A widely used blood test to measure blood-sugar trends can give imprecise results, depending on a person’s race and other factors. This test means diabetes can sometimes be misdiagnosed or managed poorly.

Doctors have been cautioned before that results from the A1C test don’t have pinpoint accuracy. A study published Tuesday underscores that shortcoming as it applies to people who carry the sickle cell trait.

Glucose levels in the blood rise and fall all the time, so it can be tricky to look at a single exam to diagnose diabetes or manage the disease in people who have it. But one test gets around this problem.

The A1C test measures sugar that binds to hemoglobin molecules in red blood cells. It provides an average of blood sugar over the past three months, “so this has turned out to be an incredibly powerful test, both for the diagnosis and treatment of diabetes,” says Dr. Anthony Bleyer, a kidney specialist at the Wake Forest School of Medicine who was not involved in the study.

The problem is that the test results can vary, depending on circumstance. For example, people with anemia may get inaccurate readings. So do people who carry unusual types of hemoglobin, the best known being sickle cell trait.

Eight to 10 percent of African-Americans carry the sickle cell trait. But only people who inherit two copies of the sickle cell trait, one from each parent, develop the disease.

And a few years ago, scientists realized that A1C readings for African-Americans typically don’t match those from whites. They are generally higher.

“The test was really standardized based on white individuals, and there were just a small number of African-American individuals in that study,” Bleyer says.

And while the difference isn’t large, it can matter a lot, especially for people who are close to the line that defines diabetes. Someone who appears to be just under the line and diagnosed as having prediabetes may in fact have a higher level of A1C, which would push them into a diagnosis of diabetes.

Vagaries in these readings can also be misleading for people whose treatment is guided by this test, because doctors may be overly aggressive in controlling blood sugar, to the point that a patient can end up with seriously low blood sugar.

In a report published Tuesday in JAMA, the journal of the American Medical Association, scientists at Brown University and the National Institutes of Health examined data from two large studies to compare test results of African-Americans with and without the sickle cell trait.

The studies used standard A1C tests that had previously been shown to give low readings for people with the sickle cell trait. The scientists were surprised to find how big a difference it made.

About 4 percent of the people in the study who carried the sickle cell trait were diagnosed with diabetes, but they expect a test corrected for bias would have identified about 7 percent — nearly twice as many people.

“We were really shocked by that, honestly,” says Mary Lacy, a graduate student at Brown University and lead author of the study. “That’s huge!”

Likewise, they found 40 percent fewer cases of prediabetes than they expected among people carrying the sickle cell trait.

The test readings are only off by a few tenths of a percentage point, but that was enough to push many people below the cutoff points that indicate diabetes or prediabetes.

This observation is one reason doctors should be cautious in interpreting A1C results, researchers say.

“Doctors generally take the test fairly literally,” says Tamara Darsow, senior vice president for research and community programs at the American Diabetes Association. “How much this impacts care and the interpretation of A1C results I think is variable.”

The association’s guidance document cautions doctors that the A1C tests can be off by plus or minus 7 percent among people with unusual hemoglobin traits. As the new study underscores, that is more than enough variability to affect a diagnosis.

So instead of making a snap diagnosis, particularly for African-Americans, doctors could additionally run some more traditional blood-sugar tests. Those aren’t influenced by race or sickle cell status (though they can vary for other reasons).

“Information together from all of these tests can be much more powerful than those taken in isolation,” Darsow says.

The American Diabetes Association would ultimately like to come up with more concrete treatment guidelines, but for now their word to doctors is this: Be aware this is an issue and use your best judgment.

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Everyone expects Congress to change the Affordable Care Act. But no one know exactly how.

The uncertainty has one group of people especially concerned — the homeless. Many of these people received health coverage for the first time under Obamacare. They’re worried it will disappear.

Joseph Funn, homeless for almost 20 years, says his body took a beating while he lived on the street.

Now, he sees nurse practitioner Amber Richert fairly regularly at the Healthcare for the Homeless clinic in Baltimore.

At a recent visit he mentioned that he’d been having some chest pains.

“And when exactly did you quit smoking?” Richert asked.

In December, he said, when he moved into his first apartment in decades.

That was a big change for the 56-year-old. Last winter, Funn was living outside and trudging through deep snow for days. His left foot got so swollen, he could hardly walk.

“It was frostbite,” he recalled. “I thought when you had frostbite, it’s like when you turn purple and blue. But when I came to see Dr. Amber, she said, ‘No, that’s when they have to cut something off.’ So I was like, ‘Whoa!’ “

Funn was admitted to the clinic’s convalescent center to be treated. The staff also signed him up for Medicaid, the government’s health insurance program for the poor and disabled.

Like many people who are homeless, Funn was uninsured. But under the Affordable Care Act, Maryland is one of 31 states and the District of Columbia that expanded Medicaid to cover nondisabled childless adults.

Healthcare for the Homeless President Kevin Lindamood said before Obamacare, only 30 percent of the patients they saw had health insurance. The group provides health care to people without homes as well as others who are in transition to more settled lives.

“Now [it’s] 90 percent of our clients, from 30 percent insured to 90 percent insured, either through Medicaid or Medicare,” he said. “That’s a transformation.”

He said the change allowed Healthcare for the Homeless to open new clinics, including one for dental care, and to double the number of clients that can be seen. The group also hired more outreach workers to encourage homeless people to come in for help.

Homeless advocates have argued that better health coverage should eventually reduce costly emergency room visits. They also say coverage can help people get off the streets by dealing with chronic problems, such as mental health issues, that might keep them outside.

Lindamood said his clients are now worried. “We’re working with very vulnerable people who are now coming to us, hearing the news in general and saying, ‘Wait a minute, I just got access to care. Does this mean I’m going to lose it?’ ” he said.

Republicans have promised to replace Obamacare but haven’t said how. President Trump has said no one will lose coverage.

But White House counselor Kellyanne Conway has also said the administration hopes to turn Medicaid into a block grant — meaning states would get a set amount of money, along with more control over how to spend it.

The approach has supporters.

“I think there’s a good case to be made that states will have more money to devote to the truly needy folks, because states will be more aggressive, in reining in wasteful expenditures, reining in unnecessary expenditures, reining in fraud,” said Michael Cannon, director of health policy studies at the libertarian CATO Institute.

But others are skeptical. Barbara DiPietro, policy director for the National Health Care for the Homeless Council, says block grants will likely mean less federal funding for Medicaid, forcing cash-strapped states to make tough choices about whom to cover.

“So when we talk about no one will lose coverage, that’s heartening,” said DiPietro. “But the details are always very important. What does that coverage look like? The population we serve typically falls through the cracks.”

Almost 900,000 patients are served by Health Care for the Homeless projects around the country. At the end of 2015, two years after Obamacare went into effect, about half those patients had Medicaid coverage.

Joseph Funn said losing Medicaid would be a hardship for him, but he also thinks there are a lot of people on the streets of Baltimore who are worse off than he is. “I can see them cutting me and giving the money to the people that need the most help,” he said. Now that he has his own apartment, he plans to get healthier so he won’t need as much care.

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There’s a moment in the Broadway musical Hamilton where George Washington says to an exasperated Alexander Hamilton: “Winning is easy, young man. Governing’s harder.”

When it comes to health care, it seems that President Trump is learning that same lesson. Trump and Republicans in Congress are struggling with how to keep their double-edged campaign promise — to repeal Obamacare without leaving millions of people without health insurance.

During the campaign, Trump promised to repeal and replace the Affordable Care Act immediately upon taking office. Last month, in an interview with The Washington Post, he said he had a replacement law “very much formulated down to the final strokes.”

But on Sunday, he dialed back those expectations in an interview with Fox News.

“It’s in the process and maybe it will take till sometime into next year, but we are certainly going to be in the process. It’s very complicated,” Trump said.

He repeated his claim that Obamacare has been “a disaster” and said his replacement would be a “wonderful plan” that would take time “statutorily” to put in place. And then he hedged the timing again.

“I would like to say by the end of the year, at least the rudiments,” he said.

Trump’s recent hesitation comes as Republicans in Congress tame their rhetoric surrounding the health care law.

Sen. Lamar Alexander, R-Tenn., chairman of the Senate health committee, said he’d like to see lawmakers make fixes to the current individual market before repealing parts of the law.

“We can repair the individual market, which is a good place to start,” Alexander said on Feb. 1.

He has also urged his colleagues to leave the other parts of the health care sector — Medicare, Medicaid and the employer market — alone.

Throughout the campaign, and over the six years since the law passed, Republicans in Congress have vowed to completely repeal the Affordable Care Act.

But in the time since the law went into effect, it has helped as many as 20 million people get insurance who didn’t have it before, according to the Department of Health and Human Services.

Just last week, the open enrollment period for 2017 ended and HHS reported that 9.2 million people bought insurance through the federal government’s insurance marketplace — slightly lower than last year but still a large number. About 3 million more people likely bought coverage on state-run exchanges, based on enrollment in past years.

In addition, about 10 million people qualified for health coverage because of the expansion of Medicaid in most states.

That left Trump and Republicans, the day after the election, facing the choice of fulfilling their clear promise to repeal the ACA and the reality that doing so could leave millions of people without access to health care.

At that time the public seemed to gain a new appreciation of the law once it was actually threatened with repeal. In recent weeks, several polls have shown that more people view it more favorably than they did before the election.

Another reality Republicans have had to face is that, even though they control both houses of Congress and the White House, their ability to repeal the ACA is limited. That’s because Democrats in the Senate can block bills using their filibuster power.

But laws dealing with taxes and the budget are protected from filibuster, so Republicans can roll back many Obamacare provisions because they involve tax credits and federal spending.

That leaves lawmakers having to build a new health care system that works within the general framework of the Affordable Care Act. They can get rid of subsidies to help people buy insurance, but the law creating government-run insurance exchanges, for example, will still be on the books.

That’s why Alexander and a handful of other Republicans are beginning to talk about repairing the current system. Currently, not enough young healthy people have signed up for coverage to offset the costs to insure sicker, older people. The result is that premiums have risen and insurance companies that lost money pulled out of many markets.

But not everyone is on board. House Speaker Paul Ryan, R-Wis., said last week in an interview on Fox that repairing the health care system means “You must repeal and replace Obamacare.”

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What’s going to happen to the federal health law? The quick, accurate answer is that no one knows.

But amid the uncertainty about the future of the Affordable Care Act, states still have to manage their insurance markets. Most states have muddled through the 2017 enrollment season without making changes.

Minnesota, for its part, took three unusual actions that are worth a closer look.

In January, Minnesota:

• passed a one-time bailout for some consumers in the individual insurance market dealing with skyrocketing premiums;
• rejected an attempt to let insurers offer cheaper, bare-bones coverage;
• laid the groundwork for a sort of homegrown “public option” insurance plan.

Here’s more.

The Bailout

In response to some of the highest premium hikes in the country—50 to 67 percent, on average—Minnesota lawmakers passed a bailout for people who earn too much to qualify for the Affordable Care Act’s federal tax credit. The $300 million law will cut monthly premiums by 25 percent for about 125,000 Minnesotans.

Democratic Gov. Mark Dayton has backed the measure since October, saying the ACA is “no longer affordable to increasing numbers of people.” But passage wasn’t assured, as both houses of Minnesota’s Legislature are controlled by Republicans. The bill passed in January and is supposed to go into effect by April 30, and will be retroactive to the beginning of the year.

It is thought to be the second time a state has offered up state tax money to stabilize an insurance marketplace created by the health law. (Alaska came up with a $55 million bailout in 2016.)

Bare-Bones Coverage

A failed amendment to the Minnesota legislation sought to strip dozens of so-called essential benefits from health plans, with the expectation that slimmed-down coverage would cost less.

Republican Minnesota State Rep. Steve Drazkowski offered the amendment.

“What we’re doing is trying to create an environment that, if and when the ACA goes away, that Minnesotans will have the freedoms they need in order to start to bring some free-market competition, some free market ingenuity and innovation into the health insurance market,” Drazkowski said, adding that he was trying to eliminate the current, “government-controlled, one-size-fits-all, dictating set of mandates.”

Drazkowski’s amendment caught the eye of Minnesota-native and former Centers for Medicare & Medicaid Services administrator Andy Slavitt, who tweeted about it.

The list of benefits that consumers could choose to have covered — or not — under Drazkowski’s amendment included maternity care, diabetes treatment and mental health care, among others. Some items on the list are very specific: Lyme disease, prostate cancer screening and outpatient surgery.

“Telling people, ‘Only buy what you need,’ implies that people know that they’re not going to need the emergency room or that there’s not going to be an addiction problem in their family,” Slavitt said. “I don’t think we, as a country, want people to not have access to the services they need.”

Dayton and other Democrats opposed the amendment and it was dropped from the final legislation. But Slavitt said it’s a cautionary tale about high-deductible catastrophic plans that cover little or no basic care.

He doesn’t dispute the notion that the individual market needs help, but he says offering extremely limited plans amounts to ill-conceived, “gotcha” insurance.

“This is the most blatant one I’ve seen,” Slavitt said, of the failed amendment’s approach.

But other amendments did make it into the final law, including a provision that changes Minnesota’s longstanding state laws requiring HMOs to be not-for-profit. The new law allows out-of-state, for-profit HMOs to sell health plans in Minnesota.

Dayton said these measures were not well thought out. “I think it is unnecessary and unwise to rush the reforms added to this bill, without proper public review or full consideration of their consequences,” said Dayton.

A State-Based Public Option?

Minnesota is one of a handful of states that offers a so-called basic health plan for some lower-middle class residents. Called MinnesotaCare, the plan provides subsidized health coverage to about 100,000 Minnesotans. Eligibility for a family of four is capped at $49,000 per year. Dayton wants to open the plan to all to all Minnesotans, with higher income residents paying full price for their coverage.

“This public option could offer better benefits than any policies presently on commercial markets, more options for people to keep their doctors and clinics and less expensive than what is available today,” said Dayton during an announcement of his annual budget plan last week.

Dayton says allowing people with higher incomes to buy MinnesotaCare coverage, paying full freight, would reduce prices and increase competition on the individual market.

Supporters of the “public option” say it could provide better coverage and cost less because the government could take advantage of its buying power to negotiate better deals with insurance companies.

Opponents say expanding government’s role in health care is a bad idea. As he campaigned for the presidency, Donald Trump said a public option would drive away private insurers, “leaving Americans with fewer options and eventually no choices but a government-run plan.”

The one-time bailout is just the beginning of what are expected to be broader health insurance reform efforts in Minnesota. Among them is a renewed call for state-sponsored health insurance that is not expected to be well-received in the state’s Republican legislature.

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

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Republicans are working on plans to repeal and replace the Affordable Care Act. One of the possibilities that has been put forward, reinstating high-risk pools. NPR’s Audie Cornish talked to Ryan Burt, who’s been involved with high-risk pools for 25 years and helped establish Minnesota’s high-risk pool, one of the oldest and most highly regarded high-risk pool programs in the country.

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President Donald Trump and other Republican leaders have been working to repeal and replace the Affordable Care Act. And the millions of Americans who have health insurance through the Obamacare marketplaces aren’t the only ones wondering about their fate. Leaders of insurance companies are, too.

Sabrina Corlette, a research professor the Center on Health Insurance Reforms at Georgetown University and colleagues interviewed executives at 13 different insurers to get their perspectives in this moment of uncertainty. Their report was published by the Robert Wood Johnson Foundation and The Urban Institute.

All Things Considered‘s Audie Cornish talked with Corlette Friday about the findings. The conversation has been edited for length and clarity.

Interview Highlights

On what worries insurers most about repeal and replace

The big issue across every insurance executive’s mind is the uncertainty. Particularly concerning is the potential that two legs of the ACA’s three-legged stool might get knocked out. You have number one, subsidies that help people afford insurance premiums; and, number two, a mandate that helps get healthy people to enroll in health care. Congress has threatened to repeal both of those things. And if that happens, insurers are going to need to leave the market, because they won’t be able to make a go of it.

On how uncertainty affects insurance plans

First thing to know about insurers in the Obamacare marketplace is that they’re not monolithic. We talk to large national carriers, for-profits, nonprofits, local community-based provider plans, all really coming at this from different perspectives. Some are very committed to staying in the market and serving populations, others not so sure. But across the board they all said we cannot tolerate uncertainty.

There comes a certain point where they can’t price the product high enough to account for the uncertain environment they’re in. And they have to make those decisions right now because they’re putting together their [2018] products for review process starting in May. My guess is, when they come out in May we’ll see some pretty big price hikes because the uncertainty they feel in the policy world from Congress and the White House will play out into the premiums that people will ultimately pay.

On what provisions of Obamacare need to remain

One thing we heard over and over was the need to maintain some form of incentive for healthy people to sign up for coverage. The Obamacare approach has had a penalty for people who don’t enroll, which has been very controversial in Congress. But insurance companies will tell you they don’t think it was a strong enough incentive. They feel like it needs to stay or replaced with something at least as strong to get people to sign up.

On if insurers will fight to keep healthy people in the system

Whether or not they’ll fight for a specific mandate, I’m not sure. But they’ll fight for the balance of healthy and sick. If [that’s not there], if it’s a market that just allows sick people to come in without healthy people, it’s not a workable market. Another thing they could do is say, ‘If you’re getting rid of the original mandate you have to allow us to go back to the days when we can deny people insurance if they have a health issue.’ Because you can’t have it both ways.

On whether insurance companies want to revert to pre-ACA times

No, not at all. Before the Affordable Care Act, insurance companies were in many ways the bad guys. People didn’t like them because they denied coverage to sick people and charged more. Now I think their public image has improved. Everyone gets covered, even with preexisting conditions. I don’t think they want to go back to the days when they were the bad guys.

On the other hand, I don’t think they feel that Obamacare was a perfect law. They found plenty to criticize. But my sense is that they’d rather see improvements to basic structure rather than starting back from scratch.

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Through years of acrimony over the relative merits of Obamacare, one kind of health insurance has remained steady, widespread and relatively affordable: Employer-sponsored plans.

Job-based medical plans still cover more Americans than any other type, typically with greater benefits and lower out-of-pocket expense. Recent cost increases for this sort of coverage have been a tiny fraction of those for Obamacare plans for individuals.

Now, as President Donald Trump promises a replacement for the Affordable Care Act that will provide “insurance for everybody,” employers worry Republican attempts to redo other parts of the insurance market could harm their much larger one.

“We’re deeply embedded” in the health law, said Neil Trautwein, vice president of health care policy for the National Retail Federation, a trade group. “Pick your analogy — it’s like being tied to the railroad tracks or having a bomb strapped across your chest. It’s tough to disarm these things.”

Businesses dislike many parts of the ACA, including its substantial paperwork, the mandate to offer coverage and the Cadillac tax on high-benefit plans (which is set to take effect in 2020). But large companies in particular — those that have always offered job-based insurance — say a poorly thought-out replacement might turn out to be worse for them and their workers.

“Whatever the Republicans are going to do, they’ve got to make it look as different from the ACA as they can” for political reasons, said Edward Fensholt, a senior benefits lawyer at Lockton Companies, a large insurance broker. “There are some pieces that aren’t broken, and the more you … make something different from the ACA, the more you risk screwing up things that look OK.”

Any new health law would need substantial revenue to replace the Cadillac tax and the other ACA taxes on health insurers, medical devices and high-income households that paid for care expansion — assuming those measures are repealed. Otherwise, a replacement plan risks stranding the millions who are now getting government-subsidized Obamacare coverage.

Leaders in big business worry that Republicans may be tempted to limit the exemption from income and payroll taxes that job-based coverage has enjoyed for decades. Taxing workers and employers for health benefits could raise billions to pay for a replacement plan.

Such a measure has occasionally been floated by Republicans since the days of President Ronald Reagan, often under the argument of leveling the field between employer plans and other coverage that the tax code treats far less generously.

Republicans still don’t agree on what a replacement for Obamacare should look like.

But capping the tax exclusion for employer plans is in replacement legislation introduced by Rep. Tom Price, the Georgia Republican poised to become secretary of Health and Human Services. It’s also in House Speaker Paul Ryan’s Better Way plan. A third proposal would keep the ACA taxes.

Depending on how it’s structured, limiting the employer-plan loophole could add hundreds of dollars to workers’ tax bills as a portion of their expensive health insurance is counted as taxable income.

“I can’t understand why nobody has asked the president about this,” said James Gelfand, the top health policy official at ERIC, a lobbying group of very large employers focused on benefits and pay. Taxing employer insurance to subsidize non-employer insurance, he said, “is a 100 percent redistribution of wealth.”

Big business has a vested interest in that argument. A tax on health benefits would be a pay cut for its workers. Corporate payroll taxes would also rise if the value of worker health benefits counted toward required employer contributions to Social Security and Medicare.

But other, independent health policy analysts share the concern.

Taxing medical benefits could spur employers to erode or drop those benefits and make workers less likely to accept them, said Larry Levitt, a senior vice president with the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

More concerning, Levitt said, are proposals such as Price’s that could give workers who now rely on company health plans the option of instead using tax credits to buy individual coverage outside their company’s plan. While offering workers more choice — a Republican goal — it would also erode the ACA’s “firewall” that protects employer coverage from market turbulence.

“There could be much more movement from employer coverage to individual plans, especially among younger and healthier workers,” Levitt said.

That could, Fensholt said, leave company plans with the same “adverse selection” problem experienced by many individual plans now sold via Obamacare’s online marketplaces — too high a percentage of members who are older, sicker and more expensive.

“What the administration and Congress must do immediately is stabilize the individual insurance marketplace and not destabilize the employer marketplace,” said James Klein, president of the American Benefits Council, which advocates for large companies.

Job-based coverage has remained stable even as annual increases in insurance premiums for individual plans reached double-digit percentages and enrollments missed expectations, pressuring the health insurance market despite the support of government subsidies.

Employer health plans cover some 150 million people, while last year individual plans covered about 20 million, according to Mark Farrah Associates, a data firm. That included some 10 million who bought coverage through the health law’s subsidized exchanges.

The portion of non-elderly Americans covered by employer-sponsored plans has stayed almost unchanged since the health law was passed.

Recent premium increases for job-based plans have been below 5 percent on average, less than the historical trend and far lower on average than premium hikes for individual insurance. Employers still pay most of the premium.

One way companies have contained premiums is by shifting to high-deductible plans, in which the insurance covers little until workers have incurred thousands in medical bills. Even so, benefits in employer plans are generally richer than those in the average individual plan, say health policy analysts.

In the contentious political climate, executives at individual companies were reluctant to be interviewed for this story. More than a half dozen employers declined to comment.

But there is enormous interest and concern, among business executives who specialize in health benefits, in what a Republican plan might look like. A post-election session on “repeal and replacement” aimed at these executives drew the biggest webinar audience ever for the National Business Group on Health, said Steve Wojcik, the advocacy and research group’s vice president of public policy.

If the executives attending that webinar were anything like the benefits analysts at the American Staffing Association, a trade group that advocates for temp and recruiting firms, they had some catching up to do.

Edward Lenz, senior counsel for the ASA, said that before Donald Trump’s election, “we ignored lots of the talk of the Republicans about repeal. First of all there was no chance of that happening with the president [Obama] in the White House. And frankly no one here counted on President Trump’s victory.”

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. You can follow Jay Hancock on Twitter: @jayhancock1.

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They are just three little words — “health savings accounts” — but they are generating a lot of buzz as Republicans contemplate plans to repeal and replace the Affordable Care Act.

Expanding the use of these accounts, based on a long-held conservative view that consumers should be more responsible for their health care spending, is a part of almost every GOP replacement plan under consideration on Capitol Hill.

Here’s the theory behind HSAs: Making consumers bear a bigger upfront share of medical care – while making it easier to save money tax-free for that purpose – will result in more judicious use of the health system that could ultimately slow rising costs.

While the details of the current proposals differ, they all generally seek to allow larger tax-free contributions to the accounts and greater flexibility on the types of medical services for which those funds can be used. Some include tax credit subsidies to help fund the accounts.

Supporters say premiums for the insurance linked to an HSA are lower, and they like HSAs’ trifecta of tax savings: no taxes on contributions, the growth of the funds in the account or on their withdrawal if spent on medical care. But skeptics note the tax break benefits wealthy people more than those who earn less.

Still, expect to hear a lot more about HSAs in the coming months. Here’s a rundown of some of the basics:

How do HSAs work?

HSAs currently must be paired with qualifying health insurance plans that have annual deductibles of at least $1,300 for individuals or $2,600 for a family, although surveys show average deductibles are generally higher than those minimums. Unlike some other types of insurance, the consumer pays the full cost of most doctor visits, drugs or hospital stays until the deductible is met. There are some exceptions for services deemed preventive, such as certain vaccines, prescription medications or cancer screenings.

To pay for those deductibles and other medical costs, consumers can make tax-free contributions to the HSA account. This year, that allowable amount maxes out at $3,400 for individuals or $6,750 for families, and unused portions can roll over to the following year. The amounts in the HSA grow tax-free, similar to retirement accounts. Some employers who offer HSA-coupled insurance contribute to the accounts on behalf of their employees.

Money in the funds moves with the policyholders, even if they change jobs or insurers, similar to how workers can take their 401(k) retirement fund to a new employer. Still, polls have shown that most Americans already have little or no money saved for an emergency, so skeptics say they are not likely to embrace medical accounts.

“Americans who are struggling to afford health insurance right now don’t have the money to set aside,” said Maura Calsyn, managing director, health policy, at the Center for American Progress. “Raising the limits is essentially just providing high-income individuals with a greater tax benefit and doesn’t do anything to increase coverage.”

Critics also point out that older or sicker people could blow through their entire fund every year and never accumulate any savings.

How would they change under GOP proposals?

Several proposals – including the Better Way white paper authored by House Speaker Paul Ryan, R-Wis., would increase HSA contribution limits. Ryan’s plan would allow the tax-free contributions to total as much as the insurance plan’s annual deductible and out-of-pocket maximum. For families, that could be more than $14,000 a year.

Kentucky Republican Sen. Rand Paul’s Obamacare Replacement Act would get rid of the upper limit on contributions entirely. It would also allow the accounts to be coupled with any type of insurance, not just high-deductible plans.

What services can HSA funds cover?

Currently, money in the accounts can be used only for certain health costs, such as deductibles, copayments for doctor visits, hospital care and other out-of-pocket costs. The funds cannot be used to pay premiums on health insurance plans. Both the Ryan proposal and one from Rep. Tom Price, R-Ga., the physician nominated to head the Department of Health and Human Services, would allow the funds to be used to pay fees directly to doctors, for “concierge care,” which refers to arrangements in which consumers pay annual or monthly fees for special coverage that provides quicker access, longer visits or, in some cases, all primary care services.

Christopher Condeluci, an attorney and former counsel to the Senate Finance Committee, said Republicans might seek to loosen the rules around what services are exempt from the deductible, potentially to incorporate medical care important to people with chronic illnesses, such as annual eye exams for people with diabetes. “That would recognize that there are individuals who are high medical utilizers and high-deductible plans just are not appealing to them … unless you can change the definition to make them more appealing,” he said.

How common are HSAs?

An estimated 26 million Americans — policyholders and their dependents — are covered by some type of HSA-eligible plan. That’s a small share of the overall 178 million who have coverage through their jobs or purchased on their own, but it has steadily grown since HSAs first became available in 2003. Among employers who offered insurance last year, about 24 percent had HSA-eligible plans, with average annual deductibles of $2,295 for single policies and $4,364 for families, according a survey by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Paul Fronstin, with the Employee Benefit Research Institute, noted that the slow ramp-up is similar to most trends in health benefits. Now, he said, with the GOP focus on changing the health system, “we could see an acceleration of that trend.”

How much do they cost and what are the advantages?

Eligible health plans may have lower premiums than other types of insurance because of their higher deductibles. Policy experts and economists say the accounts might make people better consumers of health care because they have more “skin in the game” and are more likely to shop for the best prices on drugs, medical care or hospitalizations — and avoid running to the doctor with the sniffles. “It makes people more conscious that the health care they are getting is being paid for with real dollars and not coming out of the ether,” said Joe Antos with the American Enterprise Institute.

What are the disadvantages?

For one thing, it isn’t easy for people to comparison shop on the prices for medical care. And, consumers don’t always make good choices. Among those with HSAs, overall spending on medical care does indeed go down, Fronstin and other researchers have reported. But they also uncovered a disturbing trend: at least in the first year or two, policyholders cut back on everything, including high-value services they should really seek. ER visits go up. And many even forgo screening exams – such as mammograms or other cancer tests – even though they are specifically excluded from the deductible and are therefore “free” to the consumer. Bypassing preventive or other care could lead to higher costs in the future.

Follow Kaiser Health News’ Julie Appleby on Twitter: @Julie_appleby.

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Federal health officials may be about to get greatly enhanced powers to quarantine people, as part of an ongoing effort to stop outbreaks of dangerous contagious diseases.

The new powers are outlined in a set of regulations the Centers for Disease Control and Prevention published late last month to update the agency’s quarantine authority for the first time since the 1940s.

The outlined changes are being welcomed by many health lawyers, bioethicists and public health specialists as providing important tools for protecting the public. But the CDC’s increased authority is also raising fears that the rules could be misused in ways that violate civil liberties.

The update was finalized at the end of the Obama administration and was scheduled to go into effect Feb. 21. But the Trump administration is reviewing the changes as part of its review of new regulations. So the soonest the changes could go into effect has been pushed to the end of March.

Under the old rules, the CDC’s authority was primarily limited to detaining people entering the country or crossing state lines. The agency was also limited to quarantining people who had one of about a dozen diseases, including cholera, diphtheria, tuberculosis, plague, smallpox and yellow fever.

Yet even then, the CDC rarely exercised these powers and generally deferred to state and local health officials.

With the new rules, the CDC would be able to detain people anywhere in the country without getting approval from state and local officials.

The agency could also apprehend people to assess their health if they are exhibiting medical problems such as a high fever, headache, cramps and other symptoms that could be indicative of a dangerous infectious disease.

“Because of the breadth and scope of the definition of ill persons, CDC can target a much wider swath of persons to assess and screen,” says James Hodge Jr., a professor of public health law and ethics at the Sandra Day O’Connor College of Law at Arizona State University.

Hodge says the new rules are “really necessary,” given the potential threat that infectious diseases pose. Some others who have studied the issue agree.

“The CDC has been operating its infectious disease powers under really antiquated regulations,” says Lawrence Gostin a professor of global health law at Georgetown University.

But other attorneys say they fear the new rules give the CDC too much power — with insufficient safeguards to protect an individual’s rights.

“It could represent a great danger to Americans’ health and civil liberties,” says Wendy Parmet, a health policy lawyer at Northeastern University.

For example, she says, the rules would allow the CDC to hold someone in quarantine for 72 hours before their case is subject to review. And that review would be conducted by the CDC itself instead of an outside, objective entity.

“The concern,” Parmet says, “is that unless these regulations are carried out with care, and by people who [base their actions] on science, they can be used to trammel the civil liberties of Americans.”

Parmet is especially concerned that the CDC’s enhanced powers would take effect just as the Trump administration is assuming control over the agency.

“A lot of the signals we’ve received from President Trump suggests he may be inclined to not always listen to the science,” Parmet says, “and to ground policy in what I guess we’re now calling ‘alternative facts,’ instead of scientific facts. That’s scary.”

When contacted by NPR, officials at the federal Department of Health and Human Services would only confirm that the new rules are under review; they declined further comment. NPR also contacted the CDC, but the agency has not made anyone available to discuss the new quarantine powers.

“My worst fear is we have a replay of Ebola and we have, say, President Trump assert the policy he thought we ought to have when he was citizen Trump,” says Scott Burris, a professor of law at Temple University.

During the 2014-2016 Ebola outbreak in West Africa, Burris points out, Trump tweeted that American health workers who got sick while treating victims should be prevented from returning to the United States for medical care.

Some public health specialists fear the CDC’s new powers could backfire on efforts to prevent disease. For example, some sick people might hide their symptoms for fear of being detained.

“The worst-case scenario is that people may try to evade these procedures by, say, taking medicines to reduce their fever, or be afraid to report it if they are feeling ill on a plane,” says Jennifer Nuzzo, a research epidemiologist at the Johns Hopkins Center for Health Security.

“We don’t want to drive cases underground by putting measures in place that seem as though they carry some penalties associated with them,” Nuzzo says.

Gostin agrees that the rules are imperfect and that quarantining anyone is a very serious step. “It’s really a quite, I would say, draconian public health measure,” he says. “The most draconian measure, because it allows you to literally imprison somebody who you don’t know for sure is a danger to the public.”

But quarantines also can be key to stopping an outbreak, Gostin says. He believes the new rules give the CDC much-needed flexibility.

“We know that the United States is vulnerable to a whole range of infectious diseases that are circulating around the world,” Gostin says. “But we don’t know which one will be next. And so when something sweeps up on our shores, we don’t want to have delay and have political debate.”

While he agrees the civil liberties protections in the new regulations should be even stronger, Gostin argues they’re better than relying on the protections in the old rules. The new president is a self-described “germophobe,” Gostin notes.

“If you’re a germophobe, then you’re going to overreact and the last thing we want in the face of a public health crisis is overreaction,” he says. “And I think having rules in place that are modern at least will provide some buffer against the whims of an administration that may over react.”

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As Congress weighs repeal of the Affordable Care Act, the home state of Vice President Mike Pence Tuesday sought to keep its conservative-style Medicaid expansion under the federal health the health law.

Indiana applied to the Trump administration to extend a regulatory waiver and funding until Jan. 31, 2021, for its package of incentives and penalties that are intended to encourage low-income Hoosiers on Medicaid to adopt healthful behaviors. Beneficiaries pay premiums, get health savings accounts and can lose their benefits if they miss payments.

Though Pence now supports the health law’s repeal, the Healthy Indiana Plan that he established in 2015 as the state’s governor has brought Medicaid coverage to more than 350,000 people. The architect of the plan was health care consultant Seema Verma, who has been nominated to head the Centers for Medicare & Medicaid Services.

Without Trump administration approval, federal money for Indiana’s expansion will run out Jan. 31, 2018. Indiana officials said the Medicaid expansion would continue even if Washington follows through on a Republican proposal to distribute federal Medicaid funds through a block grant program that would give states more flexibility in setting benefits and eligibility levels.

State officials refused to say whether the expansion would continue if Congress repealed Obamacare and eliminated funds for Medicaid expansions. If that happened, it’s unlikely states would have the money to make up for the lost federal aid.

Indiana’s effort to continue its Medicaid expansion demonstrates how states that expanded Medicaid under the Affordable Care Act — even Republican-controlled ones — are counting on additional federal dollars to pay for those expansions. It also reflects deadline pressure: They can’t wait for Congress to finish its debate over the future of the health law because they need to set budgets and programs now for next year.

According to Indiana’s request, continuing the Medicaid expansion will cost Indiana $1.5 billion but bring $8.6 billion in federal funding from 2018 to 2020.

“Indiana has built a program that is delivering real results in a responsible, efficient, and effective way,” Gov. Eric Holcomb, a Republican, said in a statement. “I look forward to maintaining the flexibility to grow this remarkably successful tool and to preserve our ability to respond to the unique needs of Hoosiers.”

Several other states including Kentucky and Ohio are considering adopting features of Indiana’s Medicaid plan.

Tuesday’s filing continues most core elements of the Healthy Indiana Plan, but also expands beneficiaries access to substance abuse treatment and adds incentives for members to quit smoking, use chronic disease management programs and take part in voluntary job referral and training programs.

“Certainly I think the new administration would give the waiver a friendly reception,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University. “But again that doesn’t answer the question about whether the money is going away,” if Congress repeals the health law and the Medicaid expansion.

Rep. Susan Brooks, R-Ind., broke the news of the waiver submission plans at a House committee hearing on Medicaid on Tuesday.

“It’s an outstanding program that I hope folks on both sides of the aisle see it is a way to save and help people who truly need it, and it can be replicated,” Brooks said.

Some Republican plans to scrap and replace the Affordable Care Act don’t include a Medicaid expansion. Republicans have argued for years that the Medicaid program is broken and non-disabled adults who gained coverage under the expansion should not be covered.

Under expansion, states received additional federal funding to expand eligibility to everyone with annual incomes at or below 138 percent of the federal poverty level, or about $16,000.

Holcomb isn’t the only Republican governor counting on Medicaid expansion and the additional federal funding continuing at least through 2018.

Ohio Gov. John Kasich proposed a budget Monday that maintains expansion coverage for 700,000 individuals.

But Kasich plans to switch from a traditional Medicaid expansion to a more conservative version that will require beneficiaries to pay more out of pocket.

This story was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health care policy research organization. You can follow Phil Galewitz on Twitter: @philgalewitz.

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