Almost half a million veterans gained health care coverage during the first two years of the Affordable Care Act, a report finds.

In the years leading up to the implementation of the ACA’s major coverage provisions, from 2010 to 2013, nearly 1 million of the nation’s approximately 22 million veterans didn’t have health insurance. Almost half of all veterans are enrolled in the VA health system; others get health care through employers or Medicare. But some don’t quality for those options, and others don’t know that they have them.

Two years after the ACA’s implementation, 429,000 veterans under the age of 65 gained coverage, which is a 40 percent drop in vets without insurance from 2013 to 2015. The vets were covered for the most part through Medicaid expansion, privately purchased plans and marketplace coverage, according to the report.

The number of insured veterans rose across demographics like age, gender, race and education level. “The gains in coverage were really broad,” says Jennifer Haley, a research associate at the Urban Institute, a research group based in Washington, D.C., who was an author on the report.

Veterans with the lowest incomes saw the greatest increase in coverage, especially in states that adopted Medicaid expansion. Vets with incomes up to 138 percent of the federal poverty level, or $16,394 a year for an individual, became eligible for Medicaid in expansion states, the report notes.

In 2015, just 4.8 percent of veterans were uninsured in states that participated in Medicaid expansion, compared to 7.1 percent in states that did not.

One in 5 uninsured vets live in states that did not expand Medicaid and would have been eligible for coverage had their state chosen to expand the program, the report found. Haley says these are key data points when considering changes to policy.

“If states would adopt the expansion, more vets would qualify for publicly supported coverage,” she says. Currently, 31 states and the District of Columbia have expanded Medicaid programs, including California, New York, Pennsylvania and Illinois. Another 19 states, including Florida and Texas, have not expanded access to the program.

Veterans weren’t the only ones to benefit from expanded insurance access. Their family members had access to more coverage, too, and by a similar margin.

The overall rate of uninsurance among relatives sank from 9.2 percent in 2013 to 4.5 percent in 2015. For children, the rates fell from 4.5 to 2.9 percent. Overall, 730,000 fewer vets and their family members were lacking health insurance from 2013 to 2015.

The report, published by the Urban Institute, used data from the American Community Survey, which is performed annually by the U.S. Census Bureau. It surveys around 100,000 veterans and 100,000 family members of veterans. The report also considered data from the National Health Interview Survey which is conducted by the Centers for Disease Control and Prevention’s National Center for Health Statistics.

A repeal of the ACA or a rollback of Medicaid could negate these coverage increases and leave more vets without health insurance coverage, the authors note in their report. The VA health system continues to struggle with delays in delivery of services to veterans.

On Wednesday, President Donald Trump signed a law extending the Veterans Choice program, which allows some vets get health care from private providers paid for by the VA and was created to help improve access to timely care.

The $10 billion program has been riddled with problems, as Montana Public Radio’s Eric Whitney reports, including long waits, a confusing, complicated system and delayed payments to providers.

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It’s a fix that hasn’t fixed much, but the troubled Veterans Choice program has been extended anyway.

On Wednesday, President Donald Trump signed a bill extending the program intended to speed veterans’ access to health care beyond its original August end point.

Veterans Choice is a $10 billion response to the 2014 scandal in which Veterans Affairs health facilities altered records to hide months-long waits for care in Phoenix and elsewhere. The Choice program pays for private-sector health care for veterans and was set to expire in August, but the VA and some of the program’s harshest critics in Congress have agreed to extend it, with a few changes, until January. They said that will give the VA time to propose a more comprehensive package of reforms — fixes for the fix.

Sen. Jon Tester, D-Mont., authored the extension bill, which won bipartisan support in the House and Senate.

Veterans Choice is designed to allow veterans who have waited more than 30 days for an appointment at a VA facility, or who live more than 40 miles from one, instead to get care from private providers who then bill the VA. But it has been plagued with problems. Many vets complain that Choice actually makes getting care more difficult and time-consuming, and some health care providers have dropped out due to slow payments or administrative hassles.

The bigger reforms the VA wants to make following this extension bill will be aimed at fixing more than a half-dozen other systems the VA has for purchasing care from the private sector.

“The idea of having seven, eight ways of doing the same thing is part of the problem, because it’s confusing to veterans, it’s confusing to the community providers,” VA Deputy Undersecretary Dr. Baligh Yehia said last year.

Yehia says the VA has issued a request for proposals to streamline how it buys care from non-VA providers across the board. It expects to receive those proposals this summer.

VA leaders have said a big reason Veterans Choice foundered is because Congress provided only 90 days to set it up. The VA invited 57 companies to bid on running Choice, but only two responded, given the short timeline. Those two companies, Health Net Federal Services and TriWest, have struggled to make it work.

Tester, the ranking Democrat on the Senate Veterans’ Affairs committee, says he hopes to have draft legislation incorporating private-sector reform proposals ready in the fall.

Tester says his goal is to “cut the red tape and make sure it’s easy to work with for the providers. And I think we’ll get more providers jumping on board, and we’ll get more veterans using it, if the time to set up those appointments is reduced dramatically.”

Tester says he’ll defend the VA from those who “don’t want the government involved in health care at all.”

“I think it’s idealism versus realism,” Tester says. “We have folks that have borne the wounds of battle, and I think the VA is best suited to take care of those folks. So that VA needs to be there, and then we need to have a private sector that fills in the gaps around that VA.”

That’s particularly important in rural states like Tester’s Montana, where VA facilities are an important part of a generally understaffed health care landscape. They provide vital services, but rely on partnerships with private-sector doctors, clinics and hospitals to provide specialty care, or appointments that don’t require hours of driving.

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

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With the approval this month of two drugs to treat hepatitis C in children, these often overlooked victims of the opioid epidemic now have a better chance at a cure. Kids may actually have an easier time than adults getting approved for the treatment, according to some health policy specialists.

Researchers estimate that 23,000 to 46,000 children in the United States are infected with hepatitis C, a blood-borne infection that causes inflammation of the liver and can lead to liver failure, cancer and death. Most of the estimated 2.7 million to 3.9 million people overall who have chronic hepatitis C in the U.S. got it from sharing needles and other equipment while injecting opioids or other illicit drugs or (especially in earlier decades) from transfusions of contaminated blood.

But only about 20 percent of children get it from drug use. The majority of kids become infected by their mom during pregnancy. A baby has about a 6 percent chance of contracting hepatitis C if their mother has it.

The two drugs approved for pediatric use by the Food and Drug Administration, Harvoni and Sovaldi, have both been highly effective in treating adults with the disease, though Medicaid programs and private insurers often have balked at paying for the pricey drugs for adults.

In two clinical trials of Harvoni and Sovaldi in the treatment of children between the ages of 12 and 17, the drugs eliminated all traces of the virus in 97 to 100 percent of patients, generally in 12 weeks. Trials that test the effectiveness of the drugs in younger children are ongoing.

“It’s great news for our kids,” said Dr. Jessica Wen, medical director for the viral hepatitis clinical care program at Children’s Hospital of Philadelphia, which had more than a dozen kids in the trials. “Historically every new medication that’s approved for adults, there’s always a lag for pediatrics,” she said, noting that the wait can be as long as a decade.

The FDA approved Sovaldi in 2013 and Harvoni in 2014 for adults, and the drugs were widely hailed because they cured nearly everyone with minimal side effects, typically in 12 weeks. Earlier treatment regimens that required interferon injections and antiviral pills for six months or more were less effective and frequently caused severe side effects.

But the new drugs weren’t approved for kids, and many doctors have been delaying treatment in anticipation of pediatric approval by the FDA. Because the FDA approval applies to children over age 12 who weigh at least 77 pounds, this group would require an adult dose.

Since neither adults nor children are routinely screened for hepatitis C and many don’t develop any symptoms after becoming infected, people may have the disease for years before learning that they’re sick.

Children often come to clinicians’ attention when their regular pediatrician learns the mother is infected, said Dr. Karen Murray, a professor of pediatrics at University of Washington medical school who works at Seattle Children’s Hospital, which had several children in the trials.

Children who contract hepatitis C may suffer less liver damage over time than those who contract the virus as adults, Murray said.

Still, “there are all these social and biological events that may happen like marriage and childbirth, and it would be nice if they were cleared of the virus before then,” she said.

When Harvoni and Sovaldi first came on the market, insurers often balked at the price tag, which typically approached $100,000 for a course of treatment. Medicaid programs, in particular, restricted access to the drugs for adults, often requiring that people have significant liver damage and/or prove that they’d been drug- and alcohol-free for several months before they would approve treatment. (Since the drugs weren’t approved for children, many pediatricians said they didn’t attempt to prescribe them back then.)

Increased competition from other drugs since then has helped reduce the price somewhat, and insurers aren’t creating quite as many obstacles to treatment now, said Ryan Clary, executive director of the National Viral Hepatitis Roundtable, a patient advocacy group.

However, “coverage is still a very significant problem,” Clary said.

Insurance coverage may be less problematic for children. Under federal law, state Medicaid programs must cover “early and periodic screening, diagnostic, and treatment services” for children under age 21 that are necessary to correct or ameliorate physical and mental illnesses.

“The short answer is that [Medicaid] will likely require coverage for all kids, regardless of whatever the coverage policies for adults may be,” said Matt Salo, executive director of the National Association of Medicaid Directors.

State Medicaid programs have leeway with adults to decide that a treatment isn’t medically necessary unless the person’s liver is damaged, explained Kelly Whitener, an associate professor at Georgetown’s Center for Children and Families.

“But for kids, the federal standard … is broader, so medical necessity could not be linked to severity of illness/liver disease,” she said.

It’s unclear what private insurers will do regarding coverage of Harvoni and Sovaldi for kids.

“Given these are recently approved drugs, we expect plans will follow their normal practices,” said Kristine Grow, a spokesperson for America’s Health Insurance Plans, a trade group. “This includes evaluating the evidence, systematic review of the medication’s effectiveness, considering any federal or state mandates, and updating their policies as new evidence is available.”

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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The public could soon get a look at confidential reports about errors, mishaps and mix-ups in the nation’s hospitals that put patients’ health and safety at risk, under a groundbreaking proposal from federal health officials.

The Centers for Medicare and Medicaid Services wants to require that private health care accreditors publicly detail problems they find during inspections of hospitals and other medical facilities, as well as the steps being taken to fix them. Nearly nine in 10 hospitals are directly overseen by those accreditors, not the government.

There’s increasing concern among regulators that private accreditors aren’t picking up on serious problems at health facilities. Every year, CMS takes a sample of hospitals and other health care facilities accredited by private organizations and does its own inspections to validate the work of the groups. In a 2016 report, CMS noted that its review found that accrediting organizations often missed serious deficiencies found soon after by state inspectors.

In 2014, for instance, state officials examined 103 acute-care hospitals that had been reviewed by an accreditor in the past 60 days. The state officials found 41 serious deficiencies. Of those, 39 were missed by the accrediting organizations. This disparity “raises serious concerns regarding the [accrediting organizations’] ability to appropriately identify and cite health and safety deficiencies” during inspections, CMS officials wrote when they released draft regulations including the proposed change on Friday.

The move follows steps CMS took several years ago to post government inspection reports online for nursing homes and some hospitals. ProPublica has created a tool, Nursing Home Inspect, to allow people to more easily search through the nursing home deficiency reports; the Association of Health Care Journalists has done the same for hospital violations.

Those government inspection reports do not identify patients or medical staff, but they do offer a description—often detailed—of what went wrong. This includes medication errors, operations on the wrong patient or the wrong body part, and patient abuse.

But private accrediting organizations, the largest of which is The Joint Commission, have not followed suit, creating a patchwork of disclosure in which some inspections are public and others are not. CMS’ proposed rules are designed to fix this.

“We believe it is important to continue to lead the effort to make information regarding a health care facility’s compliance with health and safety requirements” publicly available, CMS officials wrote.

“It’s huge, absolutely,” says Rosemary Gibson, a patient safety expert who wrote a book, Wall of Silence, about medical errors. “Right now the public has very little information about the places where they’re putting their life on the line, and that’s just not acceptable. If you’re a good place, what are they afraid of?”

Medical errors are a leading cause of death and injuries in U.S. hospitals. A 1999 report by the Institute of Medicine estimated that up to 98,000 people a year die because of mistakes in hospitals; subsequent reports have said the number is much higher.

To qualify for federal funding, health facilities have to meet minimum requirements, known as Medicare conditions of participation. If a health facility has problems and doesn’t fix them, it stands to lose its Medicare funding. Though this rarely happens, it can be crippling for an institution and could force it to close.

State health departments get funding from CMS to inspect facilities to ensure they comply with these requirements. But the law also allows hospitals, ambulatory surgery centers, home health agencies and hospices to pay private, national accrediting organizations for such oversight. The Joint Commission conducts unannounced inspections at hospitals at least once every 39 months, and more often if complaints arise.

Though accreditors have to be approved by the secretary of Health and Human Services, they rarely take punitive action against the organizations they oversee. Of the 4,018 hospitals listed on the The Joint Commission’s website, more than 99 percent have full accreditation and only seven are on track to lose their “gold seal of approval.”

The Joint Commission said it is reviewing the CMS proposal and couldn’t comment further. A smaller competitor, the Healthcare Facilities Accreditation Program, said it supports the goal of transparency but is studying what the change would mean in practice, both in terms of staffing and costs. “We haven’t talked to our hospital partners,” says Gary Ley, its executive director. “It would be a major change for them also. It’s hard not to support the goals but we have to look at the execution.”

For its part, the American Hospital Association said it supports providing the public “useful information” about hospital quality, but has doubts that detailed inspection reports fit that description.

“It’s important that the information shared with consumers has a clear purpose, is transparent and is readily understood by folks from all walks of life, not just those with deep expertise in health care,” says Nancy Foster, AHA’s vice president of quality and patient safety, in a statement. “We are concerned that sharing a detailed report may not be the most useful or effective strategy for informing the public.”

Foster says it might be more useful to provide a one- or two-page “accurate summary” of inspection findings, with “key takeaways” and why they are important. “This summary could also draw from the plan of correction the hospital creates and summarize how the hospital plans to address the findings,” Foster says.

For years, accreditors have been accused of putting the interests of the facilities that pay them ahead of patient safety. In 2002, the Chicago Tribune reported how The Joint Commission gave its seal of approval to “medical centers riddled by life-threatening problems and underreporting of patient deaths due to infections and hospital errors.”

Last week, BuzzFeed News reported how an Oklahoma psychiatric hospital was named a “Top Performer in Key Quality Measures” by The Joint Commission even though police records, state inspection reports and lawsuit records showed that it “is a profoundly troubled facility where frequent violence endangers patients and staff alike, where children as young as 5 are separated from their parents and held in dangerous situations, and where wards lack adequate staffing and staff lack adequate training.”

In a response to BuzzFeed, the company that runs the hospital, Universal Health Services, said it “is proud of the care it provides patients at Shadow Mountain Behavioral Health.”

On its website, The Joint Commission allows users to check the accreditation status of hospitals but provides scant information of what went wrong, even when hospitals are described as receiving a “preliminary denial of accreditation.” For one hospital, the explanation is: “Existence at time of survey of a condition, which in The Joint Commission’s view, poses a threat to patients or other individuals served.” The threat itself is not disclosed.

Consumers Union’s Safe Patient Project and other patient safety organizations have been pushing for years for more information about hospital inspections. Lisa McGiffert, who directs the Safe Patient Project, hopes this may be the opportunity for change. “The information that’s available now is so minimal and would not really inform anyone about real quality of a hospital,” she says.

Comments on the proposal may be submitted from April 28 to June 13 through the CMS website.

Disclosure: Ornstein was previously president of the Association of Health Care Journalists. While he served in that position, AHCJ called for The Joint Commission to make its inspection reports public. The Joint Commission declined to do so. Have you complained about a hospital to The Joint Commission or another accrediting body? We’d like to hear from you. Email Charles.ornstein@propublica.org. ProPublica is an independent nonprofit newsroom based in New York.

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A nonprofit organization that has orchestrated a wide-reaching campaign against foreign drug imports has deep ties to the Pharmaceutical Research and Manufacturers of America, or PhRMA, the powerful lobbying group that includes Eli Lilly, Pfizer and Bayer.

The nonprofit, called the Partnership for Safe Medicines, has recently emerged as a leading voice against Senate bills that would allow drugs to be imported from Canada.

Both the lobbying group and the nonprofit partnership have gone to great lengths to show that drugmakers are not driving what they describe as a grass-roots effort to fight imports, including an expensive advertising blitz and an event last week that featured high-profile former FBI officials and a former Food and Drug Administration commissioner.

However, a Kaiser Health News analysis of groups involved in the partnership shows more than one-third have received PhRMA funding or are local chapters of groups that have received PhRMA funding, according to PhRMA tax disclosures from 2013 to 2015.

Forty-seven of the organizations listed in the ads appear to be advocacy organizations that received no money from PhRMA in those years.

A PhRMA senior vice president, Scott LaGanga, previously led the Partnership for Safe Medicines for 10 years. At PhRMA, LaGanga was responsible for the lobbying group’s alliances with patient advocacy groups, and he was simultaneously listed as the executive director of the Partnership for Safe Medicines on each of that group’s annual tax filings since 2007, the earliest year for which they are available from ProPublica’s Nonprofit Explorer.

LaGanga wrote a 2011 article about the partnership’s origins. Published in the Journal of Commercial Biotechnology, it described “public-private partnerships in addressing counterfeit medicines.” His PhRMA job was not disclosed in the article.

From 2010 to 2014, the organization hosted a conference called the Partnership for Safe Medicines Interchange. In a video from a 2013 event, LaGanga thanks pharmaceutical companies, most of them PhRMA members, for sponsoring the event.

In February, LaGanga moved to a senior role at PhRMA and stepped down as executive director of the Partnership for Safe Medicines, just as the group’s campaign to stop import legislation was revving up.

The partnership’s new executive director, Shabbir Safdar, said LaGanga resigned from the group to avoid the appearance of a conflict of interest.

“That’s why Scott’s not executive director anymore,” he said. PhRMA declined to make LaGanga available for an interview.

Considering Legislation

The Senate push to allow Americans to buy pharmaceuticals from Canada comes as more patients balk at filling prescriptions because of soaring drug prices. Prescription medicines purchased in the U.S. can run three times what they cost in Canada, data from the company PharmacyChecker.com show.

In 2016, about 19 million Americans purchased pharmaceuticals illegally from foreign sources through online pharmacies or while traveling, according to a Kaiser Family Foundation poll. Many survey respondents cited pricing disparities as the reason.

A bill cosponsored by Sen. Bernie Sanders (I-Vt.) would provide a mechanism for Canadian drug manufacturers to sell to U.S. consumers and pharmacies. Sanders introduced the bill in February. In January, Sens. John McCain (R-Ariz.) and Amy Klobuchar (D-Minn.) also introduced a bill to allow drug imports from Canada.

In the House, Rep. Elijah Cummings (D-Md.) introduced a similar bill to Sanders’, along with 23 other Democrats.

The U.S. drug industry has strongly opposed efforts to open the borders to drug imports, but the PhRMA lobbying group is not mentioned in the nonprofit partnership’s recent advertising blitz against the proposed legislation. The nonprofit says its grass-roots effort is supported by 170 members, including professional organizations and trade groups.

The nonprofit describes PhRMA as a dues-paying member with no larger role in shaping the group’s activities. Partnership spokeswoman Clare Krusing would not say how much each member contributes. PhRMA spokeswoman Allyson Funk declined to say whether PhRMA funds the partnership.

“PhRMA engages with stakeholders across the health care system to hear their perspectives and priorities,” Funk said. “We work with many organizations with which we have both agreements and disagreements on public policy issues, and believe engagement and dialogue are critical.”

Campaigning Against Drug Imports

The partnership recently launched its ad campaign, warning against the alleged dangers of legalizing Canadian drug imports. It includes television commercials, promoted search results on Google and a full-page print ad in The Washington Post and The Hill. The group’s YouTube page shows recent commercials targeted to viewers in 13 states.

“We don’t disclose specific ad figures, but the campaign is in the high six figures,” Safdar said.

The commercials ask voters to urge their senators to “oppose dangerous drug importation legislation.”

The newspaper ad reads, “Keep the nation’s prescription drug supply safe. Urge the Senate to reject drug importation measures.” Its headline declares that “170 healthcare advocacy groups oppose drug importation,” noting a letter to Congress signed by its members. The ad lists 160 members who signed the letter, and PhRMA’s name is not included.

“Having a big membership allows the coalition to present what looks like a unified show of grass-roots support … but it does raise questions about which members of the coalition are really driving and funding the group’s policy-making,” said Matthew McCoy, a postdoctoral fellow at the University of Pennsylvania who studies patient advocacy groups.

The list of groups includes at least 64 trade organizations representing the biomedical industry, professional associations representing pharmacists, a private research company and two insurance companies.

One group that signed the letter, the “Citrus Council, National Kidney Foundation of Florida Inc.,” represents a single volunteer, according to an email from the group. A spokesman for the National Kidney Foundation of Florida said the volunteer’s views contradict the position of the umbrella group, and said the foundation supports “any sort of drug importation that allows our patients to have access to drugs at the best price.”

Two of the hepatitis patients’ advocacy groups that were listed, the National Association of Hepatitis Task Forces and the California Hepatitis C Task Force, are run by the same person, Bill Remak. Remak said the groups receive small amounts of PhRMA funding.

“I don’t enjoy having to take this extreme position of saying we shouldn’t import at all, but until we have some oversight regime, some way of protecting consumers, it’s a really tough call,” he said.

“Current drug importation proposals do not appear to have equal safety and chain-of-custody accountability laid out adequately for patient safety concerns,” said William Arnold, president of the Community Access National Network, which is also listed in the ad and is an advocacy and support group for people living with HIV/AIDS or hepatitis in Washington, D.C. His group did not accept money from PhRMA between 2013 to 2015, the Kaiser Health News analysis found.

Concerns About Safety And Price

Last week, the partnership hosted a panel at the National Press Club featuring former FBI director Louis Freeh and former FDA commissioner Dr. Andrew von Eschenbach. The discussion focused on the alleged health and legal dangers of online pharmacies.

“You can talk about lowering prices, but if a drug comes with a high probability of toxicity and death, that comes at a high cost to the patient,” von Eschenbach said. “That’s what’s at issue with drug importation.”

Each speaker argued that the bill co-sponsored by Sanders would be harmful to patients. Around the same time that bill was introduced, the partnership also sent emails to member organizations seeking help to stop such a measure.

Speakers at the partnership event claimed importation would lead to a flood of counterfeit medicines laced with arsenic, fentanyl and lead paint.

“These drugs are manufactured in jungles, in tin drums, in basements. … Those are the sort of sanitary conditions we’re talking about here,” said George Karavetsos, a former director of the FDA’s Office of Criminal Investigations.

Both von Eschenbach and Karavetsos have ties to the pharmaceutical industry. Von Eschenbach left the FDA in 2009 to join Greenleaf Health, which counsels pharmaceutical clients, before starting his own consulting company, and Karavetsos counsels pharmaceutical clients at DLA Piper, a Washington, D.C., law firm.

In an interview, Josh Miller-Lewis, Sanders’ deputy director of communications, refuted Karavetsos’ arguments. He said Canadian drugmakers can apply for licenses, and all drugs would have to come from FDA-inspected plants.

Politico reported in October that PhRMA is bolstering its war chest by another $100 million per year, suggesting to many industry analysts that drugmakers are gearing up for a ferocious fight.

“I think it’s safe to say pharmaceutical corporations are prepared to spend some fraction of their multibillion-dollar profits to fight drug importation and any other policy that might end the plague of overpriced medicine,” said Rick Claypool, research director for Public Citizen, a watchdog group critical of the drug industry.

Kaiser Health Newsis an editorially independent newsroom that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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Hannah Berkowitz is 20 years old. When she was a senior in high school her life flew off the rails.

She was getting high on whatever drugs she could get her hands on. She was suicidal. Berkowitz moved into a therapeutic boarding school to get sober, but could only stay sober while she was on campus during the week.

“I’d come home and try to stay sober really hard — really, really hard,” says Berkowitz. “Sometimes I’d make it through the weekend, and sometimes I just couldn’t make it. It was white-knuckling it, just holding on.”

The transition back home always triggered a relapse for Berkowitz.

“I thought it was just my fault and there was no hope,” she says.

No hope — but Berkowitz did have luck. She had private health insurance and she lived in Connecticut, where a startup company, Aware Recovery Care, had begun treating clients in the very environment where Hannah was struggling to stay sober: her home.

A chronic disease approach

Treating addiction is a growing business, but a lot of the treatment that’s available is expensive and patients often relapse. Fortunately, there is a way to help some people pay less for better results, says Matt Eacott, vice president of Aware Recovery Care.

“Ninety-nine percent of the industry really treats addiction as an acute problem — like a rash on your arm that you rub lotion on and you’re done,” says Eacott.

Instead, Aware treats addiction as a chronic illness — it doesn’t disappear just because symptoms are temporarily under control. The approach is a cost-effective way of treating addiction, Eacott says, with better results than most competitors achieve.

Aware comes into clients’ homes and connects them with a nurse, a primary care doctor, a therapist, peer support, 12-step meetings and a case manager. Clients hooked on opioids can get medication-assisted treatment. They can also submit to urine screening and GPS tracking, if that helps them stick with the program.

Hannah’s mother, Lois Berkowitz, says the program is intense at first. But as Hannah built coping skills the supports faded into the background.

“It’s not like they’re doing the work for the addict,” says Lois Berkowitz, “they’re just basically taking them by the hand and saying, ‘Here are the places you need to go that will help you. And I’m going to go with you to start, so it doesn’t feel that uncomfortable. And then we’re going to let you fly.’ “

Before they “fly,” Aware clients have a pretty long runway. The treatment lasts for a full year.

Benefits worth the initial cost, insurer says

Aware has now expanded from its base in Connecticut into New Hampshire. The program is expensive. It costs $38,000 a year. As of now, it’s only available to private-pay clients and people insured through Anthem health insurance in New Hampshire and Connecticut.

Anthem became the first insurer to pay Aware, because the treatment is based on hard science that’s yielding solid results for clients, says Dr. Steven Korn, Anthem’s behavioral health medical director. Science and results are rare in addiction treatment, he says.

“There are old, old notions that have hung pretty tough,” says Korn. “When I was young — when I was in training — as soon as substance abuse was mentioned, the response of physicians was, ‘Well, go to AA. That’s not our problem. We don’t treat that.’ “

For a year of treatment, Anthem says it’s paying Aware about the same as the cost of a month or two of inpatient treatment. Anthem also says 72 percent of Aware clients are either sober at the end of one year or still in active treatment.

That’s about twice the sobriety rate of people who check in to a facility for a month and then get no follow-up care, says Dr. Stuart Gitlow, past president of the American Society of Addiction Medicine.

Treating addiction at home makes sense because it’s the exact place where people learned all their bad habits, Gitlow says.

“It’s all based on this concept that addiction is not about the substance use,” he says, “but is about what led to the substance use in the first place. And you can’t really get there without getting to know the patient.”

Aware says it’s in negotiations with four more major insurers. The program hopes to have a couple hundred clients in New Hampshire by the end of the year.

This story is part of NPR’s reporting partnership with New Hampshire Public Radio and Kaiser Health News.

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In Indian Country, a gym membership is not a cultural norm and the incidence of heart disease and obesity are high. Native Americans are 60 percent more likely to be obese than non-Hispanic whites. The Coeur D’Alene tribe, whose headquarters is in northern Idaho, is trying to combat the problem by incorporating culture into fitness programs.

The tribe has created an exercise routine — called “Powwow Sweat” — based on traditional dancing. The program features a series of workout videos that break down six traditional dances into step-by-step exercise routines.

“Drop the pringles and let’s jingle,” commands Shedaezha Hodge, as she demonstrates the steps that make up the women’s “Jingle Dress” dance.

High steps, box steps, cross steps and kicks combine into a routine that would give any Zumba class a run for its money.

“Sweating yet?” Hodge asks, as she encourages the dancers to go faster and kick higher.

All the dances in the exercise program are typical at powwows, including the “Men’s Fancy Dance,” — which features four basic steps and a hip move. The hip move involves lifting your knee up, then circling it out to the side, all the while bouncing to the drum beat.

“I lost 13 1/2 pounds,” says Ryan Ortivez, who attends the weekly “Powwow Sweat” classes at the Coeur D’Alene Wellness Center, in Plummer, Idaho.

“I’m aiming to lose 40 more pounds by the end of the year,” he adds.

Ortivez quit smoking this year. He also gave up junk food and soft drinks.

There are some real health challenges in this community, says Terry O’Toole, senior health advisor with the division of nutrition, physical activity and obesity at the Centers for Disease Control and Prevention. The CDC has given the Coeur D’Alene tribe $2 million to develop “Powwow Sweat.” It also supports a community garden on the reservation and a project that stocks the gas station market with healthy food options.

“Combating obesity requires more than just one initiative or one program,” O’Toole says. “It takes a variety of what we call ‘population-based strategies.’ “

The goal is to achieve community-wide results, O’Toole says.

That isn’t going to be easy, says LoVina Louie, director of the tribe’s wellness center. Mainstream fitness and nutrition programs don’t meet the needs of tribal members, she says.

“What they lack is spirituality,” says Louie. “Most programming is only physical, or it’s only nutrition. It’s in these compartments — whereas we’re more holistic,” Louie says. “We want to incorporate the mind, body and spirit into what we do.”

“Powwow Sweat” is a good example of that — using traditional dance for a high-intensity workout.

“It’s almost like jumping rope for 25 minutes straight,” Louie says, as she keeps everyone moving through dance steps at one of the weekly exercise classes. “If you don’t do it regularly, your calves will hurt, like you’re just out of breath, because you’re just constantly bouncing.”

It’s this combination of tradition and exercise that keeps tribal member Ryan Ortivez and his neighbors coming to class each week, to watch the videos and dance alongside each other.

“It’s a lot more attractive than doing jogging or the bicycle for me, because it also relates to my culture,” says Ortivez.

“I’m in love with my community, first and foremost,” he says. “My people. I love to see my community get involved and get active and be healthy.”

In addition to losing weight and getting healthy, Ortivez wants to get in good enough shape to dance in the tribe’s powwow this summer. If he does, it will be his first time.

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Not everyone who reaches so-called retirement age is ready to retire. But they may be ready for a change. That’s one of the reasons that the tech giant Intel pays longtime employees a stipend while they try out new careers at nonprofit organizations.

One of those employees is 61-year-old Gail Dougherty. The former project manager now sits at a desk at the Virginia Garcia Memorial Health Center in Oregon, poring over a spreadsheet on her computer. She’s crunching patient data with input from doctors and nurses to figure out better ways of delivering care to the health center’s high number of patients with diabetes.

“Out of my own non-medical, non-health-care … head, [I] proposed a workflow that seemed like, from what I was hearing might be the most helpful thing for our patients,” Dougherty says.

Those patients are migrant workers and others who have no health insurance or who qualify for Medicaid. Dougherty says the skills from her old job fit in with her new one, even though the two jobs couldn’t be more different.

“At Intel, deadlines are king,” says Dougherty. “You’ve got a product, you’ve got to get it out, either first or by the time you promised. Schedules are king.” But at the health center? “Not so much,” she says, “because what’s primary is the patient care.”

Dougherty is what’s known as an Encore Fellow. She’ll work at the health center part time for about a year and receive a stipend of $25,000. This is part of a nationwide program started by Encore.org that brings retiring corporate workers into mission-driven organizations. [You may have heard sponsorship messages about Encore on NPR and other media outlets.] But Intel is the only company that pays the stipend for its retirees’ fellowships as a basic employee benefit. In the past 5 years, that’s meant the company’s paid for about 1,000 fellowships at a cost of more than $30 million.

“In the scheme of our total labor cost, it’s a very small number,” says Ogden Reid, Intel’s vice president for human resources.

He says it’s also a worthwhile expense. “We feel like we’re helping our communities,” Reid says. “Our retirees give us really positive feedback … and our workforce that’s here see that happening to folks who’ve had a long career and I think that makes them feel good about the company.”

Right now, there are seven Encore Fellows at the Virginia Garcia Memorial Health Center. Gil Munoz, the center’s CEO, says they play a crucial role.

“They bring a certain discipline, a certain rigor, to looking at problems and solving them,” Munoz says. “Having these Encore Fellows who could help lead a project can be the key to whether it’s successful or not.”

That may be why Jinny Meade, 73, is still here. She came to the health center a couple of years ago as an Encore Fellow. Now she’s a permanent part-time employee, working as a project consultant.

“I’m sort of the nag that helps them stay on track as much as possible,” she says, laughing.

It’s rewarding to know that her management skills are serving the mission of the health center, but Meade also derives satisfaction from what she gets back in return.

“It’s really exciting to be part of something that’s … bigger than ourselves,” she says. “Health care for the underserved is a worthy cause.” And in Meade’s case, it’s also a second career.

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For most of his life, Carl Goulden had near perfect health. He and his wife, Wanda, say that changed 10 years ago. Carl remembers feeling, “a lot of pain in the back, tired, fatigue, yellow eyes — a lot of jaundice.”

Wanda, chimes in: “Yellow eyes, gray-like skin.” His liver wasn’t working, she explains. “It wasn’t filtering.”

Carl was diagnosed with hepatitis B. Now 65 and on Medicare, he had a flower shop in Littlestown, Pa., back then, so had been buying health insurance for his family on the market for small businesses and the self-employed.

The medications to manage Carl’s hepatitis cost more than $10,000 a year — and if he ever needed a liver transplant, as some people with hepatitis eventually do, the further costs could be formidable. Thank goodness they had health insurance, the couple thought.

But then, Carl says, “the insurance renewals went way up.”

After a few years he could no longer afford to buy the coverage — more than $1,000 a month — and also maintain his business. So he dropped the health insurance.

“I was devastated,” he says, “because I didn’t know when my liver might fail.”

But that steep increase in his insurance rate was completely legal, says Pennsylvania insurance commissioner, Teresa Miller. And back then, before the Affordable Care Act became law, a patient like Carl Goulden might have had a very hard time buying another policy; he likely would have been turned down by other insurers because he now had what’s called a “pre-existing” medical condition.

A family like the Gouldens would “just have been out of luck,” Miller says.

Pennsylvania: The wild, wild West

Before the ACA, states had differing approaches to handling pre-existing conditions.

Pennsylvania was typical. Until the ACA mandated that insurers treat sick and healthy people equally, buying insurance was the wild, wild West.

Insurers couldn’t overtly kick people off a plan if they got sick, but they could find ways to charge them a lot more, even those whose chronic condition wasn’t all that serious — such as acne. For individuals looking to sign up in the first place, “an insurance company could simply decline to offer you insurance at all because of your pre-existing condition,” Miller says.

Insurers who did offer a policy to someone with a pre-existing medical condition might have done so with a catch — the plan could require a waiting period, or might exclude treatment for that condition.

“So, let’s say you had diabetes, for example,” Miller says. “You might have been able to get coverage for an unexpected health care need that arose, but you’d still be on your own for any treatment and management of your diabetes.”

From the perspective of the insurance company, these practices were intended to prevent the sick from signing up for a health plan only when they needed costly care.

Pennsylvania did try to partially solve this problem. It created a more scaled-back health plan, called Adult Basic, for those with lower incomes who didn’t have any coverage. Lots of people signed up, but the plans didn’t include coverage for mental health care, prescription drugs or more than two nights in a hospital. Even so, Miller says, the strategy proved too expensive for the state.

“That program was spending $13 million to $14 million a month when it was shut down,” she says.

High-risk pools

More than 30 other states dealt with pre-existing conditions by setting up what are called “high-risk pools,” a separate insurance plan for individuals who couldn’t get health coverage in the private market.

These plans could be real lifesavers for some people with conditions like cancer — which can cost tens if not hundreds of thousands of dollars to treat.

The experiences with high risk pools varied, but states faced lots of challenges, says John Bertko, an insurance actuary with the state of California. And the main problem was the high cost.

“The one in California, which I was associated with, limited annual services to no more than $75,000, and they had a waiting list. There was not enough money,” Bertko says. “The 20,000 people who got into it were the lucky ones. At one point in time, there were another 10,000 people on a waiting list.”

The pools also had catches; premiums were expensive, as were out-of-pocket costs. And plans often excluded the coverage of pre-existing conditions for six months to a year after the patient bought the policy.

New Jersey: Pre-existing conditions were covered, but with a catch

Around that same time, across the Delaware River, the state of New Jersey was trying something different.

“Insurers could not take health status into account,” says Joel Cantor, director of Rutgers University’s Center for State Health Policy who has been analyzing the New Jersey experience.

Before the ACA, New Jersey was one of just a handful of states that prohibited insurers from denying coverage to people with pre-existing conditions. Insurers also weren’t allowed to charge people a whole lot more for having a health issue, and the plans had to offer robust coverage of services.

There was a one-year waiting period for coverage of a pre-existing condition, but a larger issue became cost. The entire individual market in New Jersey became expensive for everyone, regardless of their health status, Cantor says. Because there was no mandate to have health insurance coverage, those who signed up tended to really need it, and healthy people did not enroll.

And so, “the prices went up and up,” he says. And the premiums and enrollment “went down and down.”

The state tried to address this in the early 2000s by introducing a “skinny” health plan, Cantor says.

“By that I mean very few benefits,” he explains. “It covered very, very limited services.”

The plan was affordable and really popular, especially among young and healthy people and about 100,000 people signed up. But if something did happen, or if a person had a chronic health need, lots of the costs shifted to the individual.

“It left people with huge financial exposure,” he says.

That’s, in part, why the ACA included a rule that insurance plans now have to offer good benefits and be available to everybody. In exchange, insurers have the mandate and subsidies — so that everybody will buy in.

Cantor says these experiences point to an ongoing dilemma in health care: A small portion of people consume a big chunk of health care costs. It’s hard to predict who among us will cost a lot — or when. So, the question becomes, what kind of care should insurance plans cover and who should shoulder that cost?

This story is part of a reporting partnership with NPR, WHYY’s health show The Pulse and Kaiser Health News.

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Your federal income taxes are due April 18 this year, and — for perhaps several million people — a fine for failing to get health insurance is due that day, too.

Despite a lengthy debate, Congress has not yet acted on a bill to repeal portions of the Affordable Care Act. That means the law and almost all of its regulations remain in force, at least for now.

For the majority of tax filers, who had health insurance through an employer for 2016 or through a government program, all they have to do is check the box on the 1040 form that says they were covered for a full year. That’s it.

The Obama administration had called for the IRS to begin rejecting tax returns for 2016 that left that box blank. But the IRS under the Trump administration has canceled that policy, citing a Trump executive order that calls on federal agencies to “minimize the burden” of the health law.

Still, those who lacked insurance for more than three consecutive months, or who bought individual insurance and got federal help paying the premiums, need to do a little more work to figure out what, if anything, they owe.

Those with no insurance, and those who have had a lengthy gap in coverage, may be required to pay what the federal government calls a “shared responsibility payment.” It’s a fine for not having coverage, on the theory that even those without insurance will eventually use the health care system at a cost they can’t afford, which means that someone else — other patients, hospitals, health care providers and taxpayers — will have to pay that bill.

Many people who don’t have insurance, however, qualify for one of the several dozen “exemptions” from the fine. Nearly 13 million tax filers claimed an exemption for 2015 taxes, according to the IRS. Most often those exemptions came from people whose income was so low (less than $10,350 for an individual) that they are not required to file a tax return, or from Americans who lived abroad for most of the year, or from people for whom the cheapest available insurance was still unaffordable (costing more than 8 percent of their household income).

The fine for 2016 taxes is the greater of $695 per adult or 2.5 percent of household income. Fines for children who lack insurance coverage are half the amount for uninsured adults. Fines are pro-rated by the number of months each person was uninsured.

The maximum fine is $2,676; that is the national average cost of a “bronze” level insurance plan available on the health exchanges. But most people do not pay anywhere near that much. Last year, said the IRS, an estimated 6.5 million tax filers paid a fine that averaged $470.

If you bought your own insurance from the federal marketplace or a state health insurance exchange and you got a federal tax credit to help pay for that coverage, you have to take another step before you can file your taxes.

People who got those tax credits must fill out a form that “reconciles” the amount of subsidies they received based on their income estimates with the amount they were entitled to according to their actual income reported to the IRS.

In tax filings for 2015, about 5.3 million taxpayers had to pay the government because they got too much in tax credits, compared to 2.4 million who got additional money back. But among those who underestimated their incomes and had to pay back some of those tax credits, 62 percent still received a net refund on their taxes.

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

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