also focused on appealing to blacks and Hispanics who have been less likely to join Medicare Advantage.
"We see a lot of opportunity in markets where there are underserved populations," Garipalli said.
Clover has received funding from Alphabet Inc., the parent company of Google. Clover sold Medicare plans in New Jersey last year and is expanding for 2019 into El Paso, Texas; Nashville, Tenn.; and Savannah, Ga.
Newton, Mass.-based Devoted Health is moving into Medicare Advantage with plans in South Florida and Central Florida. Minneapolis-based BrightHealth is expanding into several new markets including Phoenix, Nashville, Cincinnati and New York City.
BayCare, based in Clearwater, Fla., is offering a Medicare plan for the first time in 2019.
"We think there is enough market share to be had and we are not afraid to compete," said Jim Beermann, vice president of insurance strategy for BayCare.
Hospitals are attracted to the Medicare business because it gives them access to more of premium dollars directed to health costs, said Frack of L.E.K. Consulting. "You control more of your destiny," he added.
What's clear is that voters want the protections. Even majorities of Republicans told pollsters this summer that it is 'very important' that guarantees of coverage for preexisting conditions remain law.
Ensuring that people with preexisting health conditions can get and keep health insurance is the most popular part of the Affordable Care Act. It has also become a flashpoint in this fall's campaigns across the country.
And not only is the ACA, which mostly protects people who buy their own coverage, at risk. Also potentially in the crosshairs are preexisting conditions protections that predate the federal health law.
Democrats charge that Republicans' opposition to the ACA puts those protections in peril, both by their (unsuccessful) votes in Congress in 2017 to "repeal and replace" the law, and via a federal lawsuit underway in Texas.
"800,000 West Virginians with preexisting conditions in jeopardy of losing their health care," claimed Sen. Joe Manchin (D-W.Va.).
Republicans disagree. "Preexisting conditions are safe," President Donald Trump declared at a rally in West Virginia for Manchin's GOP opponent, Patrick Morrisey. Morrisey, West Virginia's attorney general, is one of a group of state officials suing to overturn the ACA.
Who is right? Like everything else in health care, it's complicated.
What is clear, however, is that voters want protections. Even majorities of Republicans told pollsters this summer that it is "very important" that guarantees of coverage for preexisting conditions remain law.
Here are some key details that can help put the current political arguments in perspective.
Preexisting conditions are common.
Preexisting conditions are previous or ongoing medical issues that predate health insurance enrollment. The problem is that the term is a grab bag whose limits have never been defined. It certainly applies to serious ongoing conditions such as cancer, heart disease and asthma. But insurers also have used it to apply to conditions like pregnancy or far more trivial medical issues such as acne or a distant history of depression.
The Kaiser Family Foundation estimated in 2016 that more than a quarter of adults younger than 65 — about 52 million people — have a preexisting health condition that likely would have prevented them from purchasing individual health insurance under the pre-ACA rules. (Kaiser Health News is an editorially independent program of the foundation.)
Protections vary by what kind of insurance you have.
But what protections people with preexisting conditions have depends on how they get their coverage. For that reason, it's not right to say everyone with health problems is potentially at risk, as Democrats frequently suggest.
For example, Medicare, the federal health program for seniors, and Medicaid, the federal-state health plan for low-income people, do not discriminate in either coverage or price on the basis of preexisting conditions. The two programs together cover roughly 130 million Americans — nearly a third of the population.
The majority of Americans get their coverage through work. In 1996, Congress protected people with preexisting conditions in employer-based coverage with the passage of the Health Insurance Portability and Accountability Act, known as HIPAA.
HIPAA was intended to eliminate "job lock," or the inability of a person with a preexisting condition (or a family member with a preexisting condition) to change jobs because coverage at the new job would likely come with a waiting period during which the condition would not be covered.
HIPAA banned those waiting periods for people who had maintained "continuous" coverage, meaning a break of no more than 63 days, and the law limited waiting periods to one year for those who were previously uninsured. In addition, it prohibited insurers from denying coverage to or raising premiums for workers based on their own or a family member's health status or medical history.
HIPAA was less successful in protecting people without job-based insurance. It sought to guarantee that people with preexisting conditions leaving the group market could buy individual coverage if they had remained continuously covered. But the law did not put limits on what individual insurers could charge for those policies. In many cases, insurers charged so much for these "HIPAA conversion" policies that almost no one could afford them.
The Affordable Care Act, passed in 2010, built on those 1996 protections, and specifically sought to help people buying their own coverage. It barred all health insurers from excluding people due to preexisting conditions, from charging them higher premiums and from imposing waiting periods for coverage of that condition.
While the protections were mostly aimed at the individual insurance market, where only a small portion of Americans get coverage, the ACA also made some changes to the employer market for people with preexisting conditions, by banning annual and lifetime coverage limits.
Will protections on preexisting conditions become collateral damage?
In 2017, the GOP-controlled House and Senate voted on several versions of a bill that would have dramatically overhauled the ACA, including its protections on preexisting conditions. Under the last bill that narrowly failed in the Senate, states would have been given authority to allow insurers to waive some of those protections, including the one requiring the same premiums be charged regardless of health status.
In February, 18 GOP attorneys general and two GOP governors filed suit in federal court in Texas. They charge that because Congress in its 2017 tax bill eliminated the ACA's penalty for not having insurance, the entire federal health law is unconstitutional. Their argument is that the Supreme Court upheld the ACA in 2012 based only on Congress' taxing power, and that without the tax, the rest of the law should fall.
The Trump administration, technically the defendant in that case, said in June that it disagreed that the entire law should fall. But it is arguing that the parts of the law addressing preexisting conditions are so tightly connected to the tax penalty that they should be struck down.
Clearly, if the lawsuit prevails in either its original form or the form preferred by the Trump administration, preexisting protections are not "safe," as the president claimed.
Even more complicated, the protections written into HIPAA were rewritten and incorporated into the ACA, so if the ACA in whole or part were to be struck down, HIPAA's preexisting conditions protections might go away, too.
Republicans in Congress have introduced a series of proposals they say would replicate the existing protections. But critics contend none of them covers as many situations as the ACA does. For example, a bill unveiled by several Republican senators in August would require insurers to offer coverage to people with preexisting health conditions, but not require coverage of the conditions themselves.
That hasn't stopped Republicans from claiming that they support protections for preexisting conditions.
"Make no mistake about it: Patients with preexisting conditions should be covered,” said Wisconsin GOP Senate candidate Leah Vukmir, who is running to unseat Democratic Sen. Tammy Baldwin. Health care has been a major issue in that race, as well as many others. Yet Vukmir was recently hailed by Vice President Mike Pence as someone who will vote to "fully repeal and replace Obamacare."
Meanwhile, Democrats who are chastising their Republican opponents over the issue are sometimes going a bit over the top, too.
An example is Manchin's claim about the threat to coverage for 800,000 people in West Virginia. West Virginia's population is only 1.8 million and more than a million of those people are on Medicare or Medicaid. That would mean every other person in the state has a preexisting condition. A recent study found West Virginia has a relatively high level of preexisting conditions among adults, but it is still less than 40 percent.
Some patients refuse to answer. Many doctors don't ask. As the number of Americans with dementia rises, health professionals are grappling with when and how to pose the question: "Do you have guns at home?"
While gun violence data is scarce, a Kaiser Health News investigation with PBS NewsHour published in June uncovered over 100 cases across the U.S. since 2012 in which people with dementia used guns to kill themselves or others. The shooters often acted during bouts of confusion, paranoia, delusion or aggression — common symptoms of dementia. Tragically they shot spouses, children and caregivers.
Yet health care providers across the country say they have not received enough guidance on whether, when and how to counsel families on gun safety.
Dr. Altaf Saadi, a neurologist at UCLA who has been practicing medicine for five years, said the KHN article revealed a "blind spot" in her clinical practice. After reading it, she looked up the American Academy of Neurology's advice on treating dementia patients. Its guidelines suggest doctors consider asking about "access to firearms or other weapons" during a safety screen — but they don't say what to do if a patient does have guns.
Amid a dearth of national gun safety data, there are no scientific standards for when a health care provider should discuss gun access for people with cognitive impairment or at what point in dementia's progression a person becomes unfit to handle a gun.
Most doctors don't ask about firearms, research has found. In a 2014 study, 58 percent of internists surveyed reported never asking whether patients have guns at home.
"One of the biggest mistakes that doctors make is not thinking about gun access," said Dr. Colleen Christmas, a geriatric primary care doctor at Johns Hopkins School of Medicine and member of the American Neurological Association. Firearms are the most common method of suicide among seniors, she noted. Christmas said she asks every incoming patient about access to firearms, in the same nonjudgmental tone that she asks about seat belts, and "I find the conversation goes quite smoothly."
Recently, momentum has been building among health professionals to take a greater role in preventing gun violence. In the wake of the Las Vegas shooting that left 58 concertgoers dead last October, over 1,300 health care providers publicly pledged to ask patients about gun ownership and gun safety when risk factors are present.
The pledges came in response to an article by Dr. Garen Wintemute, director of the Violence Prevention Research Program at the University of California-Davis. In response to feedback from that article, his center has now developed a toolkit called What You Can Do, offering health professionals guidance on how to reduce the risk of gun violence.
In a nation bitterly divided over gun ownership issues, in which many staunchly defend the right to bear arms under the Second Amendment, these efforts have met dissent. Dr. Arthur Przebinda, director of Doctors for Responsible Gun Ownership, framed Wintemute's efforts as part of a broader anti-gun bias on the part of institutional medicine. Przebinda said asking physicians to sign such a pledge encourages them "to propagandize Americans against their constitutionally protected rights to gun ownership and privacy."
Przebinda said he gets several requests a day from patients looking for gun-friendly physicians. Some, he said, are tired of their doctors sending them anti-gun YouTube videos and other materials. His group, which he said has over 1,400 members, has set up a referral service connecting patients to gun-friendly doctors.
For doctors and other health professionals, navigating this politically fraught issue can be difficult. Here are the leading issues:
Is it legal to talk to patients about guns?
Yes. No state or federal law bars health professionals from raising the issue.
Why don't doctors do it?
The top three reasons are lack of time, being unsure what to tell patients and believing patients won't heed their advice about gun ownership or gun safety, one survey of family physicians found.
"There's no medical or health professional school in the country that does an adequate job at training about firearms," Wintemute argued. He said he is now working with the American Medical Association to design a continuing medical education course on the topic.
Other doctors don't believe they should ask. Przebinda argues that doctors should almost never ask their patients about guns, except in "very rare, very exceptional circumstances" — for example, if a patient is despondent or homicidal. He said placing patients' gun ownership information into an electronic medical record puts their privacy at risk.
When should they broach the subject?
The Veterans Health Administration recommends asking about firearms as part of a safety screening when "investigating or establishing the suspected diagnosis of dementia." The Alzheimer's Association also recommends asking, "Are firearms present in the home?" as part of a safety screening. That screening is part of a care planning session that Medicare covers after initial dementia diagnosis and annually as the disease progresses.
The American College of Physicians recommends physicians "counsel patients on the risk of having firearms in the home, particularly when children, adolescents, people with dementia, people with mental illnesses, people with substance use disorders, or others who are at increased risk of harming themselves or others are present."
Wintemute said he does not suggest all doctors routinely ask every patient about firearms. His group recommends doing so when risk factors are present, including risk of violence to self or others, history of violent behavior or substance misuse, "serious, poorly controlled mental illness" or being part of "a demographic group at increased risk of firearm injury."
What should health care providers recommend patients do with their guns?
The Alzheimer's Association advises that locking up guns may not be enough, because people with dementia may "misperceive danger" and break into a gun cabinet to protect themselves. To fully protect a family, the organization recommends removing the guns from the home.
But health professionals may be reluctant to recommend that due to legal concerns, said Jon Vernick, co-director of the Johns Hopkins Center for Gun Policy and Research. Most states allow the temporary transfer of firearms to a family member without a background check. But seven states don't: Connecticut, Hawaii (for handguns), Massachusetts, Michigan, New Jersey, North Carolina and Rhode Island, according to Vernick. He recommends health professionals look up their state gun laws on sites such as the NRA Institute for Legislative Action or the Giffords Law Center to Prevent Gun Violence.
In addition, 13 states have passed "red flag" laws allowing law enforcement, and sometimes family members, to petition a judge to temporarily seize firearms from a gun owner who exhibits dangerous behavior.
What happens when clinicians ask about guns?
Natasha Bahr, an instructor and social worker who works with geriatric patients at a clinic focusing on memory disorders at the University of North Texas Health Science Center, said as part of a standard assessment, she asks every patient, "Do you have firearms in the home?"
"I get so much pushback," she said. About 60 percent of her patients refuse to answer, she said.
Patients tell her, "It's none of your business," "I have the freedom to not answer that question" or "It's my Second Amendment right," she said. "They make it sound like I'm judging, and I'm really not."
Dr. John Morris, director of the Knight Alzheimer’s Disease Research Center at Washington University in St. Louis, said he asks his patients about firearms in the context of other safety concerns. When safety is at risk, he typically advises families to lock up firearms and store ammunition separately.
"People with dementia typically lack insight into their problems. So they will protest," he said. Dementia is characterized by "the gradual deterioration not just of memory but of judgment and problem-solving and good decision-making," Morris noted.
In one case, Morris said, he had to persuade the daughter of a dementia patient to secure her father's hunting rifles. Uncomfortable with the role reversal, she was reluctant to do so.
"It's very difficult to tell your father he can no longer have his firearms,” Morris said. The father responded: "I have never misused my firearms. … It's not going to be a problem," Morris recalled. "But, he's remembering his past history — he can't predict the future."
Eventually, the daughter decided to remove the rifles from the home. After a few weeks, her father forgot all about them, Morris said.
Morris said the story highlights how difficult it is for families to care for people with dementia. "They're forced to make decisions, often against the persons' will,” he said, “but they have to do it for the person's safety and well-being."