And now, some heartening news in the global health world: Injuries are down by a pretty big chunk.

“Injury” in this case encompasses everything from car accidents and falls to suicides and gunshot wounds. Since 1990, the world has managed to cut down the number deaths and disabilities caused by all these factors by a third, according to a report published Thursday in the British Medical Journal.

“As for what has brought about this change, we can only speculate,” says Theo Vos, a professor of global health at the University of Washington and the report’s senior author. “For example, we’ve seen a huge decline in suicide in China, whereas in India that is not the case.” Going forward, researchers will have to dig beyond the statistics to figure out why some countries are doing better than others.

But while the stats look good overall, he says, “there are a number of parts of the world that are lagging behind,” Vost says. In many developing countries, road accidents are up — especially in parts of South America, sub-Saharan Africa and South Asia. In South Africa, for example, over 13,000 people died in road accidents in 2010.

That’s likely because more people in the developing world are moving into cities and frequenting not-so-safe city roads, Vos says. “It’s true that cars are probably safer today than they were 20, 30 years ago,” he notes. “But maybe some of these countries in southern Africa, West Africa and South America need to see what they can do to improve road safety.”

To do that, countries that are lagging behind need to look to places like Sao Paolo, Brazil. says Claudia Adriazola, who researches urban transportation and road safety at the World Resources Institute. The city’s mayor has reduced speed limits across the city and added more sidewalks and bike lanes. “Maybe more cities can start doing similar things,” she says.

And maybe global health organizations can start thinking differently about how they allocate their funds. Dollars traditionally go to combating infectious diseases like AIDS and Ebola. But improving road safety as well as emergency medical care is also critical, says Michael Haglund, a neurosurgeon at Duke University who has been helping train surgeons in East Africa.

“I totally get that some of these developing countries have to first take care of things like malaria, tuberculosis and HIV,” Haglund says. “But now we’re starting to reign in some of those infectious diseases.”

If developing countries started allocating a fraction of what they spend trying to contain and cure those diseases into improving surgical care, Haglund notes, they’d be able to reduce the number of preventable deaths from car accidents, falls and other common injuries.

“Once you’re injured, if you’re in the U.S. you’re probably in the emergency room right away, within minutes,” Haglund says. “Imagine you get injured in northern Uganda and it takes 12 hours to get to the nearest hospital for surgery. A simple neck fracture or a blood clot can easily be fixed, but only if you’re able to treat it quickly.”

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Surrounded by stacks of packages in a brightly lit room, Michael Palone gingerly folded a box and taped it shut. His eyes averted, he shuffled to the front of the warehouse to retrieve scissors, skirting by people and tables in his path.

Palone, 26, has Asperger’s and mild autism that makes it nearly impossible for him to socialize with others and adjust to the constant changes of a full time job. Instead, he assembles packages with about 40 others at a Union City, Calif., work center run by The Arc of Alameda County.

The Arc is a national nonprofit with chapters across the country that offer programs and services for people with developmental disabilities. “It means a lot to me,” Palone says. “It gets me out of the house, and it helps me interact with people.”

Before joining the work activity center, Palone mostly stayed at home, in his room, playing computer games all day. He couldn’t complete simple tasks like doing his laundry without his mother’s help. But since he joined The Arc two years ago, his mother, Rosemary, said that the change in his behavior has been remarkable.

“When I first found out how good the program was for him, it made me cry,” she said.

Now Michael voluntarily joins her on trips to the grocery store, sits with the family in the living room and even washes his own clothes without needing a reminder. Plus, his work is paid. He earns about $300 per month, which he uses to buy magic cards or to treat his niece to lunch. “We talk more now than we ever did throughout his entire childhood,” Rosemary Palone says.

But she fears that her son will return to his former reclusive ways. Due to a lack of funding and the increasing cost of living in the San Francisco Bay area, the Arc can no longer shoulder the costs of running the program and plans to close the work center in a few months.

Rosemary Palone worries that Michael and other clients like him will have nowhere else to go. “If he doesn’t keep going to this program, all of the progress that he’s made over the past two years will just be gone in two weeks,” she said.

The work activity center is funded through a combination of state and federal money. But Ron Luter, president and CEO of The Arc of Alameda County, says it’s not enough to cover costs, and it’s hurting the rest of the agency. “The work activity center is really pulling this facility down,” Luter says.

During its heyday, the workshop bustled with activity as the main co-packager for Ghirardelli Chocolate, but it lost the contract when the company moved its packaging facility to Modesto several years ago. Now packaging machines sit in the room collecting dust.

Although The Arc of Alameda County’s annual budget is $5 million, Luter said that the four centers he heads in the East Bay have lost about $1 million over the past three years. Luter has been running clothing drives and dipping into savings from the sale of two former Arc of Alameda properties, but the pool of extra money will soon run dry, he says.

The Arc of Alameda’s plight echoes that of similar organizations across the state. California was once known as a pioneer for spearheading alternatives to confining people with developmental disabilities in state-run institutions that were notoriously overcrowded and separated patients from their loved ones.

In 1965, the California legislature passed AB 691, a pilot program that created the first regional centers. These agencies were designed to coordinate community-based services so people with developmental disabilities could live independently or with their families. Today there are 21 nonprofit regional centers across California that handle case management and program development, among many other services.

But in the wake of The Great Recession, more than $1 billion in state budget cuts threaten the system. In a grimly-titled report, On the Brink of Collapse, the Association of Regional Center Agencies (ARCA) noted that state has the lowest funding in the country for individuals with a developmental disability who qualify for services.

In addition, payments to service providers have been frozen since 2003, meaning that agencies are running on a rate model that was created over a decade ago. The situation is especially pronounced in the expensive Bay Area because provider rates are the same statewide.

Eileen Richey, executive director of ARCA, says the lack of funding puts Californians with developmental disabilities at risk. “All of these challenges now mean that more people have to wait to get into a program,” Richey said. “And everyone throughout the system ends up having to do more with less … continually worsening the quality of life for people with developmental disabilities and their families.”

Richey added that it’s nearly impossible to find qualified long-term staff to work at the rate the organizations offer. Constant staff turnover makes providing quality care even more challenging.

“The turnover rate is so high,” Luter of the Arc of Alameda says of his dwindling staff. “We’re competing with people for jobs at In-N-Out Burger. Half of the people who work for me have two jobs just to survive.” At his work activity center, Luter said that the ratio of clients to staff should be 10 to 1, but it’s currently double that because he can’t afford to pay any more workers.

The work activity center at The Arc of Alameda in Union City is just one of the programs in the Bay Area that will be shutting down over the next few months because of funding issues. Luter also plans to close a child care program in Hayward, where he said deficits have run from $40,000 to $100,000 per year since 2010. The center serves children ages 2 to 5 with mild to moderate disabilities or developmental delays.

A combination of factors forced Barbara Maizie, executive director of Contra Costa ARC, to decide to close the Lynn Center, a program serving children 15 months to 5 years with developmental delays and autism, on Dec. 1.

Maizie says the low funding levels had already strained her agency. Then the Lynn Center faced relocation when the elementary school housing its program was taken back by the district. Maizie realized that they couldn’t afford the relocation costs.

“There have been many challenges to running this program in the past, and we were always able to rise to the occasion,” she says. “But the funding has just become so impossible that we can’t any longer.”

The Lynn Center closure is the fourth her agency has seen over the last year, says Ronke Sodipo, director of community services at the Regional Center of the East Bay. The nonprofit agency works with California’s Department of Developmental Services to coordinate programs in Alameda and Contra Costa counties for people with developmental disabilities. Out of the 102 clients in the closed programs, she says, up to half have not yet been placed in another center.

Recent changes in labor laws have exacerbated funding issues for the scores of organizations that provide services throughout the East Bay, Sodipo says. A new statewide law that requires paid sick leave; the Affordable Care Act requirement that employers with more than 50 full time employees provide health insurance; an increase in overtime pay; and the higher minimum wage in Oakland and Emeryville have all created additional costs for the organizations.

“I don’t know that our service providers would be as severely impacted if their costs were taken into consideration and they were given rate adjustments to absorb some of it,” Sodipo said.

Seeking to address the losses from years of underfunding, The Lanterman Coalition — an alliance of 20 organizations and businesses including agencies that provide services for those with disabilities and advocacy groups — took action earlier this year and lobbied state legislators for a 10 percent across-the-board funding increase for service providers. The proposal was ultimately removed from the state budget that was signed in June. But Gov. Jerry Brown then called a special session of the legislature this fall to address this funding question and other fiscal issues.

A bill proposed by Sen. Ed Hernandez, D-West Covina, would impose a $2 per pack tax on cigarettes and provide an annual increase of $230 million for regional centers and service providers. “California’s developmental disability system has been struggling for many years – it’s time that system sees some benefit from California’s economic recovery,” Hernandez said in an email. “I remain hopeful that we are able to use this special session to provide long overdue relief to the community.”

Legislators across party lines seem to be in general agreement that provider rates need to increase, but they differ on how much of an increase is needed — and strategies for funding it. One issue is that agencies serving people with developmental disabilities have not been required to submit a statement of their annual costs to the regional centers in over 10 years.

“That said, it begs the question of what then is the appropriate rate?” says Mark Newton, a policy analyst from the nonpartisan Legislative Analyst’s Office. “That’s a tough issue in a way, because of a lack of collected and reported cost data that would help address a formulation of an appropriate rate structure.”

Although the legislative special session is still open, legislators have not met since September 11, and there is no sign they will be reconvening before the end of the year.

Advocates for more funding are planning a march to the capitol in Sacramento on Dec. 10. Luter says he will carry a coffin symbolizing what he calls the “death” of the Lanterman Act. “We’re not treating these folks as if they’re part of the fabric of the community,” he says.

Valerie deChadenedes, 30, of San Francisco, was diagnosed with Rett syndrome when she was 10. It’s a rare neurodevelopmental disorder that inhibits brain growth and motor skills.

DeChadenedes is unable to walk, talk or feed herself and needs assistance for many aspects of her life. But her mother, Audrey, says Valerie does enjoy being social with people her own age. She can put words together into sentences through an eye-tracking communication device mounted on her wheelchair.

After she completed school eight years ago, she spent four years on a wait list before being placed into a program that could serve someone with her needs. She took art classes there and learned to be more self-sufficient.

But five months ago, she was forced to leave the program when it turned out not to be licensed to provide care for medically fragile clients. Her case manager at the Golden Gate Regional Center said that there is no other day program in San Francisco that will be able to address her needs.

Valerie now spends her days doing activities organized by her mother. “If it weren’t for me, what would happen to Valerie?” Audrey deChadenedes wonders. After she was released from the program, Audrey said that Valerie would say, “I feel lonely,” through her communication device.

Frustrated by what she considers inertia in the legislature, Audrey deChadenedes started writing weekly letters to Brown and is keeping a blog called Valerie’s Week in Review, where she details Valerie’s health and the actions she’s taking to find Valerie a new program and an apartment. In her last blog post on Nov. 3, Audrey closed this way: “As great direct-service people quit to make a living wage, as programs close, as things fall apart all around us, I am terrified for my daughter’s future.”

Melissa Hellmann is a San Francisco Bay area-based reporter who has written for Time, The Christian Science Monitor and other publications. This story first appeared on KQED’s State of Health blog.

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The rate of avoidable complications affecting patients in hospitals leveled off in 2014, after three years of declines, according to a federal report released Tuesday.

Hospitals have averted many types of injuries where clear preventive steps have been identified, but they still struggle to avert complications with broader causes and less clear-cut solutions, government and hospital officials said.

There were at least 4 million infections and other potentially avoidable injuries in hospitals last year, the study estimated. That translates to a preventable problem in about 12 of every 100 hospital stays.

Among the most common complications that were measured — each occurring a quarter million times or more — were bedsores, falls, bad reactions to drugs used to treat diabetes and kidney damage that develops after contrast dyes are injected through catheters to help radiologists take images of blood vessels.

The frequency of hospital complications last year was 17 percent lower than in 2010 but the same as in 2013, indicating that some patient safety improvements made by hospitals and the government are sticking. But the lack of improvement raised concerns that it is becoming harder for hospitals to further reduce the chances that a patient may be harmed during a visit.

“We are still trying to understand all the factors involved, but I think the improvements we saw from 2010 to 2013 were very likely the low-hanging fruit, the easy problems to solve,” said Dr. Richard Kronick, director of the federal Agency for Healthcare Research and Quality, or AHRQ, which conducted the study.

The Obama administration has been focusing on lowering the rates of medical infections and injuries as it tracks a slew of patient safety initiatives created by the 2010 federal health law. Those include Medicare penalties for poor-performing hospitals, wider use of electronic records to help track patient care and prevent mistakes, and grants to collaborations of medical providers formed to improve the quality of patient care and identify the best ways of addressing each type of problem.

The AHRQ report calculated national rates for 27 specific complications by extrapolating from 30,000 medical cases that officials examined. Decreases in infections, medicine reactions and other complications since 2010 have resulted in 2.1 million fewer incidents of harm, 87,000 fewer deaths and $20 billion in health care savings, the report concluded.

“Those are real people that are not dying, getting infections or other adverse events in the hospital,” said Dr. Patrick Conway, chief medical officer for the Centers for Medicare & Medicaid Services.

Some of the most significant progress was made in lowering the number of infections from central lines inserted into veins — down 72 percent from 2010. Medical researchers have proven that these infections can be virtually eliminated if doctors and nurses follow a clear set of procedures.

Infections from urinary catheters decreased by 38 percent and surgical site infections dropped by 18 percent. In all three cases, the reductions exceeded the goals set by the administration. Conway noted that hospitals had a financial motivation to cut these infections as they are used to determine whether hospitals get Medicare bonuses and penalties each year.

However, hospitals have not made headway in trimming the numbers of falls or pneumonia cases in patients breathing through mechanical ventilators, the report found. And the rates of adverse drug reactions and complications during childbirth were higher than what the administration estimated they should be for 2014.

Conway said that complications are difficult to address because they involve tradeoffs that can cause other problems. For instance, he said, hospitals have to balance efforts to reduce falls with the need to help unstable patients improve their ability to walk. “We’ve got to work with providers to figure out what’s the sweet spot that can keep mobilization occurring but decrease the rate of falls,” he said.

Even though overall complication rates were flat, the report found that some types of injuries became less common in 2014. One was the number of blood clots that form after surgery and travel to the lung; those rates dropped by 30 percent in a year.

In some areas, the report is more optimistic about infection declines than is the Centers for Disease Control and Prevention, which tracks the same infections but uses different methods and different years of comparison. The CDC has reported that urinary tract infections caused by catheters became slightly more prevalent through 2013, while the AHRQ method has found a substantial drop, said Dr. Jennifer Meddings, an assistant professor at the University of Michigan Health System who studies hospital infections. “This is what’s very confusing to hospitals,” she said. “Different data gets picked in different reports.”

Maulik Joshi, an executive at the American Hospital Association, predicted that complications will become even rarer in future years. “Hospitals are working on projects that are just not reflected in these data points,” he said.

But a few conditions became more prevalent in 2014. Infections from methicillin-resistant Staphylococcus aureus bacteria, known as MRSA, increased by 55 percent to an estimated 17,000 incidents last year. The number of times a catheter punctured a femoral artery during an angiography increased by 25 percent to 74,000, the report estimated.

“We think we addressed a lot of the areas where there was a strong evidence base on how to improve patient safety,” Conway said. “We’ll now have to tackle that next wave that has multiple causes.”

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Medicare recipients who have arthritis, cancer or other complex conditions may find they have to pay thousands of dollars a year for their medications, even if their insurance plan covers most prescriptions.

For 2016 the out-of-pocket costs can reach as high as $11,538 for a single drug — far more than the maximum catastrophic threshold of $4,850 for Medicare beneficiaries, according to an analysis of Medicare Part D drug coverage released Tuesday by the Kaiser Family Foundation and Georgetown University’s Health Policy Institute.

That threshold is supposed to be the upper limit for the out-of-pocket expenses a beneficiary has to pay during a single year. But Tricia Neuman, director of the program on Medicare policy at Kaiser, called that limit “leaky,” because Medicare still requires seniors to pay 5 percent of a drug’s cost after they reach the limit.

And that out-of-pocket amount can increase quickly, especially for someone taking multiple expensive medications for cancer, hepatitis C, multiple sclerosis or certain other illnesses or chronic conditions.

“We were struck by the thousands and thousands of dollars that some people can pay for specialty drugs, in some cases, even after they reach the catastrophic level,” Neuman says.

The analysis showed, for example, that seniors taking Revlimid for cancer could end up paying $11,538 of their own money in 2016, even when that medicine is covered under their Medicare prescription drug plan.

Some people may not realize they can be on the hook for such expenses, Neuman says. “They could find themselves with an unpleasant surprise when they exceed the limit and still have to pay hundreds, if not thousands, of dollars,” she says.

Neuman urges people to shop around for a Medicare plan that covers the particular prescriptions they need. “It really does pay to shop,” she says. “We found that plans vary widely in terms of the drugs they cover and what they charge.” Open enrollment for Medicare plans, including Part D prescription drug plans, ends on Dec. 7.

If Medicare customers take a medication that has been excluded from their plan, the costs can be exceptionally high, the report showed. The out-of-pocket cost for Enbrel, a rheumatoid arthritis medicine, for example, could reach almost $50,000 a year, if it’s not covered. Other specialty drugs for conditions such as multiple sclerosis or hepatitis C can climb even higher.

And even for lower-priced drugs that are covered by the plans, a patient’s out-of-pocket costs can vary widely. For example, Spiriva, a drug for chronic obstructive pulmonary disease, costs $33 under one Medicare plan and $472 under another, according to the report.

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Citing flexibility, many consumers choose health plans that provide some coverage outside the insurer’s network. Traditionally, the plans not only paid a portion of the bill for doctors and hospitals not in the core plan, but also set an annual cap on how much policyholders paid toward out-of-network care.

Not anymore.

An increasing number of the preferred provider plans, or PPOs, offered under the federal health law have no ceiling at all for out-of-network costs. Consumers who choose them face unlimited financial exposure, similar to what more restrictive and often less expensive types of coverage, such as health maintenance organizations, impose on people who use services outside their networks.

Forty-five percent of the silver-level PPO plans coming to market for the first time in 2016 provide no annual cap for policyholders’ out-of-network costs, an analysis by the Robert Wood Johnson Foundation finds. Uncapped plans could lead to tens of thousands of dollars in bills for patients who are hospitalized or treated by providers who aren’t part of the plan’s network.

This year, 14 percent of existing silver-level PPO plans have no annual ceiling on out-of-network care. When new plans coming to market and the existing plans that are continuing are factored together, that percentage will double, to 30 percent of silver-level PPOs with no out-of-network financial cap in 2016, the analysis finds. Silver plans, which are the second-lowest cost plans, are the most commonly purchased in the marketplaces.

Not having any maximum cap on those costs “is what you expect … in a plan that doesn’t offer out-of-network benefits,” said RWJF researcher Katherine Hempstead. “You’re paying a deductible and then some kind of co-insurance ad infinitum. The average PPO for sale in 2016 is less comprehensive than what was called a PPO in 2015.”

The trend stretches the definition of a PPO and could catch consumers unaware, especially because many people mainly check premium and deductible costs when shopping. Additionally, information about out-of-network costs is often harder to find on insurance websites, generally requiring consumers to click through to an 8-page summary of benefits.

But consumers should take that step before they sign up, say advocates, to know what their potential exposure might be. They should take special care with PPOs, which many people choose specifically because they cover some out-of-network costs, generally paying a portion of the bill after a patient meets an annual deductible.

The move of many plans to go without an annual cap puts a bigger burden on policyholders. “This trend creates even greater risk for consumers going out of network,” said Betsy Imholtz with Consumers Union, the advocacy arm of the organization that produces Consumer Reports.

All of UnitedHealth’s plans in Arizona, for example, have no annual cap on out-of-network costs. This year, for the first time, neither do any of the PPOs offered by the Blue Cross Blue Shield plans in Illinois, Oklahoma and New Mexico. Plans offered through a partnership between insurer Aetna and the Northern Virginia hospital system Inova also have no maximum cap for out of network.

Insured consumers have long faced costly consequences for going out of network.

But those concerns have grown in recent years, especially among people who buy their own insurance because they don’t get it through their jobs. That’s partly because the federal health law changed the way insurers do business, including barring them from rejecting people with health problems.

While that has helped consumers with preexisting conditions, insurers have sought other ways to cut their costs in order to slow premium growth. To do that, many now offer plans with smaller networks of doctors and hospitals, which can make it more likely that a policyholder will see non-network providers, either on purpose or inadvertently. For example, a patient might go to an in-network hospital, but be treated by a physician or lab service not covered by the insurer’s contract.

The resulting bills can run into thousands of dollars. And the providers can bill patients for the difference between what the insurer pays toward their care and their actual charges, which are generally far higher. The amount billed doesn’t count toward a plan’s annual deductible or annual out-of-network maximum, if it has one.

Vince Hess of Grandview, Mo., racked up about $800 in costs related to surgery for a broken hand in 2013. Hess, an actuary, first checked that his surgeon was in network. He had the operation at an in-network surgical center, but only learned later when he was billed that the two anesthesiologists who assisted in the surgery were not.

“Everything added up pretty fast,” said Hess, 57, who said he should have been told that he might be treated by out-of-network physicians. “I … have read a thousand health insurance contracts. That’s the irony, that I got burned. I don’t know how the average person does it who is not as familiar.”

Insurers and policy experts say there are sound reasons to have networks. They’re one way insurers negotiate with large hospital systems to bring costs down. The networks can also be used to steer patients to doctors or hospitals with higher quality ratings, better prices, or both.

“Members get the most out of their benefits by using in-network providers,” said Thomas Meier, vice president of market solutions for Health Care Service Corporation, which owns Blue Cross Blue Shield plans in five states, including Illinois.

This year, to slow premium growth, Meier said his company’s PPO plans switched from having out-of-network caps to not having them in three states – Illinois, New Mexico and Oklahoma – and setting the cap at three times the in-network maximum in Montana.

“We do have to look at ways we can keep those premiums as affordable as possible,” he said. “If we offer a significant amount of out-of-network coverage, then the premium will come up and won’t meet that goal.”

While consumers’ concerns about out-of-network costs predate the Affordable Care Act, the law doesn’t set any limits on what insurers or medical providers can charge policyholders for out-of-network care.

The law does, however, cap what insurers can charge policyholders annually for in-network care.

For 2016, plans must limit out-of-pocket costs for policyholders, which include deductibles and copayments, to $6,850 for individual coverage or $13,700 for family plans. Additionally, the law says insurers must charge in-network copayments for emergency department services at non-network hospitals because patients in urgent situations often can’t choose where they go.

Many PPO plans still do include annual limits on what a consumer might have to pay toward non-network care. (Any balance bill amounts generally do not count toward those deductibles or annual caps.) Often, those maximums are set at amounts double the in-network limits, but can range far higher.

In Montana, the silver-level Blue Preferred Silver PPO 101 offered by Blue Cross Blue Shield for 2016 has an out-of-network cap three times the in-network rate: $26,000 for individuals and $52,800 for family coverage.

A bronze-level plan offered by Anthem next year in Indiana has an out-of-network maximum of $30,000 a person, or $60,000 for a family. In Pennsylvania, Independence Blue Cross offers a silver-level PPO that carries a $20,000 a person and $40,000 a year out-of-pocket cap for non-network care.

Nationally, the mean out-of-pocket cap for non-network care for an individual in silver-level PPO plans $16,700, the RWJF analysis finds.

While not an exact comparison, another study, this one by the benefits firm Mercer, showed the midpoint for these caps for workers with job-based insurance is $6,000 for individuals and $12,000 for families.

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Women who have an abnormal mammogram should stay vigilant for cancer for for the next decade, even when follow-up tests fail to detect cancer, a study released Wednesday finds.

That’s because there’s a “modest” risk that cancer will develop during the next decade, says lead author Louise M. Henderson of the University of North Carolina School of Medicine in Chapel Hill.

The absolute increase in risk amounts to about 1 additional cancer in every 100 women who have a false positive mammogram over a 10-year period, she says.

But when put another way, the numbers may appear alarming. The study divided women into two groups — those who got additional imaging and those who also got biopsies.

Women with an abnormal screening mammogram had a 39 percent higher risk of cancer if they got additional imaging that turned out to be negative, too. That’s compared with women who were truly negative and never developed breast cancer.

For women who got biopsies that turned out negative, the chance of cancer was increased by 76 percent over the next 10 years.

“We don’t want women to read this and feel worried,” Henderson says. Instead, the findings should be considered one more “useful tool” when weighing all the other factors that might be raising a particular woman’s risk, such as age, race, breast density and family history of breast cancer.

Henderson says the study wasn’t designed to figure out why a falsely positive mammogram is associated with an increased cancer risk.

It’s possible, she says, that the increased risk “could be the fact that the radiologist sees an abnormal pattern that’s not cancerous, but it’s a radio-graphic marker,” and it could be that this is a precursor to some subsequent cancer diagnosis.

The study, done at several leading universities, looked back at more than 2.2 million screening mammograms considered to be false alarms between 1994 and 2009. It was published Wednesday in Cancer Epidemiology, Biomarkers & Prevention. The mammograms were done in 1.3 million women, ages 40 to 74.

Earlier studies have had conflicting results. But the size of this study makes researchers more confident that whatever is going on is a true phenomenon and not chance, says Dr. Richard Wender, chief cancer control officer of the American Cancer Society.

“If you’ve had a false positive, that is a risk factor,” he says, “so it’s very important that a woman stay up to date with regular mammography.”

As it is now, Wender says, at least one-third of women who should be getting routinely screened for breast cancer are falling behind schedule.

The cancer society created controversy in October, when it changed its guidelines to recommend that regular screening start at age 45. Other groups recommend starting earlier, at age 40, and some say it’s OK to wait until age 50.

Studies have shown that the chance of getting an abnormal screening mammogram that is falsely positive is about 50 percent over the course of 10 years. That often leads to further testing, including more mammograms, possible ultrasound exams, MRIs and even biopsies.

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Kentucky Gov.-elect Matt Bevin, who takes office Dec. 8, plans to dismantle the state’s successful health insurance exchange and shift consumers to the federal one. It’s a campaign promise that has sparked controversy in the state.

Supporters of Kentucky’s exchange, called Kynect, have asked Bevin to reconsider. They say the exchange created under Obamacare and an expansion of Medicaid have improved public health by dramatically increasing the number of Kentuckians with health coverage.

But health analysts say Bevin’s plan to move Kentucky to HealthCare.gov would have little immediate effect on consumers. “The federal exchange is a perfectly viable alternative,” says Jon Kingsdale, a health care consultant who formerly led the Massachusetts agency that started the state’s exchange in 2006, providing the model for the federal health law. On a federal exchange, consumers would still be able to shop and enroll in private plans and apply for federal subsidies to lower their costs.

And even if Kynect goes away, other states with exchanges will likely decide individually what’s best for them rather than rush to follow Kentucky’s example.

State-run exchanges do have some advantages, Kingsdale says. For instance, they make it easier for people to enroll in Medicaid because the exchanges connect directly to the state-federal program health insurance program for the poor in each state. State exchanges also generally have lower premium taxes than the federal exchange, fees that insurers pass on to consumers. And states that run their own exchanges have more say about insurance options for consumers than those states that use the federal marketplace.

Bevin’s plan to end Kynect has brought a strong rebuke from Obamacare advocates and outgoing Kentucky Gov. Steve Beshear, but it’s also revived questions about whether the states or the federal government are best positioned to run the marketplaces. Bevin is a Republican and Beshear is a Democrat.

The exchanges are a linchpin in the federal law that has brought health coverage to 16 million people since 2010. The law’s drafters initially thought all but the smallest states would run their own exchanges. Most Republican governors blocked them in their states, citing opposition to the Affordable Care Act.

Thirteen states run their own insurance exchanges. The rest are run fully or in part by the federal government. If Bevin follows through on his plan, Kentucky would be the first state to close its exchange and push most responsibilities to the federal government.

Nevada, Oregon and Hawaii ran into technological problems with their enrollment systems and have shifted in the past year to using the federal HealthCare.gov site. But the states still handle other marketplace functions, including marketing and offering consumer assistance. Nevada and Oregon both posted solid enrollment gains in the second annual enrollment period ended in March 2015 after switching to HealthCare.gov.

Overall, state-run exchanges have enrolled higher percentages of their uninsured citizens than states using the federal exchange. That’s partly because all but one state with its own exchange also has expanded Medicaid, making millions more people eligible. Idaho is the only state that has its own exchange and has not broadened Medicaid. Twenty states have not expanded Medicaid.

Kentucky’s exchange is considered one of the best-run state exchanges because of its innovative, extensive marketing to uninsured consumers and its ease of use. About 500,000 Kentucky consumers have enrolled on Kynect since 2013, most of them for Medicaid. The state’s uninsured rate has dropped from 20 percent to 9 percent over the past two years, according to the latest Gallup poll.

Bevin says he is concerned that the state could end up being on the hook financially if its revenues from premium taxes don’t keep up with Kynect’s operating expenses. That wasn’t a problem in the exchange’s startup years when the federal government paid all the costs for state exchanges. But the federal money has run out, and Kynect, like other state exchanges, must rely mainly on premium taxes to fund operations.

Several states including Vermont and Minnesota are struggling to raise enough revenue through premium taxes. With less money, some state exchanges including Rhode Island have greatly curtailed marketing to attract more enrollees.

States that run their own exchanges retain more control over their individual insurance markets and the consumer sign-up experience, says Dan Schuyler, at health care consulting firm Leavitt Partners. California’s exchange, for instance, limits which insurers can participate to help it negotiate better rates. Connecticut’s exchange requires all insurers to offer standardized plans so it’s easier to compare rates and benefits.

Even so, a shift by Kentucky to the federal exchange wouldn’t change their insurance choices right away. “If you take consumers out of Kynect and put them into the federal marketplace from a product perspective nothing changes as consumers have access to same plans,” Schuyler says.

But the move would cost Kentucky control over which nonprofit groups provide consumer assistance and the state’s call center would likely move out. State exchanges could lower their costs by using HealthCare.gov for enrollment while retaining other functions such as consumer assistance and marketing. Starting next year, the federal government will charge state exchanges to use its enrollment system.

Kynect has an annual budget of about $28 million, funded by its 1 percent assessment on health premiums. The assessment would increase to 3.5 percent in a federal exchange, and dismantling Kynect would cost the state an estimated $23 million in one-time expenses, said Audrey Tayse Haynes, head of Kentucky’s Cabinet for Health and Family Services.

The earliest that Bevin could shut down Kynect would be in 2017, because the health law requires a 12-month notice to the federal government.

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If you’re a low-income woman, you’re more likely to get screened for breast cancer if you live in a state that expanded Medicaid under the Affordable Care Act than in a state that didn’t.

According to new research, low-income women who lived in a handful of early-adopter states that implemented Medicaid expansion by 2011 were 25 percent more likely to be screened for breast cancer in 2012 than women in non-expansion states. That’s a big change from 2008, when low-income women in both sets of states had similar odds of being screened. The study was presented Monday at the annual meeting of the Radiological Society of North America.

The researchers had hoped to see an effect from the Medicaid expansion, says lead author Soudabeh Fazeli Dehkordy. “We would expect to see actually greater differences if we redo the analysis today with 2015 [data],” says Fazeli Dehkordy, a resident at St. John Providence Hospital in Southfield, Mich.

Under the Affordable Care Act, states had the option of expanding Medicaid to cover low-income people living at or below 138 percent of the federal poverty level. Thirty states and the District of Columbia have expanded the health insurance program for low-income people, while 20 states are not adopting the expansion at this time.

Fazeli Dehkordy and her colleagues used data from the 2008 and 2012 Behavioral Risk Factor Surveillance System to look at roughly 31,000 American women ages 40 to 70 who self-reported how often they got mammograms. When the researchers adjusted for age, race, education and income, they found that low-income women in the early-expansion states in 2012 – which included California, Connecticut, Minnesota, New Jersey, Washington and the District of Columbia – were 25 percent more likely to get screened than women in non-expansion states.

Several studies have indicated a general decline in mammography rates following updated recommendations from the U.S. Preventive Services Task Force in 2009, Fazeli Dehkordy says. Those recommendations suggested that women could wait until age 50 before beginning regular mammograms and, at that point, begin getting them every other year. “There has been a lot of controversy regarding the importance of screening mammography, especially regarding the best age,” Fazeli Dehkordy says.

Indeed, the guidelines can still be confusing to women: the American Cancer Society updated its guidelines in October, pushing back the age at which it recommends women begin annual screenings from 40 to 45.

Yet despite the overall decline in screening rates, screening rates among low-income women stayed steady from 2008 to 2012 in states that expanded Medicaid early on, the researchers found.

The next step for research, Fazeli Dehkordy says, is to explore whether expanded coverage and more mammograms translate to better health outcomes with regard to breast cancer. For this study, the researchers did not look into whether low-income women who are now on Medicaid had difficulty finding providers where they could obtain screenings or specialists to follow up with if a screening finds something abnormal.

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The suspect in the shooting at Planned Parenthood in Colorado Springs was in court Monday. Robert L. Dear faces multiple counts after the deadly attack that left three people dead and nine wounded.

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