Every month, a group of older adults goes to Washington, D.C.’s Sibley Memorial Hospital, but they don’t see a doctor or get tests. They’re not sick. They come just for laughs.

They gather in a room next to the hospital cafeteria for the “Laugh Cafe,” one of the activities offered to local seniors, including the 7,300 members of Sibley’s Senior Association. The price of admission is one joke, recited out loud. Experts say laughing can be good for your health, and everyone in the room strongly agrees.

“Absolutely, it’s the best medicine,” said Joanne Philleo, 79, from Bethesda, Md.

“I like to come with Joanne, and I love the jokes,” said Jean Altimont, 89. “I never dreamed of telling a joke in front of a group, and the first time I came, I was real nervous.”

Some jokes took a few twists before getting to the punchline, a few were almost R-rated, others were one-liners: My husband wanted more space, so I left him outside. I sold my vacuum because it was gathering dust. Why do men like smart women? Because opposites attract.

And if one had been told before, no one cared.

The association for those age 50 or older also offers other activities, including French and Italian conversation classes, day trips to museums, a current events group, and — the latest addition — tango lessons. In addition, members receive discounts on hospital parking and at the gift shop, pharmacy and restaurant. In all, more than 10,000 seniors participate.

“I call this a senior center without walls,” said Marti Bailey, the association’s director. The program started in 1987 with exercise and patient-support groups. Members pay a one-time $40 membership fee.

Concerns About Marketing

Sibley is one of several hospitals in the Washington area — along with others across the country — offering social activities and other benefits to help seniors stay healthy and out of the hospital, while encouraging them to visit. Participants do not need to have been patients.

But some hospital finance experts are concerned that the activities are less about health than about marketing to Medicare beneficiaries, especially those who can go to the hospital of their choice when they need care because they are not enrolled in private insurance plans with limited provider networks.

Gerard Anderson, director of the Center for Hospital Finance and Management at the Johns Hopkins Bloomberg School of Public Health in Baltimore, said such programs across the country can be a good business strategy. (Anderson was not speaking on behalf of Johns Hopkins Medicine, whose six hospitals include Sibley.)

“If they can get you in the door and you have a pleasant experience, then the next time you need to go to the hospital, you have a place you’ve been to and where you feel comfortable,” Anderson said.

Medicare, which covers 55 million older and disabled Americans, provides as much as half of some hospitals’ income. “Medicare may not be the best payer, but they are still a very good payer, and a filled bed is better than an unfilled bed,” he said.

While hospitals may be seeking brand loyalty, they can also appeal to the increasing number of older adults living independently who are looking beyond traditional senior centers and local social service agencies to meet their needs.

“Hospitals are trying to promote the notion of the health and wellness of aging and trying to change their image from places of sickness and death to ones of health and wellness,” said Fredda Vladeck, director of the Aging in Place Initiative at the United Hospital Fund, a health research and philanthropic organization.

And the strategy may be working.

“This is isn’t a hospital per se, because there’s so many things to do,” said Philleo, joining her friends for lunch in the Sibley cafeteria after the Laugh Cafe event. “This is a place that contains a hospital.”

“And they make a great Philly cheese steak,” said Tom Reynolds, 78, the Laugh Cafe’s volunteer leader and joker-in-chief.

The Virginia Hospital Center in Arlington runs a similar outreach project for seniors. Its program, called the Senior Health Department, offers free lectures on healthy aging, assessment of fall risk and memory, exercise classes (for a small fee), yoga and a mall-walking group. A separate Senior Associates program provides 1,600 members — who are at least 60 years old and pay an annual fee of $45 ($65 for couples) — with annual blood screenings, complimentary parking and discounts on exercise classes and meals.

“Some older people don’t like to cook for themselves, and this may be the only hot meal they get” for the day, said Cathy Turner, the hospital’s director of health promotion and senior health.

The hospital setting provides “a level of comfort,” said Turner, especially for seniors who may feel intimidated at a fitness club or YMCA.

‘Dance And Rock-And-Roll’

“You can exercise at home, but it’s not the same,” said Donna Miller, 56, who recently drove with her friend Glorious “Glo” Mary Cooper, 61, to downtown Silver Spring, Md., for an event run by Holy Cross Hospital’s Senior Source program. The main attraction was a dance class where participants practice routines set to Broadway show tunes — with top hats and canes — and Motown hits.

“The best way to stay healthy is to do things you like, like dance and rock-and-roll,” Cooper said.

“When you get into a group like this, it’s so inspiring, it just works, it flows,” Miller said.

Last year, 4,800 people 55 and older participated in Senior Source programs. Offerings include classes on disease management, financial planning, fall prevention, low-impact exercise, dance, art appreciation and a current-events discussion group. A class called “Are You Smarter Than Your Smartphone?” promises to unlock the secrets of cellphones.

The Senior Advantage program at George Washington University Hospital has about 9,000 members. Anyone 65 or older can join for a one-time $10 fee ($15 for couples) and receive hearing tests, health insurance counseling and discounts at the cafeteria and gift shop.

Several other Washington-area hospitals also offer programs for seniors, including Inova Health System and Suburban Hospital.

Some activities require a nominal fee, but the hospitals generally pick up the bulk of the cost. Nonprofit hospitals consider those expenses part of their community benefits, the wide variety of services that they offer along with free medical care for low-income patients that help maintain their tax-exempt status.

Although it may seem counterintuitive for hospitals to try to keep people healthy when they are in business to treat illness, new Medicare payment incentives and penalties encourage hospitals to reduce patient readmissions, improve care and make hospitals “think more broadly about what health care really is,” said J.B. Silvers, a professor of health-care finance at the Weatherhead School of Management at Case Western Reserve University in Cleveland.

During a break between classes at Sibley Hospital, Bailey acknowledged the hospital’s changing mission.

“Health-care transformation requires we do everything we can to increase people’s health, rather than waiting for them to get ill,” she said. “Health care doesn’t stop when you leave the hospital.”

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Backers of a bill that would have allowed terminally ill Californians to get lethal prescriptions to end their lives shelved the legislation Tuesday morning because they lacked the votes to move it out of a key committee.

The End of Life Option Act, had already cleared the state Senate, but faced opposition in the Assembly Health Committee.

Among those expected to vote against the bill were a group of southern California Democrats, almost all of whom are Latino, after the Archdiocese of Los Angeles increased its lobbying  efforts. Church officials argued that some poor residents could feel pressured into ending their lives prematurely if they couldn’t afford expensive medical treatment. Disability rights advocates have also fought against the legislation.

“We continue to work with Assembly members to ensure they are comfortable with the bill,” said a joint statement from Sens. Lois Wolk, D-Davis, and Bill Monning, D-Monterey, and Assemblywoman Susan Eggman, D-Stockton. “For dying Californians like Jennifer Glass, who was scheduled to testify today, this issue is urgent. We remain committed to passing the End of Life Option Act for all Californians who want and need the option of medical aid in dying.”

Under the bill, mentally competent adults who are terminally ill with less than six months to live could request lethal medication from a physician.

“We’re going to review our options,” Monning said in an interview later. “We walk away from the decision today knowing that we’re going to have to spend more time cultivating our colleagues in the Assembly.”

The aid-in-dying issue was brought home to Californians last year after 29-year-old resident Brittany Maynard moved to Oregon so she could get a lethal prescription under that state’s death with dignity law. Maynard was terminally ill with brain cancer and died last November. A video she recorded 19 days before she took life-ending drugs was shown at a Senate hearing in March.

Last month, a poll found that 69 percent of Californians and 70 percent of Latinos supported the bill. The poll was conducted by the advocacy group Compassion and Choices.

The bill also got a boost after the California Medical Association changed its stance from opposed to neutral.

It was modeled after a 1994 Oregon law that permits aid in dying. Four other states — Washington, Montana, Vermont and New Mexico — have similar laws.

This story is part of a reporting partnership with NPR, KQED and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Women are saving a lot of money as a result of a health law requirement that insurance cover most forms of prescription contraceptives with no additional out-of-pocket costs, according to a study released Tuesday. But the amount of those savings and the speed with which those savings occurred surprised researchers.

The study, in the July issue of the policy journal Health Affairs, found that the average birth control pill user saved $255 in the year after the requirement took effect. The average user of an intrauterine device (IUD) saved $248. Those savings represented a significant percentage of average out-of-pocket costs.

“These are healthy women and this on average is their No. 1 need from the health care system,” said Nora Becker, an MD-PhD candidate at the University of Pennsylvania and lead author of the study. “On average, these women were spending about 30 to 44 percent of their total out of pocket (health) spending just on birth control.”

The study looked at out-of-pocket spending from nearly 800,000 women between the ages of 13 and 45 from January 2008 through June 2013. For most plans, the requirement began Aug. 1, 2012, or Jan. 1, 2013. So-called “grandfathered” health plans, those that have not substantially changed their benefits since the health law was passed in 2010, are exempt from the mandate, as are a small subset of religious-based plans.

Becker said that while making birth control substantially cheaper may not increase the number of women who use it, the new requirements could well shift the type of birth control they use to longer-acting, more effective methods like the IUD. “If prior to the ACA a woman was facing $10 to $30 a month for the pill but hundreds of dollars upfront for an IUD and now both are free, we might see a different choice,” she said.

Researchers also found that while out-of-pocket spending dropped dramatically for most types of prescription contraceptive methods — “the majority of women were paying nothing by June 2013” –spending barely budged for the vaginal ring or hormonal patch.

That could be because under the original rules, many insurers declined to make the ring or patch free, since, like pills, they are essentially hormone delivery methods.  Earlier this year, the Obama administration issued a clarification saying that while insurers do not have to offer every brand of every method, they do have to cover at least one product in each category, including rings and patches.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

ANAHEIM, Calif. — When Fabiola Ortiz heard California had granted health coverage to poor children lacking legal immigration status, she felt grateful. Since arriving in the U.S. illegally 12 years ago, she has taken her two youngest children to the doctor only for required school physicals and relied on home remedies for everything else.

“The truth is that we really need insurance,” the 46-year-old Anaheim resident said. “For the children, it will be a big help.”

The coverage under Medi-Cal, the state’s version of Medicaid, is expected to result in more preventive care and better long-term health for an estimated 170,000 children who have long relied on safety-net clinics and emergency rooms. But while many policymakers, advocates and researchers celebrated the budget deal announced by Gov. Jerry Brown last month, they also said the new coverage is limited because it doesn’t guarantee access to doctors and doesn’t include adults.

“This is an important investment,” said Claire D. Brindis, director of the University of California San Francisco’s Institute for Health Policy Studies. “But it is not the full solution.”

About 1.16 million low-income adults are in California illegally and ineligible for comprehensive Medi-Cal services, though they may qualify for pregnancy and emergency care. In many areas of the state, they can get county-based coverage, but it also is not comprehensive and can’t be used in other counties.

Orange County, where Ortiz lives, doesn’t offer such coverage. She wishes the state would allow her and her oldest son to sign up for Medi-Cal, too. He is 22 and has heart problems that have landed him in the emergency room about three times a year. She has to pay out-of-pocket for his regular visits to a cardiologist.

State Sen. Ricardo Lara, a Democrat from Bell Gardens, has proposed legislation that could extend Medi-Cal to low-income adults living in the state illegally, depending on available funding. The bill also requests a waiver from the federal government enabling higher-income immigrants to buy unsubsidized insurance through the state’s insurance marketplace.

In the meantime, Aracely Patchett, an administrator at Central City Community Health Center in Anaheim, where Ortiz gets care, said the new health coverage will enable her staff to refer the children to specialists. “Not being able to provide the care they deserve has been frustrating,” she said.

And Carmela Castellano-Garcia, president of the California Primary Care Association, said having the children covered will boost community health centers’ bottom line because many centers until now have been serving this population at a loss.

“These victories just fuel the fire continuing forward,” she said. “These incremental steps are very critical.”

Health researcher Laurel Lucia said she isn’t surprised that the state decided, for now, to cover children because there are fewer of them than adults and they are less costly. In addition, providing them with preventive care is a good long-term investment for the state, said Lucia, health care program manager at the University of California Berkeley Center for Labor Research and Education.

Also, Lucia said, “there is more sympathy toward kids.”

The children’s insurance will only help health and immigration advocates in their fight to cover everyone, said Wendy Lazarus, co-president of The Children’s Partnership, a nonprofit child advocacy organization.

“It is a hugely important step forward for the state and something we can build on,” she said. “Momentum is really building in California to finish the job and cover all residents, regardless of age.”

Opponents said California shouldn’t force its citizens to pay for health care for people here illegally.

“We’re talking about transferring tens of millions of dollars from taxpayers–citizens and lawful permanent residents–to those who have flouted our nation’s immigration laws and are now laying claim to the property of others,” said John C. Eastman, a law professor at Chapman University in Orange.

Eastman said the magnet for illegal immigration was already large enough in California. “Governor Brown and the Democrats in the state legislature have now made that magnet even larger,” he said.

The children will enter a Medi-Cal system that has more than 12 million enrollees and is struggling to ensure access to care. About 2.3 million people have joined the Medi-Cal rolls since the beginning of 2014, when the Affordable Care Act took full effect. About half the children in the state are now on Medi-Cal.

The California State Auditor recently found that the state had failed to ensure that Californians in Medi-Cal managed care could find doctors. And last year, the auditors said that only half of children enrolled in Medi-Cal were receiving dental care. Their audit cited insufficient numbers of dentists in some areas due to low reimbursement rates.

Meanwhile, because immigrants living here illegally have long been excluded from coverage, getting them to sign up won’t necessarily be easy.

“We have a big challenge ahead of us to dispel the perception that undocumented people are forever left out,” said Daniel Zingale, senior vice president at The California Endowment, which has invested heavily in the campaign dubbed “Health for All” to cover all immigrants.

Zingale said community clinics, faith-based groups and the ethnic media will likely play a big role in educating families about the new coverage.

Experience has shown that even when immigrants living here illegally qualify for coverage, they may not apply. UC researchers found that many adults under 30 who were granted temporary legal status and became eligible for Medi-Cal were still likely to remain uninsured. That’s because they weren’t aware of their eligibility or were worried about the effect on relatives in the country without legal permission.

Jacqueline Curiel, a Santa Ana-based administrator for the AltaMed Health Services Corp. Community Health Center, said many people fear that enrolling their children in public programs could hurt the family’s chances of getting legal status. She said her staff has a tough job assuring patients that it won’t affect their immigration cases.

“There is a lot of distrust,” Curiel said.

Curiel said she is hopeful that the parents will soon be eligible for comprehensive Medi-Cal. But even if California’s policymakers don’t opt to cover adults, immigrant families are better off than in the past.

“We’ve made large strides,” she said.

Blue Shield of California Foundation helps fund KHN coverage in California.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Dr. Kendra Fleagle Gorlitsky recalls the anguish she used to feel performing CPR on elderly, terminally ill patients.

“I felt like I was beating up people up at the end of their life,” she says.

It looks nothing like what people see on TV. In real life, ribs often break and few survive the ordeal.

Gorlitsky now teaches medicine at the University of Southern California and says these early clinical experiences have stayed with her.

“I would be doing the CPR with tears coming down sometimes, and saying, ‘I’m sorry, I’m sorry, goodbye.’ Because I knew it very likely was not going to be successful. It just seemed a terrible way to end someone’s life.”

Gorlitsky wants something different for herself and for her loved ones. And most other doctors do too: A Stanford University study shows almost 90 percent of doctors would forego resuscitation and aggressive treatment if facing a terminal illness.

It was about 10 years ago, after a colleague had died swiftly and peacefully, that Dr. Ken Murray first noticed doctors die differently than the rest of us.

“He had died at home, and it occurred to me that I couldn’t remember any of our colleagues who had actually died in the hospital,” Murray says. “That struck me as quite odd, because I know that most people do die in hospitals.”

Murray began talking about it with other doctors.

“And I said, ‘Have you noticed this phenomenon?’ They thought about it, and they said, ‘You know? You’re right.’ ”

In 2011, Murray, a retired family practice physician in Los Angeles, shared his observations in an article that quickly went viral. The essay, “How Doctors Die,” told the world that doctors are more likely to die at home with less aggressive care than most people get at the end of their lives. That’s Murray’s plan, too.

“I fit with the vast majority that want to have a gentle death, and don’t want extraordinary measures taken when they have no meaning,” Murray says.

A majority of seniors report feeling the same way. Yet, they often die while hooked up to life support. And only about one in 10 doctors report having conversations with their patients about death.

One reason for the disconnect, says Dr. Babak Goldman, is that too few doctors are trained to talk about death with their patients. “We’re trained to prolong life,” he says.

Goldman is a palliative care specialist at Providence Saint Joseph’s Medical Center in Burbank, Calif., and he says that having the tough talk may feel like a doctor is letting a family down.

“I think it’s sometimes easier to give hope than to give reality,” Goldman says.

Goldman read Murray’s essay as part of his residency. Goldman too would prefer to die without heroic measures, he says, and knowing how doctors die is important information for patients.

“If they know that this is what we’d want for ourselves and for our own families, that goes a long way,” he says.

In addition, Medicare does not pay doctors for end-of-life planning meetings with patients.

Nora Zamichow wishes she had read Murray’s essay sooner. The Los Angeles-based freelance writer says she and her husband, Mark Saylor, likely would have made different treatment decisions for Saylor’s brain tumor if they had.

Zamichow says that an arduous regimen of chemotherapy and radiation left her 58-year-old husband unable to walk, and ultimately bedridden, in his final weeks.

“At no point,” she says, “did any doctor say to us, ‘You know, what about not treating?’ ”

Zamichow realized after reading Murray’s essay that doing less might have offered her husband more peace in his final days.

“What Ken’s article spelled out for me was, ‘Wait a minute, you know, we did not get the full range of options,’ ” she says.

But knowing how much medical intervention at the end of life might be most appropriate for a particular person requires wide-ranging conversations about death.

Murray says he hopes his essay will spur more physicians to initiate these difficult discussions with patients and families facing end-of-life choices.

This story is part of a partnership that includes NPR, Southern California Public Radio and Kaiser Health News.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.