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Let’s block ads! (Why?)

As I stood up to end our visit, Frank indicated he had one more question.

“You know those commercials for Cialis?” he asked. “Would that be all right for me to try?”

Here we go with the bathtubs again, I think to myself. Toned silver-hairs in side-by-side bathtubs on a deck somewhere looking out at the sunset.

Give me a break.

It’s not always drugs for erectile dysfunction. I’ve been asked about TV spots hawking pharmaceuticals for nail fungus, depression, acid reflux, cholesterol and irritable bowels, just to name a few.

Two decades ago the Food and Drug Administration loosened restrictions on advertising prescription drugs on television. Prior to that, the only ads we saw for brand-name drugs were targeted directly at us doctors, the keepers of prescription pads, and placed in the medical journals we read and in the detailed handouts given to us by pharmaceutical reps.

So for 20 years now, we have borne witness to an ever-growing number of drug ads that are targeted directly at consumers. If you’re among the 99 percent of Americans who watch television, you’ve seen scores of them by now.

No time slot of television is immune: Drug ads are rampant on daytime TV, unavoidable during the evening news, all over sports programming, and have even crept steadily into prime time. Lately the trend has been toward advertising more expensive drugs for less common conditions, such as costly new immunotherapy drugs that could help only a tiny fraction of cancer patients. When I see one of these types of commercials I usually think, “How many people even have this condition?”

Sometimes, I must admit, I’ve never heard of the condition or the drug, and have to look them up. That’s one goal of these commercials — health professionals watch TV, too. Pharmaceutical firms can hawk their products to both sides of the prescribing relationship.

But as a general internist, I’m never likely to prescribe most of the newer medications I now see advertised. Those drugs are going to be recommended by a subspecialist like an oncologist or rheumatologist. Yet many of those conversations still start with primary care doctors like me. Advertisers count on it.

It’s all in the math. Whether a pharmaceutical firm sells a niche drug for a rare condition at a high price or a blockbuster drug for a common condition at a more reasonable price, it behooves us to remember that drug companies advertise for a reason: profits.

Like many doctors, my problem with direct-to-consumer ads is that the game never really feels like a fair fight.

Sure, there are purported benefits: Patients get better information about what’s available out there. The ubiquitous phrase “Talk to your doctor” has led to more and better conversations about topics that may have been hard for patients to bring up or doctors to ask about. Probably the best example is patients willing to consider an antidepressant when previously they might not have even wanted to discuss their mood.

Other suggested benefits include adherence to a treatment regimen and a lessening of stigma for certain diagnostic categories. Particularly for mental health conditions, this has moved the national conversation forward as sufferers may be more likely to come out of the shadows.

But all too often, commercials give us the idea that something might be wrong with us. Big budget ads have driven the promotion of new disease entities. When pharmaceutical firms get FDA approval for a new indication, they can relentlessly market the product and create a torrent of demand where none previously existed.

And those helpful conversations I mentioned aren’t always so helpful if they wind up hijacking time in our brief encounter. I’d like to discuss what’s most relevant and beneficial to your health. If I have to spend my time fending off marketing for a condition you don’t have or a drug that’s of no possible benefit to you, our time hasn’t been used productively.

Further, the advertising of newer products means that they’re generally more expensive than older, well-established drugs that might now be available as an equally effective generic. And good luck figuring out how much such a drug will cost you. If I do wind up prescribing it, more often than not it won’t be “preferred” by your insurance. Then it’s down the prior-authorization rabbit hole, which can require multiple calls from the doctor’s office to the insurer, begging for coverage. If you want to see smoke come out of a doctor’s ears, just ask about THAT process.

Finally, newer drugs don’t have the track record of drugs that have been on the market longer, which means we don’t always know if they are as safe as we would like. Remember the Vioxx story?

Vioxx was a highly-touted anti-inflammatory pain medicine that was supposed to spare the lining of your stomach when used regularly, unlike its older, cheaper cousins like ibuprofen. Problem was, Vioxx turned out to increase the risk of heart attacks and strokes. The drug had annual sales of $2.5 billion before it was pulled off the market.

Perhaps the saving grace of these drug commercials is that the FDA still requires advertisers to list potential side effects of their products. This has created an entire comedy genre, as the sotto voce reading of the lengthy list usually makes any of us that can hear it think: “Why would I take a drug that will give me a side effect that I took it to alleviate in the first place?”

Those lists always make me think of my favorite parodic side effect, which afflicted Saturday Night Live’s Kristin Wiig in a spoof ad for the anti-smoking drug Chantix: “jazz hands.”

John Henning Schumann is an internal medicine doctor and serves as president of the University of Oklahoma’s Tulsa campus. He also hosts Studio Tulsa: Medical Monday on KWGS Public Radio Tulsa. You can follow him on Twitter: @GlassHospital.

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Gerald Chinchar, a Navy veteran who loves TV Westerns, isn’t quite at the end of his life, but the end is probably not far away. The 77-year-old’s medications fill a dresser drawer, and congestive heart failure puts him at high risk of emergency room visits and long hospital stays. He fell twice last year, shattering his hip and femur, and now gets around his San Diego home in a wheelchair.

Above all, Chinchar hopes to avoid another long stint in the hospital. He still likes to go watch his grandchildren’s sporting events and play blackjack at the casino.

“If they told me I had six months to live, or [could instead] go to the hospital and last two years, I’d say leave me home,” he said. “That ain’t no trade for me.”

Most aging people would choose to stay home in their last years of life. But for many, it doesn’t work out: They go in and out of hospitals, getting treated for flare-ups of various chronic illnesses. It’s a massive problem that costs the health care system billions of dollars and has galvanized health providers, hospital administrators and policymakers to search for solutions.

Sharp HealthCare, the San Diego health system where Chinchar receives care, has devised a way to fulfill his wishes and reduce costs at the same time. It’s a pre-hospice program called Transitions, designed to give elderly patients the care they want at home and keep them out of the hospital.

Social workers and nurses from Sharp regularly visit patients in their homes to explain what they can expect in their final years, help them make end-of-life plans and teach them how to better manage their diseases. Physicians track their health and scrap unnecessary medications.

Unlike hospice care, patients in this program don’t need to have a prognosis of six months or less to live, and they can continue getting treatment that is aimed at curing their illnesses, not just treating symptoms.

Before the Transitions program started, the only option for many patients in a health crisis was to call 911 and be rushed to the emergency room. Now, they can get round-the-clock access to nurses, one phone call away.

“Transitions is for just that point where people are starting to realize they can see the end of the road,” said Dr. Dan Hoefer, a San Diego palliative care and family practice physician, and one of the creators of the program. “We are trying to help them through that process,” he said, “so it’s not filled with chaos.”

The importance of programs like Transitions is likely to grow in coming years as 10,000 baby boomers — many with multiple chronic diseases — turn 65 every day. Transitions was among the first of its kind, but several such programs, formally known as home-based palliative care, have since opened around the country. They are part of a broader push to improve people’s health and reduce spending through better coordination of care and more treatment outside hospital walls.

But a huge barrier stands in the way of pre-hospice programs: There is no clear way to pay for them. Health providers typically get paid for office visits and procedures, and hospitals still get reimbursed for patients in their beds. The services provided by home-based palliative care don’t fit that model.

In recent years, however, pressure has mounted to continue moving away from traditional payment systems. The Affordable Care Act has established new rules and pilot programs that reward the quality of care, rather than the quantity. Those changes are helping to make home-based palliative care a more viable option.

In San Diego, Sharp’s palliative care program has a strong incentive to reduce the cost of caring for its patients, who are all in Medicare managed care. The nonprofit health organization receives a fixed amount of money per member each month, so it can pocket what it doesn’t spend on hospital stays and other costly medical interventions.

‘Something that works’

Palliative care focuses on relieving patients’ stress, pain and other symptoms as their health declines, and it helps them maintain their quality of life. It’s for people with serious illnesses, such as cancer, dementia and heart failure. The idea is for patients to get palliative care and then move into hospice care, but they don’t always make that transition.

The 2014 report “Dying in America,” by the Institute of Medicine, recommended that all people with serious advanced illness have access to palliative care. Many hospitals now have palliative care programs, delivered by teams of social workers, chaplains, doctors and nurses, for patients who aren’t yet ready for hospice. But until recently, few such efforts had opened beyond the confines of hospitals.

Kaiser Permanente set out to address this gap nearly 20 years ago, creating a home-based palliative care program that it tested in California and later in Hawaii and Colorado. Two studies by Kaiser and others found that participants were far more likely to be satisfied with their care and more likely to die at home than those not in the program. (Kaiser Health News is not affiliated with Kaiser Permanente.)

One of the studies, published in 2007, found that 36 percent of people receiving palliative care at home were hospitalized in their final months, compared with 59 percent of those getting standard care. The overall cost of care for those who participated in the program was a third less than for those who didn’t.

“We thought, ‘Wow. We have something that works,'” said Susan Enguidanos, an associate professor of gerontology at the University of Southern California’s Leonard Davis School of Gerontology, who worked on both studies. “Immediately we wanted to go and change the world.”

But Enguidanos knew that Kaiser Permanente was unlike most health organizations. It was responsible for both insuring and treating its patients, so it had a clear financial motivation to improve care and control costs. Enguidanos said she talked to medical providers around the nation about this type of palliative care, but the concept didn’t take off at the time. Providers kept asking the same question: How do you pay for it without charging patients or insurers?

“I liken it to paddling out too soon for the wave,” she said. “We were out there too soon. … But we didn’t have the right environment, the right incentive.”

A bold idea, rooted in experience

Hoefer is a former hospice and home health medical director and has spent years treating elderly patients. He learned an important lesson when seeing patients in his office: Despite the medical care they received, “they were far more likely to be admitted to the hospital than make it back to see me.”

When his patients were hospitalized, many would decline quickly. Even if their immediate symptoms were treated successfully, they would sometimes leave the hospital less able to take care of themselves. They would get infections or suffer from delirium. Some would fall.

Hoefer’s colleague, Suzi Johnson, a nurse and administrator in Sharp’s hospice program, saw the opposite side of the equation. Patients admitted into hospice care would make surprising turnarounds once they stopped going to the hospital and started getting medical and social support at home, instead. Some lived longer than doctors had expected.

In 2005, the pair hatched a bold idea: What if they could design a home-based program for patients before they were eligible for hospice? Thus, Transitions was born. They modeled their new program in part on the Kaiser experiment, then set out to persuade doctors, medical directors and financial officers to try it. But they met resistance from physicians and hospital administrators who were used to getting paid for seeing patients.

“We were doing something that was really revolutionary, that really went against the culture of health care at the time,” Johnson said. “We were inspired by the broken system and the opportunity we saw to fix something.”

Despite the concerns, Sharp’s foundation board gave the pair a $180,000 grant to test out Transitions. And in 2007, they started with heart failure patients and later expanded the program to those with advanced cancer, dementia, chronic obstructive pulmonary disease and other progressive illnesses. They started to win over some doctors who appreciated having additional eyes on their patients, but they still encountered “some skepticism about whether it was really going to do any good for our patients,” said Dr. Jeremy Hogan, a neurologist with Sharp. “It wasn’t really clear to the group … what the purpose of providing a service like this was.”

Nevertheless, Hogan referred some of his dementia patients to the program and quickly realized that the extra support for them and their families meant fewer panicked calls and emergency room trips.

Hoefer said doctors started realizing home-based care made sense for these patients — many of whom were too frail to get to a doctor’s office regularly. “At this point in the patient’s life, we should be bringing health care to the patient, not the other way around,” he said.

Across the country, more doctors, hospitals and insurers are starting to see the value of home-based palliative care, said Kathleen Kerr, a health care consultant who researches palliative care.

“It is picking up steam,” she said. “You know you are going to take better care of this population, and you are absolutely going to have lower health care costs.”

Providers are motivated in part by a growing body of research. Two studies of Transitions in 2013 and 2016 reaffirmed that such programs save money. The second study, led by outside evaluators, showed it saved more than $4,200 per month on cancer patients and nearly $3,500 on those with heart failure.

The biggest differences occurred in the final two months of life, said one of the researchers, Brian Cassel, who is palliative care research director at the Virginia Commonwealth University School of Medicine in Richmond.

A home visit tailored to each family

Nurse Sheri Juan and social worker Mike Velasco, who both work for Sharp, walked up a wooden ramp to the Chinchars’ front door one recent January morning. Juan rolled a small suitcase behind her containing a blood pressure cuff, a stethoscope, books, a laptop computer and a printer.

Late last year, Gerald Chinchar’s doctor recommended he enroll in Transitions, explaining that his health was in a “tenuous position.” Chinchar has nine grandchildren and four great-grandchildren. He has had breathing problems much of his life, suffering from asthma and chronic obstructive pulmonary disease — ailments he partly attributes to the four decades he spent painting and sandblasting fuel tanks for work. Chinchar also recently learned he had heart failure.

“I never knew I had any heart trouble,” he said. “That was the only good thing I had going for me.”

Now he’s trying to figure out how to keep it from getting worse: How much should he drink? What is he supposed to eat?

That’s where Juan comes in. Her job is to make sure the Chinchars understand Gerald’s disease so he doesn’t have a flare-up that could send him to the emergency room. She sat beside the couple in their living room and asked a series of questions: Any pain today? How is your breathing?

Juan checked his blood pressure and examined his feet and legs for signs of more swelling. She looked through his medications and told him which ones the doctor wanted him to stop taking.

“What we like to do as a palliative care program is streamline your medication list,” she told him. “They may be doing more harm than good.”

His wife, Mary Jo Chinchar, said she appreciates the visits, especially the advice about what Gerald should eat and drink. Her husband doesn’t always listen to her, she said. “It’s better to come from somebody else.”

Growing acceptance of palliative care

Outpatient palliative care programs are cropping up in various forms. Some new ones are run by insurers, others by health systems or hospice organizations. Others are for-profit, including Aspire Health, which was started by former senator Bill Frist in 2013.

Sutter Health operates a project called Advanced Illness Management to help patients manage symptoms and medications and plan for the future. The University of Southern California and Blue Shield of California recently received a $5 million grant to provide and study outpatient care. “The climate has changed for palliative care,” said Enguidanos, the lead investigator on the USC-Blue Shield project.

Ritchie said she expects even more home-based programs in the years to come. “My expectation is that much of what is being done in the hospital won’t need to be done in the hospital anymore and it can be done in people’s homes,” she said.

Challenges remain, however. Some doctors are unfamiliar with the approach, and patients may be reluctant, especially those who haven’t clearly been told they have a terminal diagnosis. Now, some palliative care providers and researchers worry about the impact of President Donald Trump’s plans to repeal the Affordable Care Act and revamp Medicare — efforts that seem to be back in play.

Gerald Chinchar, who grew up in Connecticut, said he never expected to live into old age. In his family, Chinchar said, “you’re an old-timer if you make 60.”

Chinchar said he gave up drinking and is trying to eat less of his favorite foods — steak sandwiches and fish and chips. He just turned 77, a milestone he credits partly to the pre-hospice program.

“If I make 80, I figured I did pretty good,” he said. “And if I make 80, I’ll shoot for 85.”

This story is part of NPR’s partnership with Kaiser Health News. KHN is an editorially independent program of the Henry J. Kaiser Family Foundation, a nonprofit, nonpartisan health policy research and communication organization not affiliated with Kaiser Permanente. You can follow Anna Gorman on Twitter: @annagorman.

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NPR’s Audie Cornish talks with moderate Republican Congressman Leonard Lance of New Jersey about what he’s looking for in the new health care bill.

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As Republicans in Congress debate changes to the Affordable Care Act, insurance executives across the country are trying to make plans for next year.

Companies that sell policies on the exchanges created by the Affordable Care Act, also known as Obamacare, face fast-approaching deadlines to inform states about what plans they want to sell, and what they intend to charge.

“Insurance companies need to file rates in 2 1/2 months,” says Tom Policelli, CEO of Minuteman Health, which sells Obamacare policies in Massachusetts and New Hampshire.

“So basically we’ve got four to six weeks to figure out some basic things that will help all of us in the industry to have more surety and stability, so we can price our premiums lower,” he says.

To make those decisions, companies want to know whether the law is going to change altogether, something Republicans in the House have tried, failed to do and are trying again this week.

At minimum, insurers would like to know whether the Trump administration intends to continue making crucial payments to insurers that are required under the law.

On Wednesday the president seemed to agree to continue those payments, known as cost-sharing subsidies, but Thursday he tweeted that he would not “give billions to insurance companies.”

“The current debate is largely not helpful, and is heading things in a direction that will make things even worse,” Policelli says.

The payments reimburse insurance companies for discounts they are required to give to low-income customers to offset deductibles and co-payments.

Without the subsidies, a study by the Kaiser Family Foundation shows, premiums could go up 19 percent. And ending the the subsidies could also cost the government as much as $2.3 billion in 2018, according to Kaiser, because the government would need to offset those premium increases.

Policelli says the markets have lots of other problems too. It’s technical stuff, he says, such as medical loss ratios and risk adjustment schemes.

“This sounds very boring. It is very boring. I’m an insurance guy, I’m very boring,” he concedes. “But this stuff is killing the industry and driving out competition and driving prices up.”

He says lawmakers could fix the problems if they want to. And if they don’t, Trump could do a lot on his own, through regulation.

It’s not clear that the president, who has repeatedly threatened to let Obamacare “explode,” wants to make the current system work better. And Congress continues to debate changes in the law that would go into effect before next year.

So Policelli is preparing for 2018 without knowing what rules he’ll have to play by.

“At times it feels like you’re building a boat, while at sea, in a storm, at night. But that’s what we’re here to do,” he says.

In Tennessee, Julie Mix McPeak, the state’s insurance commissioner, is trying to recruit new companies to sell ACA insurance in the Knoxville area after Humana announced it was pulling out of Obamacare exchanges in that part of the state.

“Unfortunately we haven’t had a tremendous amount of success in some of those discussions,” McPeak says. “What we’re hearing from insurers is there’s a tremendous amount of regulatory uncertainty.”

She says a promise from Congress or the Trump administration to pay for the cost-sharing reductions, commonly called CSRs, would help.

“What I’m hearing from insurers in my state, and from colleagues nationally, is that the CSR funding is critical in some of these participation decisions that the insurers are contemplating for 2018,” she says.

Without that money, its going to be very difficult to offer affordable policies next year, says Dave Anderson, CEO of Buffalo-based HealthNow New York Inc. which operates Blue Cross and Blue Shield plans in New York state.

Those payments account for as much as 20 percent of the premiums for his subsidized customers, he says.

“If the funding is not adequate, then we have to make a decision of whether we want other policy holders to subsidize these, or do we have to leave that segment,” Anderson says. “Both of those are real considerations.”

Right now his company is losing money on its Obamacare exchange customers, spending $1.08 in claims for every dollar it takes in in premiums. Continuing the cost sharing payments isn’t the only fix Anderson wants, but it will help make his Obamacare plans viable.

“We’re not intending, frankly, to make them profitable,” he says. “We’d be satisfied with just breaking even. We’d stay in the market if we could just break even.”

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A ProPublica investigation reveals nursing homes waste millions of dollars in prescription drugs every year. NPR’s Steve Inskeep speaks with ProPublica’s Marshall Allen about his reporting.

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Back in the 1960s, a woman doctor in Japan created a powerful drug to help mothers who hemorrhage after childbirth.

The medicine is inexpensive to make. Safe to use. And stops bleeding quickly by helping keep naturally forming blood clots intact.

The drug’s inventor, Utako Okamoto, hoped the drug called tranexamic acid would be used to help save moms’ lives.

Every year about 100,000 women around the world die of blood loss soon after a baby is born. It’s the biggest cause of maternal death worldwide.

“It was Okamoto’s dream to save women,” says Haleema Shakur, who directs clinical trials at London School of Tropical Medicine and Hygiene. “But she couldn’t convince doctors to test the drug on postpartum hemorrhaging.”

And so tranexamic acid has gone largely unused in maternity wards for decades.

Until now.

In a massive international trial, Shakur and her collaborators have shown that tranexamic acid decreased the risk of death from blood loss associated with childbirth by about a third. (Previous studies have looked at the drug’s use in reducing bleeding deaths after traumatic injuries.)

In the study, women who were diagnosed with heavy bleeding, or postpartum hemorrhage, after a vaginal birth or cesarean sectionreceived either the drug or a placebo.

About 1.2 percent of women who got tranexamic acid within three hours of a hemorrhage died, compared with 1.7 percent of the women who got the placebo.

Side effects weren’t a serious problem. The medicine didn’t increase the risk of dying of other causes during the procedure, Shakur and her colleagues report in The Lancet journal.

The study included 20,000 women, in nearly 200 hospitals, across 21 counties, including rich countries, like the U.K., and poorer ones, like Pakistan and India.

“I think it’s exciting,” says Felicia Lester, an OB-GYN at the University of California, San Francisco, who also works in Uganda and Kenya. “I’m usually cautious in saying that. But it looks like tranexamic acid has the potential to save lives.”

It’s rare to have a new tool for helping women during childbirth, especially one that works so well, says Margaret Kruk, a global health researcher at Harvard University.

“I want to emphasize that the gains they’ve found in terms of survival from bleeding were very dramatic, particularly when this drug was given early,” she says.

And the drug even helped women when doctors used it along with other common medications, such as oxytocin, Kruk says. “It offers an additional benefit above and beyond what is being done for women already,” she says.

The medicine is inexpensive. It cost about $3 in the U.K., and a quarter of that in Pakistan, for instance.

Now, though, the big question is how to make sure this drug is available for women who need it the most — women in the poor, remote areas of the world, where maternal mortality is the highest.

“That’s, I think, the million dollar question,” Kruk says. “We in global health have a number of tools that seem very effective in large clinical trials. But then when it comes time to use them for all women, we see very large gaps in implementation.”

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The White House appears to be backing down on multiple demands that were threatening a partial government shutdown, including withholding subsidies to help low-income people under Obamacare.

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Kids with chronic conditions are especially vulnerable to health insurance changes, relying as they often do on specialists and medications that may not be covered if they switch plans. A recent study finds that these transitions can leave kids and their families financially vulnerable as well.

The research, published in the April issue of Health Affairs, examines the spending impact of shifting chronically ill kids from the Children’s Health Insurance Program (CHIP) to policies offered on the marketplaces established under the federal health law. The out-of-pocket costs to these children’s families would likely rise — in some cases dramatically — following a change to marketplace coverage, the study finds.

The research comes at a time when health insurance issues are on the front burner in Congress. Republican lawmakers are pushing for fundamental changes to the marketplaces and to the Medicaid program. At the same time, Congress must soon decide whether to extend CHIP when its funding ends in September.

Together the state-federal Medicaid and CHIP programs insure 46 million low-income children. CHIP covers kids whose family income is low, but too high to qualify for Medicaid.

The eligibility levels vary by state. Half of states set the upper income eligibility limit at 255 percent of the federal poverty level or higher (about $52,000 for a family of three). Both programs provide comprehensive coverage for children with little or no out-of-pocket cost to families.

Since passage of the Affordable Care Act in 2010, some policy analysts have advocated moving children who are enrolled in CHIP into marketplace plans and dismantling the CHIP program. But earlier evaluations found, as does this study, that CHIP coverage is better and cheaper than marketplace coverage, said Joan Alker, executive director of the Georgetown Center for Children and Families.

CHIP is much smaller than Medicaid, with more than 8 million children enrolled. Roughly 2 million have one of six chronic health conditions, including asthma, attention deficit hyperactivity disorder, diabetes, epilepsy, mood disorders and developmental disorders such as autism, according to the study.

Using data compiled from state CHIP programs and marketplace plans for 2016 and health care use data from the federal Medical Expenditure Panel Surveys from 2008 to 2013, researchers simulated the annual out-of-pocket costs for children with these six chronic conditions if they were enrolled in CHIP versus one of the plans sold on the marketplaces operated by the federal government.

The spending differences were stark. For every chronic condition and at every income level, cost sharing was higher for children enrolled in marketplace plans than for those in CHIP.

Take the case of asthma, the most common condition that researchers modeled. For a child with asthma, whose family income was between 100 and 150 percent of the federal poverty level (about $20,000 to $30,000 for a family of three), annual out-of-pocket spending on deductibles and copays would be $284 in a marketplace plan, compared with $27 in CHIP — a difference of $257.

At higher incomes, the out-of-pocket spending differences were greater. Families with incomes between 251 and 400 percent of the federal poverty level (about $51,000 to $81,000 for a family of three) would pay $1,227 out-of-pocket annually if they were enrolled in a marketplace plan but just $84 in the CHIP program — a difference of $1,143 for the year.

“The lowest income families were relatively well protected by cost-sharing reductions” in marketplace plans, said Amy Davidoff, who is a senior research scientist in the Department of Health Policy and Management at the Yale School of Public Health and one of the study’s co-authors.

Those cost-sharing subsidies (which reduce a plan’s deductible, copayments and coinsurance) are available to marketplace customers with incomes up to 250 percent of the federal poverty level (about $51,000 for three people).

These Obamacare subsidies are now the subject of a lawsuit, however, and their fate is unclear.

As family income rises, the gap between the out-of-pocket costs for the two different types of coverage increases and becomes quite substantial, Davidoff said. “For these families, it would be huge barrier,” she said.

The deductible — the amount that people have to pay on their own before insurance covers most services — was a significant factor in the cost differences. The average deductible in marketplace plans for families with incomes between 251 and 400 percent of poverty was $3,126. None of the CHIP programs for families at that income level had deductibles, the study found.

Noting that CHIP has a history of strong bipartisan support, Alker said she is hopeful that federal lawmakers will extend the program.

“I think it would be very hard for Congress to let CHIP expire,” she said, “and put those children into the marketplace, when according to their leaders it’s about to fold.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. You’ll find Michelle Andrews on Twitter @mandrews110.

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