Pew Charitable Trusts

A year ago, Laura Hall felt tired all the time, was losing weight and had a bad cough.

The 41-year-old Spanish teacher from Shelburne, Vermont, went to doctors for three months before they finally nailed the diagnosis: active tuberculosis.

“I was scared. I was horrified. Oh my gosh, how did I get this? Where did I get it?” Hall said in a video about TB survivors’ experiences. “I didn’t think that I could get TB, ever.”

While Hall underwent treatment — isolation at home and a demanding regimen of antibiotics and other drugs — the Vermont Department of Health tested about 500 students and co-workers who might have been exposed to her. Nineteen children and two adults tested positive for latent TB. (People with latent TB aren’t sick or contagious, but they carry a greater lifetime risk of developing active TB.)

Hall’s was one of seven active cases in Vermont last year, up from two the year before. Twenty-nine states and the District of Columbia also reported more active TB cases last year than in 2014, the Centers for Disease Control and Prevention reported in March.

After two decades of steady decline, the number of active tuberculosis cases in the U.S. inched up last year. Hall’s was one of 9,563 TB cases reported last year, up from 9,406 cases the year before. The CDC is still trying to determine the reason for the uptick.

The goal set by the CDC, in 1989, of eliminating TB by 2010 — defined as less than one case in a million people — remains elusive. Even if the trend of declining cases had continued, the United States would not have eliminated TB by the end of this century, the CDC said.

“We are not yet certain why TB incidence has leveled off, but we do know it indicates the need for a new, expanded approach to TB elimination,” said Dr. Philip LoBue, director of the CDC’s Division of Tuberculosis Elimination, in an email.

A dual approach is needed: continue to find and treat cases of disease and evaluate their contacts as well as identify and evaluate other high-risk persons for latent TB infection, he said.

In Vermont, health officials aren’t sure whether last year’s increase was just a statistical anomaly or the beginning of a trend. In case it is the latter, the state Health Department is considering contracting with an outside firm to help it test contacts for exposure. Last year, the shorthanded department brought in health staff from around the state as well as volunteers from the Vermont Medical Reserve Corps to test contacts for exposure.

“We were lucky it wasn’t worse,” said Laura Ann Nicolai, deputy state epidemiologist and head of the tuberculosis control program.

Airborne Bacteria

TB is an airborne infectious disease caused by bacteria that spreads through the air, person to person, when someone coughs or sneezes. One in three people worldwide have latent TB, according to the World Health Organization. In the United States, up to 13 million people have been exposed to TB and could develop the disease.

Every year, tuberculosis claims 1.5 million lives worldwide and 500 to 600 in this country.

In the United States, Asians have the most cases and the highest rate of disease — 17.9 out of 100,000 persons. The top five countries of origin for foreign-born TB patients are Mexico, the Philippines, Vietnam, India and China.

Immigrants and refugees are screened for TB and treated before entering the United States. Tourists, students and temporary workers are not screened. The CDC does not recommend across-the-board screening for everyone entering the United States, the CDC’s LoBue said.

Because TB hits some ethnic and racial groups harder than others, TB patients can face discrimination and social isolation. Public health officials worry about finding ways to target high-risk populations with TB education and treatment without stigmatizing those groups.

“Given the stigmatization of TB, our ability to do targeted interactions is limited,” said Dr. Jeffrey Starke, a pediatric tuberculosis physician at Texas Children’s Hospital in Houston. Starke is a member of the federal Advisory Council for the Elimination of Tuberculosis, which makes policy recommendations. “We’ve got to find a nonpejorative way to do it so others don’t perceive discrimination,” he said.

Going in the Wrong Direction

State and local health departments are the front line of defense for a disease that many think has already been eradicated. In the late 1800s and early 1900s, TB was a leading cause of death in this country and Europe. With no cure for the disease, patients were urged to “go west.”

More people flocked to Colorado as TB patients looking for dry air and sun than stormed the state as prospectors during the gold rush. Among them: Doc Holliday, friends with gunslinger Wyatt Earp and a participant in the shootout at the O.K. Corral.

“Colorado historically has been on the forefront of TB work,” said Dr. Robert Belknap, director of the Denver Metro TB program. “At the turn of the century, one-third of the state was here because of TB — seeking care for themselves or family members,” he said.

Some of Colorado’s first hospitals were TB sanatoriums, later closed and repurposed. Local and state support for TB prevention and control remains strong in Colorado, said Belknap, president of the National Tuberculosis Controllers Association.

Today four states — California, New York, Texas and Florida — have more than half the nation’s active TB cases, though they have only a third of the country’s population. The four states have the highest numbers of foreign-born residents. The number of cases in Texas rose 5 percent to 1,334 last year.

“We’re clearly going in the wrong direction,” Starke said.

He pointed out that TB is “a social disease with medical implications” because living conditions put someone at risk. TB is associated with poverty, overcrowding and being born outside the United States.

California, with 2,137 cases in 2015, has more than one in five of the new U.S. cases each year and a TB rate nearly twice the national average. Its TB prevention and control program is the nation’s largest — a $17.2 million annual budget split roughly in half between federal and state general funds, and a 40-person central office staff that works with TB contacts in the state’s 61 local health jurisdictions.

In addition to state TB control efforts in California, local health department programs in the counties of Los Angeles, San Diego and San Francisco also receive federal TB control grants from the CDC. Those grants total $7.7 million this year.

About 2.5 million people are infected with TB in California, but most don’t know it, said Dr. Jennifer Flood, chief of California’s TB control program.

While California has several programs aimed at latent TB, she said, “Smaller states are often challenged to test and treat latent TB” because they lack the resources.

Labor Intensive Treatment

Treating TB patients is labor intensive. To ensure that TB patients complete the course of drugs that lasts six months or longer, Directly Observed Therapy programs require a health care worker — not a family member — to watch patients with active TB swallow every dose. If a patient cannot get to a clinic, a health care worker goes to the person’s home. The worker monitors patients for side effects and other problems.

Care also involves communication and cultural challenges. In Michigan, where the number of active TB cases rose from 105 in 2014 to 130 last year, the health department reaches out to Detroit’s large Arab and Bangladeshi populations. In other parts of the state, Burmese immigrants have different needs, said Peter Davidson, Michigan TB control manager.

“Some local health departments have strong partnerships with translation services. Some rely on a less formal mechanism — a private physician or someone on staff at the hospital who speaks the language,” Davidson said.

The cost of treating an active TB case that is susceptible or responsive to drugs averages $17,000, according to the CDC. Care of patients with drug-resistant TB, which can result from taking antibiotics prescribed before TB was properly diagnosed, costs many times more: $134,000 for a multidrug-resistant patient and $430,000 for an extensively drug-resistant one.

Advocates say TB suffers from a lack of urgency and funding.

“TB isn’t as exciting a topic because it’s been around so long. It doesn’t get as much attention as Ebola and Zika, and its advocates aren’t as active as those for HIV/AIDS,” said Belknap. “We’re jealous.”

The federal Tuberculosis Elimination Act, the chief federal funding for TB programs, is authorized at $243 million a year but has received an appropriation of far less for the last several years — $142 million this year, for example.

Most of the money goes to the 50 states, the District of Columbia, 10 major cities and eight territories in grants under a formula based on the number of cases, their severity and other factors. The grants are used to pay salaries for nurses, doctors and epidemiologists, as well as for education and outreach services. Treatment costs are paid by insurance, Medicaid and state and local governments.

Funding at the authorized level could support research on a vaccine and better drugs and treatment of more cases of latent TB, advocates say. For now, no TB vaccine is approved for use in the United States. The medicines that cure TB and brought down the disease rate were developed in the mid-20th century. They require months of treatment and can have serious side effects, including hearing loss. A promising new drug may be able to prevent TB with only 12 doses over three months.

“The tools we have are inadequate,” Belknap said. “It’s a federal and a global problem.”

A Story of Success

In many ways, though, the story of TB prevention and treatment in the United States is one of success.

“We often say we’re our own worst enemy,” said Donna Wegener, executive director of the National TB Controllers Association. “We had such success in reducing TB after the resurgence in the 1990s that people think we don’t need additional dollars.”

Patients with diabetes, cancer and especially HIV infection are more likely to contract active TB because their immune systems are less able to fight off TB germs. During the HIV/AIDs epidemic, from the mid-1980s to the early 1990s, the number of TB cases jumped by 19 percent. From 1992 to 2014, the number of cases dropped 65 percent.

There were nearly as many cases of Lyme disease in Pennsylvania in 2014 (7,457) as there were TB cases in the United States (9,406).

But, Wegener said, “If we were reporting 10,000 new cases of polio a year in the U.S., that would be unacceptable. It’s criminal that we are OK with 10,000 cases of TB.”

Among those infected in the early 1990s was a young physician who volunteered to treat TB patients at a clinic in New York City. He tested positive for exposure but his latent TB did not progress to active disease. Tom Frieden now is director of the CDC, leading the fight against TB.

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Is Tuberculosis Making a Comeback?

Jonathan Mossberg has already made a smart gun — a shotgun that can only be discharged by someone wearing a ring that communicates with a chip inside the weapon, unlocking it.

The gunmaker’s smart guns, there are about 25 of them, are nearly 20 years old. They have been tested repeatedly and kept in the homes of his friends and family for self-defense. But Mossberg’s Florida-based company, iGun Technology Corp., has never scaled the high-tech components to a handgun. And cultural and political barriers have stood in the way of selling the guns commercially.

Gun safety advocates have pushed for commercially available smart, personalized guns that could only be fired by a specific person through radio frequency chips, fingerprint scans or other technology, for more than three decades. They argue that the technology could make guns safer by reducing accidental shootings and suicides, and by rendering stolen guns inoperable by crooks — if they were widely available and became more commonplace.

Now, there are signs that a commercial market for smart guns maybe has arrived. The federal government is quietly encouraging gunmakers to submit smart weapons for military-grade testing. New Jersey lawmakers are seeking to revise a law that has kept manufacturers and retailers from selling the guns for over a decade. And federal appeals court judges in the West are deciding whether states can require gunmakers to manufacture weapons with specific safety features.

“We’re getting so close,” said Stephen Teret, a longtime gun safety advocate and founder of the Center for Gun Policy and Research at Johns Hopkins University in Baltimore. “I can almost taste it now.”

Last month, the White House announced that it will work with state and local law enforcement agencies to draft baseline specifications for smart guns that could guide manufacturers in producing the weapons for police work. The Obama administration also plans to award grant money to law enforcement agencies to purchase smart guns once they’re available.

The federal government has tried since the mid-1990s to spur development of smart guns, though many of the projects it funded were abandoned because it was difficult to work the technology into handguns without compromising their function, according to an April report from the departments of Justice, Homeland Security and Defense.

The report notes that Mossberg’s shotgun was “possibly the first ever production-ready firearm equipped with user-authorization technology.”

Mossberg said he’s ready to put his technology into a handgun, but lacks the money needed to develop it. He estimates he will need $5 million to build 25 to 30 handguns for testing. Another $15 million could launch him into full production.

The iGun’s chip technology only works within centimeters and makes it impossible for anyone other than the person wearing the ring to fire it. It is more reliable than fingerprint identification, which has been tested by other gun manufactures, Mossberg said.

“You don’t need to think. You don’t need to whisper into it, ‘Rumpelstilskin’ or ‘Open Sesame,’ ” Mossberg said. “You don’t want to swipe your finger on it and say, ‘Please try again.’ There is no try again.”

Hurdles to Development

The biggest hurdles to bringing smart guns to market are political and cultural, Teret, the smart-gun advocate, said. Gun rights advocates worry their emergence will lead to government mandates dictating what kind of guns could be bought and sold, and politicians have been reluctant to counter the powerful firearms groups.

But Teret said that with federal interest in the technology, the guns could soon be available — and especially attractive to families who want to keep guns for self-defense, but have small children at home and want to ensure they will be safe from accidents.

“We make aspirin bottles that 4-year-olds can’t use,” Teret said. “Why are we making guns 4-year-olds can use?”

Between 2010 and 2014, 527 children under 18 were unintentionally killed by a firearm, according to the latest data compiled by the Centers for Disease Control and Prevention. In 2014, 33,599 people were killed by guns. Most of those deaths were suicides.

But smart guns won’t be a quick lifesaver because traditional guns are so prevalent, said James Pasco Jr., executive director for the Fraternal Order of Police.

Although it is impossible to know how many guns exist, the National Opinion Research Center at the University of Chicago reports that in 2014, 31 percent of U.S. households reported having a firearm.

“It would be centuries at the rate we’re going before it had any material effect on crime or even on accidental shootings,” Pasco said.

Pasco’s group doesn’t oppose a move to smart guns, but argues that law enforcement agencies shouldn’t be forced to adopt them.

Avoiding Mandates

Mossberg, the gunmaker, said he doesn’t want his products to be mandated either, which is exactly what many say a 2002 New Jersey law does.

“I’m first an American, second a businessman,” Mossberg said. “And that’s just wrong. Nobody should be told what to buy.”

Under the law, three years following the retail sale of a smart gun anywhere in the U.S., all guns sold in New Jersey would have to be smart guns. Lawmakers in California tried to pass a similar law in 2014, but it failed.

But Teret, who worked on the New Jersey law, admits that the mandate may have discouraged gunmakers and dealers from bringing smart guns to market across the country because they did not want to trigger the New Jersey directive. So now, he and other supporters are trying to revise the law to allow stores to carry traditional guns as long as they carry at least one smart gun model.

Opponents of revising the law, such as the National Shooting Sports Foundation and other gun groups, say it will still be expensive for retailers to comply and won’t change criminal behavior.

Gun ownership groups aren’t trying to block the technology, but gun owners should not be limited to a specific kind of gun, said Scott Bach, director of the New JerseyAssociation of Rifle and Pistol Clubs.

“If you want this technology to develop, take the mandate out,” Bach, also a National Rifle Association board member, told a New Jersey Senate committee last fall. “Take government hands off the process and let the technology develop naturally. Let’s see if there’s a market.”

Federal officials say they are trying to spur innovation and create a market for smart guns, not mandate them. And the 9th Circuit Court of Appeals in San Francisco soon may decide whether states can mandate their sale.

The court is considering a challenge to a 2003 California statute that requires that gunmakers produce firearms that indicate when there is a bullet in the chamber and won’t discharge when a gun’s magazine is detached.

Will They Work for Police?

Some local law enforcement leaders, like the San Francisco police chief, say they will welcome the opportunity to test smart guns. But it’s unclear whether police officers will embrace the technology.

Pasco, for instance, questions whether smart guns will be practical for police officers who may need to fire with the hand not wearing the radio frequency device or potentially use a colleague’s gun in an emergency.

“What do you do if your partner is down and your partner’s gun is available, but yours isn’t? You pick the gun up and you can’t shoot it,” Pasco said.

Mossberg acknowledged his guns likely won’t take off with police departments. He and Teret say they think the guns will have success with people who work by themselves and carry guns in public, such as air marshals, security guards and some school teachers — and who don’t want their guns to get in the wrong hands.

“I would hate to see some crazy guy take the air marshal’s gun when you’re 35,000 feet in the air and have the gun be able to work for him,” Teret said.

Parents who want to keep guns at home might also be eager to buy smart guns. A survey conducted last year by Teret and his colleagues found that 59 percent of Americans would be willing to buy a childproof smart gun, if they were going to purchase a new handgun.

What doesn’t appear to be in dispute is that smart guns likely could save some lives. “It’s just like airbags in cars,” Teret said. “We knew they would save lives, but we couldn’t tell how many until they got into the cars.”

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Is America Finally Ready for Smart Guns?

Drinking is more likely to be the cause of death in much of the Southwest than in other parts of the country. In parts of Appalachia and New England, it’s a drug overdose. Suicide by gun stands out as disproportionately lethal in parts of the Upper Midwest and Alaska.

Although the top causes of death are similar for most states, many states have their own peculiar hard cases —types of deaths whose rates are higher than the national norm, a Stateline analysis of 2014 data from the Centers for Disease Control and Prevention shows.

The analysis, which relies on a method similar to one used in a CDC journal, shows some understandable disparities in the causes of death in some regions. The South, the epicenter of the nation’s obesity epidemic, has high rates of heart-related deaths. New Mexico and Arizona, where American Indian reservations have struggled with alcohol for decades, have high rates of alcohol-related deaths.

Some are more puzzling. Why, for instance, are falls disproportionately killing people in Northern states such as Iowa, Minnesota and Wisconsin? Why is Alzheimer’s disease causing relatively more deaths in Washington state?

State and local health officials increasingly plumb such disparities for clues that may help them develop preventive programs and save lives.

For instance, Kentucky and New Hampshire have high rates of death by accidental poisoning, which includes drug overdose. In response, Kentucky has begun a program to monitor the prescribing of addictive painkillers. It has also expanded the availability of treatment for substance abuse.

New Hampshire Gov. Maggie Hassan, a Democrat, signed a bill in January calling for stiffer penalties for drug dealers and more tracking of prescription drugs, calling the epidemic of heroin and prescription painkillers “the most pressing public health and public safety issue facing our state.”

Sometimes states can only do so much about higher incidents of mortality. Take suicide, for example. Guns often are more available in some Western states, said Catherine Barber, who directs the Means Matter Campaign at Harvard University. Their prevalence can drive up suicide rates, she said, not because gun owners are more likely to be suicidal — but because guns are more lethal if a person decides to commit suicide.

Data Drives Action

After noticing a stubbornly high rate of liver disease, intoxicated-driving and other causes of alcohol-related deaths, New Mexico’s Health Department this year began an alcohol-awareness program that focuses on areas of the state where the problem is most acute.

“The rate was not improving over time,” said Rosa Isabel Lopez, health data dissemination coordinator for the state health agency. “The decision was made to create more data points for community audiences and get this information into the hands of our neighborhoods.”

The state also launched a public website last year that displays data on health issues in small areas of the state, which communities can use to understand problems and target them.

Local detail, plenty of data, and plain language for policymakers are important aspects of successful state efforts to prevent deaths, said Ross Brownson, an epidemiologist at Washington University in St. Louis who wrote a 2010 guide on the subject.

“We like to say, ‘What gets measured gets solved,’ ” Brownson said. Until recently, he said, communities often didn’t have enough details about health problems to make policy decisions.

In the last few years, he said, there’s been improvement nationally in collecting and distributing health data. The University of Wisconsin’s Population Health Institute, for instance, introduced county health rankings for Wisconsin in 2003, and then expanded them nationwide in 2010.

The rankings noted drug overdose deaths “reaching epidemic proportions” in some areas such as northern Appalachia, and rising 79 percent nationwide since 2002. TheStateline analysis also found high rates of accidental poisoning, which includes drug overdoses, in Massachusetts and New Hampshire.

Deadly Puzzles

In Wisconsin and nearby Iowa and Minnesota, there are disproportionate instances of accidental falls that are fatal. It’s a phenomenon that has puzzled researchers for years, said Patrick Remington, an associate dean at the School of Medicine and Public Health at the University of Wisconsin.

“We’ve supposed that it’s due to cloudy weather, no sun and so no vitamin D [which promotes bone health], but there’s not been a good answer yet,” Remington said. Wisconsin’s Health Department has a fall prevention program, which points out that the elderly are particularly susceptible to falling.

Elizabeth Stein, a preventive medicine resident at the University of Wisconsin medical school, said low vitamin D levels can lead to both fatal falls and dementia in older people, though studies have yet to confirm a link between those causes of death and the area’s cloudy weather.

Washington state prepared a plan to address Alzheimer’s disease last year after data indicated it was the state’s third leading cause of death, killing people at a rate two-thirds higher than the national average. Worse, Alzheimer’s was on the rise while other top killers like cancer and heart disease were in decline.

But the apparent rise could be attributed to better data. Washington has a more rigorous method of collecting and verifying death data than some other states. States’ totals for all deaths from dementia, which includes Alzheimer’s, suggests that many might not be reporting the disease as carefully as Washington.

Differences between the states in recognizing and coding the cause of death can muddy the picture, said Francis Boscoe, a research scientist at the New York State Cancer Registry who used differing death rates by state as a “conversation starter” about state-specific mortality issues.

“It seems entirely plausible that physicians or coroners in Washington could be coding as Alzheimer’s what other states might call pneumonia or something else,” Boscoe said. “There are explicit rules for all this, but that does not mean they are all being followed the same way.”

After Boscoe wrote last year about peculiar death patterns in states, he said he heard plenty of feedback about data-collection issues that can make for misleading numbers.

Flawed Death Certificates

As Stateline has reported, how the cause of death is recorded on death certificates, from which officials draw data, can vary widely even within a state.

In Kansas, for instance, what appeared to be the most distinctive cause of death — hardening of the arteries, or atherosclerosis, killing people there at seven times the national rate — was actually more of a data-recording problem than a medical one.

“This is a classification issue,” said Cassie Sparks, of the Kansas Department of Health and Environment. She said the state plans to emphasize better reporting and classification in training materials for medical examiners and others who sign death certificates.

But even if some data is flawed, cities and states can get life-saving or life-extending results by taking action on the evidence of health problems that do emerge. Brownson of Washington University in St. Louis points to New York City as an example.

The life expectancy in the city grew faster than the national average, paced by drops in heart disease, cancer and HIV from 2001 to 2010, a study published in the currentJournal of Public Health Management & Practice found.

New York has focused in recent years on using health trends to guide new, albeit sometimes controversial, public policy — from restrictions on trans fats and tobacco to unsuccessful bans on oversized portions of sweetened drinks.

“The city health department is really a prime example of evidence-based policy, of making the policy dependent on the data,” Brownson said.

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Where Drinking, Drugs and Alzheimer’s Are Disproportionately Fatal

California has a problem: Fifty-two percent of its managers in the state workforce could decide in the next five years that they’re tired of working, grab their retirement packages and go. Their departure would create a serious brain drain for the state, which has the largest number of state employees in the country — 220,000.

So Jeff Douglas, California’s chief of workforce development, is trying different tactics to keep senior workers on the job: offering a flexible work schedule, promoting work-life balance and creating the first government-wide employee management survey to assess the needs of workers. The idea is to find out who is leaving — and why.

Douglas knows that efforts to keep senior workers — especially managers, specialists, and highly educated and knowledgeable employees — on the job are at best stopgap measures. Eventually, the state will have to shore up its talent reserves as baby boomers age out of the state workforce. “Because people can walk right now, we have to be ready if they do,” he said.

Like California, nearly every state and locality faces the imminent departure of retirement-eligible employees. Anywhere from 30 to 40 percent of state workers are eligible for retirement, said Leslie Scott, executive director of the National Association of State Personnel Executives (NASPE). And states are scrambling to find ways to retain their most valuable seasoned employees.

Finding replacements won’t be easy. State employees are more educated than the rest of the nation’s workforce, including federal and local government employees, according to the Congressional Research Service.

So state personnel executives are experimenting with a variety of approaches to hang on to experience, including job-sharing and telecommuting, delayed retirement programs that pay lump sums to would-be retirees to keep working, training and development, and reward and recognition programs. They also are stepping up recruiting efforts to attract older employees who work in the private sector.

The idea, Douglas said, is to create a work environment “where you can stay longer and work longer.”

Retention Efforts

In Tennessee, where 32 percent of the state workforce is eligible for retirement, state workers can take advantage of the “temporary employment option.” The program allows retirees to work for up to 120 days during a 12-month period. This way, the state can “recruit” high-performing retirees to assist with special projects, said Rebecca Hunter, the state’s commissioner of human resources.

“This allows an agency to benefit from the transfer of institutional knowledge and is a nice transition to full retirement for the employee,” Hunter said.

In Ohio, state workers in the Office of Opportunities for Ohioans with Disabilities are allowed to schedule their work hours as they see fit, as long as they work somewhere between 6 a.m. and 6 p.m.

In Colorado, where 20 percent of the workforce in the state’s information technology division is eligible for retirement, the agency encourages retirement-age professionals to work with younger workers to ensure that knowledge is passed down to the next generation.

This is particularly important when it comes to dealing with older, “legacy” technology and other specialized fields, said Karen Wilcox, director of human resources in the Colorado governor’s information technology office. “Knowledge loss is the most critical issue,” Wilcox said.

In Virginia, where a quarter of state employees will be eligible to retire in the next five years, state human resources executives use “intense data” to predict who will be retiring and what is pushing them out, said Sara Redding Wilson, Virginia’s director of human resources.

“Only a small fraction is going, and we know why,” Redding Wilson said. Armed with data, she said, the state can tailor its retention efforts — while finding ways to recruit the next wave of talent.

The areas with the highest turnover rates are in corrections, juvenile justice and behavioral health, Redding Wilson said, fields with less flexibility in scheduling and that don’t pay as much.

Some states, such as Alabama and Arizona, and some localities, such as Los Angeles, Pinellas County, Florida, and St. Louis, let potential retirees take advantage of the Deferred Retirement Option Program (DROP). It works this way: public workers — such as police officers — who reach retirement age commit to continuing to work for a fixed period. They go on collecting their regular paycheck. And when they retire, they are paid a lump sum bonus of as much as 90 percent of the salaries they earned while continuing to work.

DROP programs can be an attractive incentive to keep talented employees on the job longer, while reducing costs for recruiting and training new employees, said Angela Curl, assistant professor of family studies and social work at Miami University in Oxford, Ohio.

But not all states have kept them going. In 2001, Missouri implemented a similar program, called BackDROP, which offered state workers more flexibility in the start and stop dates. (Roughly a quarter of Missouri’s state employees are eligible to retire this year.)

In a 2014 report, Missouri state employees said that the BackDROP program had been an incentive for them to stay on the job. Some used the money to pay off debt, while others put in savings for their children to inherit, something that they cannot do with traditional pension plans, Curl said.

But in 2010, legislators amended the program. Employees hired after Dec. 31, 2010, aren’t eligible to participate in the program.

Aging Out Will Continue

Public sector employees skew older than private workers. In 2013, 52 percent of full-time federal, state and local public employees were between ages 45 and 64, compared to 42 percent of full-time private sector workers, according to theCongressional Research Service. Fifty percent of state workers and 52 percent of local government workers were in that age group in 2013.

And states and local governments have already seen their workforces shrink in the past decade, thanks to budget cuts enacted during the Great Recession, according to the Center for State and Local Government Excellence.

State agencies also cut back on training and development programs, NASPE’s Scott said. As a result, younger employees aren’t prepared to step in to key management positions, she said. Meanwhile, many state workers — those who weren’t laid off in the midst of cutbacks — postponed retirement.

Some still are, which can give states some breathing room in which to plan to replace them. In Virginia, for instance, Redding Wilson said some younger boomers in their 50s are staying on the job to keep the state’s health care coverage.

But that won’t last long. As the economy continues to improve, more state workers are expected to retire, Scott said. And the remaining talent pool for top managers is much smaller. During the recession, many layoffs happened at the middle-manager level, she said.

The retirement wave will hit all sectors of government, from teachers to nurses to law enforcement. But finance, engineering and management, along with information technology, are areas that could see the biggest losses, according to Elizabeth Kellar, the center’s CEO. There are also big challenges to recruiting and retaining nurses, epidemiologists and doctors for public health jobs, she said.

“It’s a huge issue,” Kellar said. To maintain a strong workforce, she said, states need to focus on recruiting and retaining good people, develop talent through training, offer competitive compensation and have a succession plan for passing on duties to younger workers.

At the same time, states must adjust to the characteristics of a new generation of workers, who are more likely to hop from job to job, and between the private and public sectors.

“If they’re coming in [to work for the states], they’re not staying,” Scott said.

Planning for the Future

In Maine, where roughly a quarter of the state’s IT workforce is eligible for retirement in the next two years, “about 3,000 years of experience is going to be walking out the door,” said Jim Smith, Maine’s chief information officer.

“It’s going to be transformational. We’re going to need to do something radical to address this change.”

For the past couple of years, his agency has been focusing on how to keep seasoned employees on the job while attracting new talent. His agency allows retirement-age employees to work part-time. But, he said, “That’s a short-term solution.”

To attract millennials, his agency drastically streamlined its hiring process. Now, applicants can apply for jobs using a mobile app. Applications have increased 35 percent since the app launched, Smith said.

The state also launched an intern-mentor program, partnering with local universities and community colleges to identify potential hires and pair them with veteran workers. Since the program started in 2013, 70 percent of the interns have become full-time employees, he said.

But the state isn’t just focused on hiring young workers. It’s also recruiting seasoned professionals who’ve spent their careers in the private sector and don’t mind taking a pay cut to work in civil service.

One example of this: Smith. In 2012, after more than 30 years working in the private financial services sector, he decided, rather than retiring, he’d go to work for his home state. “I wanted an opportunity to give back,” Smith said.

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Beating the Brain Drain: States Focus on Retaining Older Workers

In the last couple of years, the number of sex offenders living on the streets of Milwaukee has skyrocketed, from 16 to 205. The sharp increase comes as no surprise to some. There are few places for them to live.

In October 2014, the City of Milwaukee began prohibiting violent and repeat sex offenders from living within 2,000 feet of any school, day care center or park. That left just 55 addresses where offenders can legally move within the 100-square-mile city. And their living options soon will become more limited across Wisconsin. Republican Gov. Scott Walker signed a bill in February that prohibits violent sex offenders from living within 1,500 feet of any school, day care, youth center, church or public park in the state.

Cities and states continue to enact laws that restrict where convicted sex offenders can live, applying the rules to violent offenders such as pedophiles and rapists, and, in some cases, those convicted of nonviolent sex crimes, such as indecent exposure. They are doing so despite studies that show the laws can make more offenders homeless, or make it more likely they will falsely report or not disclose where they are living. And though the laws are meant to protect children from being victimized by repeat offenders, they do not reduce the likelihood that sex offenders will be convicted again for sexual offenses, according to multiple studies, including one from the U.S. Department of Justice.

In all, 27 states have blanket rules restricting how close sex offenders can live to schools and other places where groups of children may gather, according to research by the Council of State Governments. Hundreds of cities also have restrictions, according to the Association for the Treatment of Sexual Abusers (ATSA). And many laws are becoming more restrictive — along with Wisconsin, they expanded last year in Arkansas, Montana, Oklahoma and Rhode Island.

The restrictions can make offenders’ lives less stable by severely limiting their housing options, and can push them away from family, jobs and social support — all of which make it more likely they will abuse again, according to researchers who have studied the laws, such as Kelly Socia, assistant professor of criminal justice at the University of Massachusetts, Lowell.

“If [the laws] don’t work, and they make life more difficult for sex offenders, you’re only shooting yourself in the foot,” Socia said.

Some state and local governments — in California, Florida, Iowa, Georgia and Texas — are finding the laws don’t work and are changing them or, more often than not, being told by the courts to do so. Many courts, such as in California and Michigan, have found the laws to be unconstitutional for being too vague or too restrictive in impeding where offenders can live.

False Perceptions

Psychologists who have treated sex offenders, such as Gerry Blasingame, chair of the California Coalition on Sexual Offending, say the impetus behind the laws — the belief that offenders who have been released will continue to seek out child victims who they do not know — is more perception than reality. Most perpetrators abuse children they know; just one in 10 perpetrators of child sex abuse is a stranger to the victim.

There may be merit in restricting housing for sex offenders who victimized a child they did not know, Socia said. But these laws often apply to all registered sex offenders, including anyone convicted of a sex crime, even nonviolent offenses such as indecent exposure and statutory rape.

Maia Christopher, executive director of the ATSA, said the laws are based on “the myth of the sex offender — that there is a stranger who is lurking in the bushes and grabbing people” and that they cannot be treated. Some treatment programs, such as one in Minnesota, have been found to reduce recidivism rates for sexual offenses, but researchers haven’t concluded that treatment is effective, according to the Justice Department’s Office of Justice Programs.

A U.S. Bureau of Justice Statistics study in 2003, the most recent available, found that 5.3 percent of inmates released from prison after being convicted of a sex offense are arrested for another sexual offense within three years. (Although researchersgenerally acknowledge that the recidivism rate may be low because these crimes are underreported.)

After studying housing restriction laws for about a decade, Socia said he hasn’t seen one that has been effective in reducing recidivism. Several studies, including one from Florida and another from Minnesota, have shown the laws have no effect.

What they can do is make offenders even greater outcasts. A U.S. Department of Justice report released in October 2014 said there is fairly clear evidence that residency restrictions are ineffective, and the laws cause a “loss of housing, loss of support systems, and financial hardship that may aggravate rather than mitigate offender risk.”

After California created new restrictions in November 2006, the number of homeless offenders on parole shot up from 88 to 1,986 in March 2011, according to a reportfrom the state’s Sex Offender Management Board. And the board soon will release a study that will show that, once homeless, a sex offender is more likely to reoffend.

“These guys that are homeless, they become desperate,” said Blasingame, a board member. “They look for opportunities.”

California stopped enforcing its blanket rule requiring offenders to stay 2,000 feet from schools and parks statewide last year, after the state Supreme Court ruled in March 2015 that the law imposed unconstitutional restrictions on paroled sex offenders in San Diego County. The restrictions made 97 percent of rental housing there unavailable to offenders. And, the court found, that contributed to homelessness, and hindered the parolees’ access to medical, drug and alcohol treatment, counseling and social services.

Following the court decision, the state started to enforce the rules on a case-by-case basis. As of October, a third of the 5,901 offenders in the state needed restrictions and the rest didn’t, the state found. From February 2015 to October 2015, the number of transient sex offenders without a permanent address fell by 20 percent, from 1,319 to 1,057.

Advocates — such as Christopher of the ATSA and Kurt Bumby, director of the Center for Sex Offender Management, a project run by the Center for Effective Public Policy that provides guidance on how to best manage sex offenders — are encouraged by efforts in some states. They point to Oregon, Vermont and Washington, where there is a more unified effort among state corrections and parole officials and nonprofits to provide a safe, structured re-entry for offenders, using monitoring, stable housing and access to treatment.

In a state-run program in Vermont, Circles of Support and Accountability, community volunteers meet regularly with high-risk sex offenders to offer support. Program participants have lower rates of recidivism.

‘A Dumping Ground’

In Milwaukee, most of the 55 places where offenders can move to are single-family houses, tucked in alcoves of pricy suburban areas. City officials there passed the 2014 law out of desperation, said Alderman Michael Murphy, who voted against the ordinance.

The city had become “a dumping ground” for sex offenders, he said, because most other cities in the county had passed residency restrictions, leaving nowhere else for the offenders to go. Sixty-three percent of county residents live in the city, but 2,269 sex offenders, or 82 percent of the county’s total, live there. The rules ended up pitting cities against each other, Murphy said.

But at least one state prohibits local government from creating the restrictions:Kansas passed a ban in 2006, and New Hampshire is thinking of doing the same.

Since Milwaukee enacted its law, Dereck McClendon, who works with prisoners being released from jail, said he has watched more sex offenders released onto the streets because they have no place to go. McClendon, a program director for Genesis in Milwaukee Inc., a Christian nonprofit that helps people find work after prison, said each ex-offender needs to be given an assessment, and then help re-entering the community. If not, he said, they will inevitably start to get into trouble.

“Man, I tell you, the lack of hope these men possess,” he said. “Oh man, it kills me.”

Murphy and others in Milwaukee are pleading with Walker for a statewide solution. The law the Legislature passed this year that establishes the 1,500-foot rule for violent sex offenders also requires the state to release prisoners only to the county where they lived before, and allows a judge to rule that an offender being released from jail can live within a restricted area if there are no other options. Murphy said that helps, but doesn’t solve the problem.

The new Wisconsin law also won’t address what Republican state Rep. Joel Kleefisch calls “a patchwork quilt of sex offender laws” across the state, because it does not supersede local rules.

He introduced a bill that would ban local restrictions and create a 1,000-foot restriction statewide — a smaller restriction than some cities have currently.

“Having a statewide, easily understandable residency requirement will mean we can watch them,” Kleefisch said. “If they are underground or off the grid, God only knows what they’re doing.”

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Despite Concerns, Sex Offenders Face New Restrictions

For more than a decade, doctors, dentists and nurse practitioners have liberally prescribed opioid painkillers despite mounting evidence that people were becoming addicted and overdosing on the powerful pain medications.

Now, in the face of a drug overdose epidemic that killed more than 28,000 people in 2014, a handful of states are insisting that health professionals do a little research before they write another prescription for highly addictive drugs like Percocet, Vicodin and OxyContin.

“We in the health care profession had a lot of years to police ourselves and clean this up, and we didn’t do it,” Kentucky physician Greg Jones, an anti-addiction specialist, said in an online training course he gives doctors in his state. “So the public got fed up with people dying from prescription drug abuse and they got together and they passed some laws and put some rules in place.”

By tapping into a database of opioid painkillers and other federally controlled substances dispensed in the state, physicians can check patients’ opioid medication history, as well as their use of other combinations of potentially harmful drugs, such as sedatives and muscle relaxants, to determine whether they are at risk of addiction or overdose death.

Prescribers also can determine whether patients are already receiving painkillers or other controlled substances from other sources, a practice known as doctor shopping. Patients with this type of history are at high risk for addiction and overdose and may be selling drugs illicitly.

In 2012, Kentucky became the first state to require doctors and other prescribers to search patients’ prescription drug histories on an electronic database called a prescription drug monitoring program (PDMP) before prescribing opioid painkillers, sedatives or other potentially harmful and addictive drugs.

Sixteen states have enacted similar laws, and experts, including the U.S. Centers for Disease Control and Prevention and the White House Office of National Drug Control Policy, are encouraging other states to do the same thing.

Maryland Gov. Larry Hogan, a Republican, signed a law in April that requires certain prescribers to use the state’s monitoring system, and a similar bill is moving through the Legislature in California.

Prescribers can be required to check PDMP databases in 29 states, depending on conditions that vary from state to state, according to the National Alliance for Model State Drug Laws.

Although the American Medical Association supports physician use of drug tracking systems to identify potential addiction and drug diversion to the black market, state medical societies have argued against mandatory requirements they say interfere with the practice of medicine. Patients’ privacy and legitimate pain needs, they say, could be jeopardized by requiring busy physicians to investigate potential patient abuse of pain medications.

Despite these objections from some in the medical profession, more states are imposing the requirements. “Comprehensive mandates are the single most effective thing states have done to curb opioid prescribing, and it seems to have an almost instantaneous effect,” said John Eadie, who has evaluated state programs at Brandeis University’s Prescription Drug Monitoring Program Center of Excellence in Massachusetts.

In states where physicians are required to use monitoring systems, overall opioid prescribing has plummeted, as have drug-related hospitalizations and overdose deaths, Eadie said. States also are seeing a rise in addiction treatment as more doctors refer patients to treatment after discovering they are taking painkillers from multiple sources and are likely addicted to them.

In Kentucky, hydrocodone (Vicodin) prescribing dropped 13 percent, oxycodone (Percocet) dropped 12 percent, oxymorphone (Opana) dropped 36 percent and tramadol (Ultram) dropped 12 percent between 2012 and 2013, the first year the law was implemented, according to an analysis by the University of Kentucky’s College of Pharmacy.

Since the law was passed, overdose hospitalizations declined 26 percent, and prescription opioid deaths dropped 25 percent, the first reduction in nearly a decade, according to a March 2016 report by Shatterproof, a national advocacy organization that promotes prevention and treatment of drug addiction.

In another effort to stem overprescribing of opioid painkillers, which is widely blamed for the current epidemic, the CDC in March took the unprecedented step of issuing national opioid prescribing guidelines. Along with patient education, urine drug testing, and abuse-deterrent formulations of pain pills, the federal agency recommended prescribers check prescription databases before prescribing to reduce the risk of opioid overdose and addiction.

Vastly Underused

Prescription drug monitoring systems have existed in paper form since the 1930s, and every state except Missouri has some type of system. But the rules governing who has access, how quickly pharmacies must enter dispensing data, and which medications are included vary widely from state to state.

(The creation of a prescription drug monitoring system in Missouri has been blocked by a small group of legislators, led by state Sen. Rob Schaaf, a Republican and a doctor, who argue that allowing the government to keep prescription records violates patient privacy rights. In March, the opioid-plagued county of St. Louis adopted an ordinance to create a monitoring system, and advocates and some lawmakers continue to press for a statewide program.)

In general, state databases have been used effectively by law enforcement to track down so-called pill mills, where doctors indiscriminately prescribe opioid medications for cash. And a substantial number of pharmacists have consulted them before filling a prescription. But a relatively small percentage of medical professionals are signing on to the systems to detect patients who are at risk for addiction or overdose.

In most states, health care professionals who prescribe at least one controlled medication are encouraged to use PDMPs, but only on a voluntary basis. As a result, the typical state program in 2012 had only 35 percent of doctors signed up for access, according to the center at Brandeis. In 2014, 53 percent of doctors were signed up to one of the programs, according to a survey by Lainie Rutkow, an associate professor of public health at Johns Hopkins.

Most states require prescribers to obtain access to PDMPs and use them at their discretion when they suspect a patient is at high risk for addiction, drug diversion or overdose, according to the National Alliance for Model State Drug Laws.

The problem with that, said Van Ingram, Kentucky’s director of drug control policy, is “people think doctors can just look at a patient and recognize this disease of addiction, and it’s not that simple.”

“People with addictions can fool their spouses, their children and their employers. They can definitely conceal the disease from their physician in a 15-minute visit.”

A Diagnostic Tool

In Kentucky, doctors and some patients complained about the requirement when it was first adopted, Ingram said. But these days, he said, he mostly hears doctors saying, “Wow, I treated that patient for 20 years and had no idea he had a drug problem.

“If there’s a tool out there that takes 15 seconds to use and can diagnose a disease, why wouldn’t you want to use it? To me it’s a no brainer,” Ingram said.

Before Kentucky physicians were required to check the database, patients commonly visited multiple doctors to get prescriptions for opioid painkillers, the sedative Xanax, and the muscle relaxant Soma, according to the state’s PDMP director, David Hopkins. “The cocktail,” as it’s known in Kentucky, produces a high that is similar to heroin and just as deadly. It has become much less prevalent since the law was enacted.

“We cracked down on that big time,” Hopkins said. The number of people receiving the cocktail has dropped 30 percent since the law took effect and the number of doctor shoppers has dropped 52 percent, he said.

Kentucky is also trying to curtail dangerously high doses of prescribed painkillers by flagging the database when a patient is taking medications from multiple sources that add up to the equivalent of 100 milligrams or more of morphine per day. Last year, a calculator was added to the system so doctors wouldn’t have to add up the morphine equivalents on their own.

Hopkins said the state listened to doctors’ complaints and added some commonsense exceptions after the initial rules came out. Prescribers are no longer required to check the database in emergencies or for patients in hospice, long-term care or cancer treatment. They can also skip the step if a patient was originally prescribed a pain medication by a fellow doctor in their practice and needs a refill or a different pain medicine.

Kentucky’s prescriber rules, which were developed by the state Board of Medical Licensure, allow doctors to appoint a delegate to access the drug monitoring system and review patients’ drug profiles. Doctors typically ask their assistants to run prescription drug histories on all the patients they will see the next day and add the information to their electronic medical records, said Michael Rodman, director of Kentucky’s licensure board.

If a potential drug problem is detected, prescribers can query the database to determine how other physicians in the state are addressing the pain needs of similar patients and they can discuss an individual patient’s drug history with another prescriber, something that was forbidden under previous state privacy laws.

Another part of Kentucky’s 2012 opioid law requires prescribers to attend a certain number of free training sessions each year on addiction, pain management and use of the state’s prescription monitoring system. (Jones conducts some of those training programs.)

To increase the effectiveness of drug monitoring programs, Kentucky and other states use reciprocal agreements to allow interstate sharing of drug dispensing information for pharmacists, law enforcement and physicians in nearby states. Kentucky has agreements with at least 20 other states. New Jersey Gov. Chris Christie, a Republican, announced in April that New York had joined his state in sharing PDMP information, along with Connecticut, Delaware, Minnesota, Rhode Island, South Carolina and Virginia.

As for what happens when a physician discovers a patient is doctor shopping, Rodman said, they often dismiss patients and no longer treat them.

But Jones, who heads the Kentucky Physicians Health Foundation, which supports doctors who suffer from substance use disorders, tells doctors not to do that to patients.

“Maybe you don’t keep prescribing them 90 OxyContins with five refills,” he said, “but don’t throw them out. If you do, you’re missing an important opportunity to save a life.”