If the last few years are any guide, one group that may find itself in the crosshairs of Rep. Tom Price, President Trump’s pick to lead the Department of Health and Human Services, is an influential panel of medical experts.

The U.S. Preventative Services Task Force, a group of mostly physician and academics from top universities, reviews medical practices to see whether they are supported by research and evidence.

Under the Affordable Care Act, the USPSTF’s recommendations have been used to guide private insurers. If the group gives a test high marks, insurers are required to cover it. If it doesn’t, they are free not to.

But letters reviewed by ProPublica show that Price twice pushed HHS to quash the task force’s recommendations to limit widely used cancer screenings. The panel said that the screenings too often led to unnecessary biopsies and other harmful treatment.

Democrats on the Senate Finance Committee boycotted a Tuesday vote on Price’s nomination, citing unanswered ethics questions.

In 2011, Price and other lawmakers signed a letter asking the head of HHS to “push for the withdrawal” of the panel’s draft prostate screening recommendations. The panel was made up of “bureaucrats,” the letter said, and decisions about prostate testing were best left to doctors and their patients. “This recommendation jeopardizes the health of countless American men,” the letter said.

The task force went ahead and in 2012 recommended that men of all ages forgo using blood tests to search for prostate cancer. The recommendation didn’t apply to men with a history of prostate cancer.

Three years later, Price signed two letters protesting the task force’s proposed recommendations that mammograms be given every two years for healthy and risk-free women between the ages of 50 and 74, and by individual choice for women between 40 and 49. Other groups, including the American College of Radiology, recommend starting mammograms at 40 and having them every year or two.

In May 2015, Price and other lawmakers wrote that the USPSTF recommendations “would jeopardize access to screenings.” In June, a second letter signed by Price and others with the GOP Doctors Caucus, went further, urging the head of HHS to ensure the recommendations weren’t finalized. The recommendations, the letter said, could “result in thousands of additional breast cancer deaths.”

Despite the complaints, the mammogram recommendations were issued in 2016. Proponents praised them as the fruit of the task force’s independent and evidence-based approach. But the guidelines raised the ire of a much more powerful constituency: the urologists and radiologists who made billions of dollars off the testing and related procedures.

“The dirty underbelly of screening is that it’s a great way to get more patients,” said Dr. Gilbert Welch, professor of medicine at the Dartmouth Institute for Health Policy & Clinical Practice and a close observer of the task force’s work. “The financial underpinnings are huge.”

The health care industry spends more money lobbying Congress than almost any other sector, according to the tracking site OpenSecrets.org. Price, an orthopedic surgeon, took in $479,000 in health professional donations in the 2016 campaign cycle, one of the largest sums to any member of Congress.

To be sure, the industry has a host of more pressing concerns, from the ACA and Medicare and Medicaid to the cost of drugs. But the task force’s recommendations have continued to draw complaints by lawmakers who received financial support from the industry.

In November, lawmakers bashed its screening recommendations during a hearing of the health subcommittee of the House Committee on Energy and Commerce. The task force “can deprive patients of lifesaving services,” said Rep. Michael Burgess, a Republican from Texas who received nearly $611,000 from health professionals in the 2016 campaign cycle.

His colleague, Rep. Marsha Blackburn, a Tennessee Republican who recevied $259,000 in donations from health professionals in the 2016 campaign cycle, predicted equally dire outcomes. The task force, she said, “turned its back on over 20 million women by finalizing erroneous guidelines that would limit access to mammograms.”

Earlier this month, Blackburn re-introduced legislation that would, among other things, add specialists to the panel. The group currently consults with specialists in the areas they are reviewing. Critics of the proposed bill say specialists are not ideal to perform the task force’s broad array of evidence reviews, and adding them could create conflicts of interest. “There is considerable support for ‘draining the swamp’ in Washington,” Welch wrote in testimony he submitted for the hearing. “But there is no swamp currently in the task force. Please don’t create one.”

Questions sent to Price’s office were answered by Ryan Murphy, who is currently an HHS adviser. Murphy was most recently communications director for the House Budget Committee, of which Price is chairman.

“Dr. Price’s concerns — shared by others as you noted — were with specific recommendations made by the task force,” Murphy said. “As a physician, Dr. Price knows firsthand the value of scientific research as well as how important it is to ensure patients and their doctors are able to make choices regarding treatments that they agree are in the best interest of the individual patient.”

Price has embraced task force findings that recommend more treatment. In 2014, for example, he co-signed a letter to the HHS secretary and the Medicare administrator asking that Medicare expand its coverage for lung cancer screenings for smokers based on task force recommendations.

With the shifts in power both in Congress and under the Trump administration, proponents of the task force fear setbacks in the decades-long push for evidence-based medicine. The task force has 96 current recommendations, which it routinely updates. Its $11.6 million budget is funded through HHS’s Agency for Healthcare Research and Quality, which has been on the lawmakers’ chopping block in the past. If confirmed, Price or congressional Republicans could reduce the task force’s influence or independence, or cut its funding.

“Science is really under attack,” said Fran Visco, president of the National Breast Cancer Coalition. “We’ve spent decades building a scientific and research infrastructure and community all in order to produce the evidence that will save lives. Sometimes the science doesn’t give us the answer we would like, but it actually gives us the facts and the evidence.”

While some disagree with the task force’s recommendations, its work is in line with a global push toward evidence-based medicine and with the guidelines of some other groups. The International Agency for Research on Cancer says there isn’t enough evidence to recommend for or against mammograms for women between 40 and 49. Like the task force, the American College of Physicians says mammograms should be an individual decision for women between the ages of 40 and 49 and be provided every other year at the patient’s request.

The task force and others found widespread screening often led to false positives, painful biopsies and life-altering operations for patients who were not actually at risk of cancer. Unnecessary screening also contributes to an overtreatment epidemic that the Institute of Medicine has estimated costs $210 billion a year.

Dr. Kirsten Bibbins-Domingo, chairwoman of the task force, is a internist and epidemiologist at the University of California, San Francisco. She said the attacks by Blackburn and others risk misleading patients about the effectiveness of screening for patients who are not at risk and are free of symptoms. “Patients and clinicians need to understand the benefits and the harms so they are empowered to make the best decisions for themselves,” Bibbins-Domingo said.

Regardless of what happens politically, she said, patients and doctors will still need evidence-based recommendations to make informed decisions.

The evidence-based work of the task force could be “endangered” because the panel is caught up in the political fight around the ACA, said Dr. Sheldon Greenfield executive co-director of the Health Policy Research Institute at the University of California, Irvine. “It wouldn’t surprise me if it does become a casualty.”

The worst outcome, he said, would be for health care in the United States to revert to the way it used to be. The old joke is that doctors ignore science and say, “I know best,” Greenfield said, trumping evidence-based medicine with “eminence-based” medicine.

Marshall Allen is examining how waste and overtreatment are affecting patients and raising the cost of care. If you have evidence of wasted health care dollars, please email him at marshall.allen@propublica.org.

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Tuesday is the last day of open enrollment for health coverage for 2017 under the Affordable Care Act. And while Republicans in Congress are working to repeal the law, it’s not at all clear what might replace it.

During the campaign, President Trump suggested a nationwide insurance market that would allow insurance plans to be sold across state lines.

The idea has been kicking around for years, and some states have tried it, including Rhode Island, where it didn’t work too well.

All Things Considered‘s Audie Cornish talked to Christopher Koller who was the Rhode Island’s insurance commissioner when this option was offered.

On the roadblocks of allowing out-of-state health insurance options

It’s very hard to have interstate insurance. It means that a state has to accept the rules of another regulator. That means if a Rhode Island insurer was licensed in Massachusetts, we have to say that whatever they do in Massachusetts is good for us here in Rhode Island. It also requires significant work to coordinate rules and regulations. Insurance regulators are reluctant to take on this task.

Let’s say Rhode Island didn’t allow limited benefit health plans. … If we were to allow insurance to come in from a state that allowed those plans, and they sold them in Rhode Island, you’d have insurers offering policies that were against the laws and policies set forth by Rhode Island legislature. … And if insurers are going to sell across state lines, you’ll see more variation among states which makes it harder to coordinate and for insurers to operate across state lines.

On how health insurance compares to other lines of insurance

It’s not [comparable]. There’s a big difference between a hospital and an auto body guy repairing your car. We have a lot more auto body guys than we have hospitals. We don’t compel auto body makers to take care of our car if we can’t pay for it, but we compel hospitals to treat people if they can’t afford to pay for it. We look at health care very differently from auto insurance.

On why out-of-state health insurance can’t compete with local

In Rhode Island we have one hospital system that has 80 percent of births in the state. [Insurers] need that in [their] network to be competitive. And I can tell you that if a national insurer walked into that hospital, and said, ‘Will you contract with us?’ the hospital would have no reason to give the insurer any discount compared to local established health plans have already. That national insurer can’t offer a competitive product.

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Short-term health plans have been around for decades, bridging coverage gaps for people who are between jobs or have recently graduated from school, among other things.

After the Affordable Care Act was enacted, some people gravitated toward the short-term plans because they were willing to trade comprehensive coverage for a cheaper sticker price — even if it meant paying a tax penalty for not having the comprehensive coverage required in the law. Sales increased sharply.

Now, as Republicans look for ways to loosen the health law’s coverage requirements and explore the possibility of not enforcing the requirement that people have health insurance, sales of short-term plans may be poised to grow even more. If that happens, consumer advocates say it could be bad for consumers.

As the policies’ name suggests, short-term plans provide coverage for a limited period, often six months or less. They generally don’t cover such things as pre-existing conditions, maternity services or prescription drugs. The policies typically have maximum coverage limits of about $1 million. Insurers can turn people down if they’re sick and may decide not to renew someone’s policy. All of these practices are prohibited in plans that qualify as individual insurance under the Affordable Care Act.

Precisely because of these limitations, however, the premiums are typically a lot cheaper than those for ACA-compliant coverage. In the fourth quarter of 2016, the average monthly premium a shopper would pay for a short-term plan sold through eHealth.com was $124, compared with $393 for someone who bought a regular Obamacare plan and didn’t qualify for premium subsidies.

When the health law passed, insurers increasingly began offering short-term plans that stretched the definition of “short,” sometimes providing coverage for as long as 364 days.

“Carriers were exploiting a loophole in the law that defined a health insurance plan as one that was 365 days,” said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms. “If they were shorter they didn’t have to comply with ACA protections.”

Short-term plans serve a tiny but growing proportion of the roughly 22 million people who have coverage on the individual market. At the end of 2013, before the health law’s major reforms took effect, there were approximately 108,800 people covered by these policies, which earned premiums of $97.5 million, according to figures from the National Association of Insurance Commissioners. Two years later, roughly 148,100 people had short-term plans and premium earnings have grown to $160.5 million.

Some insurers have taken notice. Online health insurance vendor Health Insurance Innovations launched Agile Health Insurance in the spring of 2015 to focus on sales of short-term plans. In the third quarter 2016, Agile sold 21,000 short-term policies.

“These short-term plans are not regulated like Obamacare plans, so carriers have a lot of flexibility in benefits and pricing,” said Sam Gibbs, Agile’s executive director. “It’s almost like the old individual market before the ACA.”

Not all insurers embrace widespread sale of short-term plans. “The big health insurance companies are really mixed on this,” said Timothy Jost, professor emeritus at Washington and Lee University School of Law and a close watcher of the health law. “They see this as a seriously destabilizing force in the market, this crap coverage.”

Last October, the Obama administration issued a final rule that would make it more difficult for consumers to buy short-term plans to substitute for regular Obamacare plans. The regulation, which takes effect April 1, said short-term plans must be less than three months in duration. People can request a renewal of the policies, but insurers can turn them down. The policies and related materials also have to prominently display a warning that they don’t satisfy the law’s requirement that people have health insurance.

Some hope that the rule may be changed or rescinded by the Trump administration or overturned by the new Congress under the little-used Congressional Review Act. Neither option can happen at the stroke of a pen, however.

Health insurance brokers and agents would like to continue to sell longer term short-term plans.

“Our folks do a lot of business with short-term plans,” said Marcy Buckner, vice president of government affairs at the National Association of Health Underwriters, an industry group. The regulation is one that the group will request that the Trump administration rescind.

“In most areas [a short-term plan] is cheaper, and it’s some consumers’ way of saying, ‘I don’t need all of those things,'” said Buckner.

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

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It’s the last day to sign up for health insurance under the Affordable Care Act.

And at Whitman-Walker Health, a community health center near downtown Washington D.C., people have been streaming in looking for help choosing an insurance plan.

Katie Nicol is a senior manager who oversees the five so-called navigators whose sole job is to help people sign up for insurance coverage.

“We’ve been busy, you know, consumer after consumer all day,” she said in an interview Monday. She expects to be busier Tuesday.

Which may be surprising, given all the uncertainty surrounding the Affordable Care Act.

Not far from Whitman-Walker, Republicans in Congress and President Donald Trump are working to dismantle the health care law.

Members of the House and Senate earlier this month took the first steps to repeal the ACA. Trump followed suit, issuing an executive order that asked his agency heads to do all they could to ease what he called the law’s “burdens” on companies, insurers and individuals.

So this could be the last enrollment day ever for Obamacare, which first provided coverage in 2014.

Even so, as the midnight deadline to sign up for coverage approaches, Nicol says demand for insurance hasn’t waned.

“Our volume has been the same as it has been in past years,” she said.

That tracks with the latest numbers released by the Department of Health and Human Services. As of January 14, 8.8 million people had signed up for coverage — slightly more than last year.

Those numbers haven’t been updated since Trump moved in to the White House on January 20, so it’s unclear whether enrollments have picked up or slowed.

At Whitman-Walker, Nicol says, her clients are worried about what’s next.

“We definitely have a lot of people coming in with a lot of anxiety surrounding the ACA and whether it’s still gong to be here just through the end of the year,” she said.

She says they are reassuring people that insurance is available now and likely will continue to be available through the year. As for next year, who knows.

That’s because Republicans have spent the last few months talking about repealing and replacing Obamacare, but details of a new plan have been sparse.

The concern about the future that Nicol sees in D.C. is showing up across the country, says Jennifer Sullivan, vice president for programs at Enroll America, which works to get people affordable health insurance.

“Between action in Congress and actions from the new administration, consumers are confused,” she says. “We are hearing that consumers are concerned and need clarification of what’s available.”

In recent weeks, several polls have shown that with Obamacare threatened, more people view it more favorably.

That’s likely at the top of the mind of many Republicans who are grappling with how to replace the ACA with a program that will insure at least as many people as the ACA.

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Humans have had to face death and mortality since since the beginning of time, but our experience of the dying process has changed dramatically in recent history.

Haider Warraich, a fellow in cardiology at Duke University Medical Center, tells Fresh Air‘s Terry Gross that death used to be sudden, unexpected and relatively swift — the result of a violent cause, or perhaps an infection. But, he says, modern medicines and medical technologies have lead to a “dramatic extension” of life — and a more prolonged dying processes.

“We’ve now … introduced a phase of our life, which can be considered as ‘dying,’ in which patients have terminal diseases in which they are in and out of the hospital, they are dependent in nursing homes,” Warraich says. “That is something that is a very, very recent development in our history as a species.”

Prolonging life might sound like a good thing, but Warraich notes that medical technologies often force patients, their loved ones and their doctors to make difficult, painful decisions. In his new book, Modern Death, he writes about a patient with end-stage dementia who screamed “kill me” as a feeding tube was inserted into his nose.

“This is probably one of the encounters that I had in residency that I have been unable to shake from my memory,” Warraich says. “I think if you ask any physician, any nurse, any paramedic, they’ll have many such stories to tell you.”

Interview Highlights

On the importance of having a healthcare proxy, living will and advanced directive

One of the biggest problems that we face in not only modern society, but in societies of olden times as well, is that people have always been very afraid to talk about death. In many cultures it is considered bad luck to talk about death and it is thought to be a bad omen. I think to some extent that extends to this very day. But … I think having a living will, having an advanced directive, or perhaps most importantly, having a designated healthcare proxy, someone who can help transmit your decisions to the team when you’re not able to do so, is perhaps the most important thing that we can do for ourselves as patients and as human beings.

On giving CPR and knowing when to stop giving CPR

One of the things about CPR, Terry, is that almost everyone in medicine knows how to start CPR, when to start CPR, really what to do in CPR under even complex situations, but the one thing that almost no one really teaches us, and there are no guidelines for, is when to stop CPR. I think in some ways that is one of the biggest challenges that we in medicine face all the time. …

I was actually working in the hospital last night and it was about 3 in the morning and I was called by one of my other colleagues who was another cardiology fellow, he asked me, “Haider, I need your help. I have a patient that we are doing CPR on,” and he wanted some help from me. So I walked over to the intensive care unit, and the patient was in her 60s. … There was an entire team in the room doing chest compressions on this woman, and they had been doing it for an hour and a half at that point, much, much, much longer than most CPRs last. …

At the same time while this CPR was ongoing, the patient’s family member, her daughter, was outside the room, and she was crying. … Even though we could give her all the information … that wasn’t perhaps what she was looking for, because what we were asking her to think about or to do was one of the hardest things anyone has to ever bear, which was, “Do you want us to stop CPR?” And that’s the type of thing that I don’t think any of us can ever prepare for, especially when it’s our parent that’s involved.

On why he wrote a book about dying

I really wanted to find answers to some very, very basic questions, like what are the implications of the sort of life extension that we have achieved? What is the role of religion, not only a patient’s religion but a physician’s religion when it comes to dealing with the end of life? How is social media affecting how people experience the end of life? …

So many times I’ve found myself in the room where there are people who were so much more experienced in life than I was, yet knew so little about death and dying. And so I wanted to write a book so that people could go into those really, really difficult places and feel like they’re armed with information, that this isn’t a completely foreign territory for them and that in some way could help them navigate and deal with the sort of difficult situations that lay ahead for them.

On the possible repeal of the Affordable Care Act

It is very unfortunate that health is so politicized in this country, because it doesn’t have to be. Health and wellness aren’t red or blue, and they shouldn’t be, but unfortunately that is where we are. I hope that when policies are being enacted in DC, patient’s voices, those who have benefited from the ACA, those who have gained insurance, those voices are not lost in the midst of all of this political activity.

On immigrating to the U.S. from Pakistan

I came to the United States in 2010 and [until now] have only lived in an America in which Barack Obama was the president. I think in some ways Trump’s victory has really shaken me, because of how invested I was in the idea that America is a special place, it’s a truly multicultural society. And I’m still trying to understand, I think like so many others, just exactly what happened. Especially as a writer and as a physician I’ve tried to separate myself from my identity as a Muslim. I’d rather be known as a physician/scientist/writer who happens to be Pakistani, rather than a young Pakistani Muslim immigrant who happens to be a doctor and a writer, but I don’t know. Given how things are changing, I’m not even sure if I’ll be able to set that narrative for myself. That’s a scary thought — to live an identity that is so politicized even when you wish for it to not be.

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Four years after Medicare officials agreed in a landmark court settlement that seniors can’t be denied coverage for physical therapy and other skilled care simply because their condition isn’t improving, patients are still being turned away.

As a result, federal officials and Medicare advocates have renewed their federal court battle, acknowledging that they cannot agree on a way to fix the problem. Earlier this month, each submitted ideas to the judge, who will decide — possibly within the next few months — what measures should be taken.

Several organizations report that the government’s initial education campaign following the settlement has failed. Many seniors have only been able to get coverage once their condition worsened. But once it improved, treatment would stop — until the people got worse and were eligible again for coverage.

Every year thousands of Medicare patients receive physical therapy and other treatment to recover from a fall or medical procedure, as well as to help cope with disabilities or chronic conditions including multiple sclerosis, Alzheimer’s or Parkinson’s diseases, stroke and spinal cord or brain injuries. Although the settlement removes the necessity to show an improving health condition, it doesn’t affect other criteria and limitations on Medicare coverage.

“We still regularly get calls from people who are told they are being denied coverage,” said Peter Schmidt at the National Parkinson Foundation, based in Miami. Denials sometimes occur because physical therapy providers use a billing code that still requires the patient to show improvement. Although Parkinson’s is a degenerative brain disease, Schmidt said physical therapy and exercise can help slow its progress.

The agreement, approved in 2013, settled a class-action lawsuit against the Centers for Medicare & Medicaid Services filed by Center for Medicare Advocacy and Vermont Legal Aid on behalf of five Medicare beneficiaries, including Glenda Jimmo, and six nationwide patient organizations. Coverage doesn’t depend on the “potential for improvement from the therapy but rather on the beneficiary’s need for skilled care,” the Jimmo settlement said.

In August, U.S. District Court Chief Judge Christina Reiss in Vermont ordered the government to work with the beneficiaries’ attorneys to strengthen its education campaign about the policy aimed at companies that process bill, claims reviewers, providers, appeals judges, people who staff the 800-MEDICARE help line and others. (Beneficiaries, however, weren’t included.) After working during the fall, both sides acknowledged this month they could not reach a compromise on the best path for getting the message out.

“There was a long-standing kind of mythical policy that Medicare contractors put into place that said Medicare only pays for services if the patient could progress,” said Roshunda Drummond-Dye, director of regulatory affairs for the American Physical Therapy Association. “It takes extensive effort to erase that.”

Medicare’s proposals include such educational efforts and a special webpage with “frequently asked questions” spelling out the proper procedures for handling claims. The government would also issue a clear statement confirming that Medicare covers physical, speech and occupational therapy along with skilled care at home, and in other settings, even if the patient has “reached a plateau” — a term seniors still hear — and isn’t improving.

Attorneys for the seniors want to monitor how Medicare officials implement these new measures and have offered to write the policy statement disavowing what’s known as the “improvement standard.” They also want the government to repeat its 2013 conference call with providers, contractors and others involved in the process in order to correct mistakes, according to papers filed with the court Jan. 13.

“The major problem for us is that they do not want the plaintiff’s counsel to have any say or involvement in what they do,” said Gill DeFord, litigation director at the Center for Medicare Advocacy in Connecticut. “We think that’s exactly the reason the educational campaign was so riddled with inaccuracies in the first place.”

But in its filing, the government said, “The Plaintiffs’ plan seeks to address perceived deficiencies that were specifically not guaranteed under the [settlement] Agreement.” It added accepting the advocates’ plan “would also grant their counsel undue control in developing CMS educational materials and an outsize role in CMS’s corrective action efforts.”

A Medicare spokesman declined to comment under agency protocol because the case is still pending.

The settlement affects care provided by a trained professional in a patient’s home, nursing home or the provider’s private office that is medically necessary to maintain the patient’s condition and prevent deterioration.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. You can follow Susan Jaffe on Twitter: @susanjaffe.

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Republican lawmakers meeting in Philadelphia this week say they want their replacement of Obamacare to be done by spring. There is no consensus on a plan yet, but several Republicans in Congress have already circulated proposals that could reduce or eliminate features of the federal health law that have benefited older Americans.

Here are some examples:

Prescription drugs

The Affordable Care Act expanded Medicare’s prescription drug benefit. Before the ACA, people on Medicare had to deal with a gap in that insurance coverage that came to be known as the doughnut hole. That’s the point at which Medicare would stop paying part of the cost of drugs, and beneficiaries would have to buy them at full price. Then, when the patient’s out-of-pocket costs reached a level deemed to be “catastrophic,” Medicare would start paying most of the cost of the drugs again.

A 2011 study from the Kaiser Family Foundation showed that when patients had to pay full price, they’d skip some of their prescribed medications — and that could, potentially, result in sicker patients and higher costs for Medicare.

Gradually, the ACA has been closing the doughnut hole coverage gap. According to the Center for Medicare and Medicaid Services, beneficiaries have saved more than $23.5 billion in prescription drug costs. It’s unknown if this program would be maintained in a Republican plan that replaces the ACA.

Medicaid

Medicaid is commonly thought of as the program that provides health care for the poor. But it also pays for long-term care for a lot of older people, including the majority of nursing home residents.

One idea in some of the Republican proposals for replacing the Affordable Care Act is to turn Medicaid from a guaranteed benefit into a block grant to states. States would get a fixed amount of money from the federal government, and could make their own decisions on how to spend it.

That’s an idea that’s been popular for some time among conservatives such as House Speaker Paul Ryan. They argue that states know their needs better than Washington does, and the block grant would give states flexibility in meeting those needs.

Critics fear this could do away with many protections that federal law currently provides for vulnerable older people. They also worry about what might happen in an economic downturn, when the demand for Medicaid goes up, but the amount of federal money allocated for it stays the same. For example, would states have to choose between cutting services for poor children versus cutting programs for the frail elderly?

Limiting the cost of insurance premiums for older adults

Before the Affordable Care Act, insurance companies could charge people in their 50s and 60s many times more than they’d charge a younger person for the same policy. The affordable care act put a limit on that. Now Insurance companies can only charge older people three times as much as they charge people a few decades younger. But the various GOP replacement proposals either set higher limits — five or six times higher — or they don’t have any limits at all.

A study sponsored by the Rand Corporation and the Commonwealth Fund found that if older Americans were charged five times more for insurance than younger people, about 400,000 would no longer be able to afford to buy health insurance.

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With open enrollment season for buying health coverage under the Affordable Care Act ending Tuesday, it seemed like an apt time to talk with folks in charge of some of the state insurance marketplaces created by the federal health law.

It’s the third year these marketplaces, also called exchanges, have been running. The marketplaces are the go-to option for people under 65 who don’t get health insurance through work or qualify for Medicaid.

This time around, there’s a last-minute wrinkle: The Trump administration has halted advertising and outreach for HealthCare.gov, the federally run exchange, in the last week of enrollment, when sign-ups typically surge.

But the states that control their own exchanges also control their own promotion and, for now, their destiny.

All told, 11 states and the District of Columbia run their own marketplaces. Under the ACA, the marketplaces were supposed to become self-sustaining businesses within a few years, supported by fees insurers pay to offer plans on the sites.

But the election of Donald Trump as president and Republican majorities in both houses of Congress mean that proposition, like the rest of the health law, is now in doubt.

Here’s what five exchange chiefs are looking at now and for the future.

California Has Ingredients To ‘Make The Individual Market Work’

Peter Lee, executive director, Covered California

More than 5 million Californians — about a quarter of all Americans now covered under Obamacare — gained insurance either through Medicaid expansion or on the state’s exchange, called Covered California.

With the Affordable Care Act now on the political chopping block, California has a lot to lose.

But Covered California’s executive director, Peter Lee, says he is planning for a different scenario. He hopes to position California as a leader in a new model for health coverage nationwide.

“I do think that we have a number of the ingredients of what can make the individual market work,” Lee says. “And we want to take those lessons to members of Congress and to policy leaders.”

In particular, Lee believes California’s market-based approach is one that would be “in sync, philosophically, with many of the things I hear from Republican and Democratic members of Congress and the Trump administration.”

“We have about 1.4 million Californians shopping in our marketplace picking private plans with the leg up of federal tax credits that make health care affordable to 90 percent of them,” Lee says.

California’s marketplace has had its share of problems. A reliance on inaccurate provider directories left some consumers exposed to higher-than-expected medical bills. Consumers also complained about narrow networks that left them unable to choose the doctors they wanted.

But overall, the state is considered an ACA success story, thanks in part to innovative approaches, including state discretion to choose which insurers could operate in its market and then to negotiate premiums and benefits with those insurers.

“It’s a consumer-centric market solution,” Lee says. “Whether you’re a Republican or Democrat or independent, it’s a market-based solution that has a lesson for the country.”

Still, Lee’s hopefulness is tempered by the knowledge that California faces a loss of $20 billion in federal funds if the promised Obamacare repeal happens without a replacement that preserves Medicaid expansion and premium subsidies.

Under that scenario, Lee says, “people would have their health insurance pulled out from under them in droves.”

“The whole issue of repeal without replace is cataclysmic not just for California or Californians but for any of the 20 million Americans that have coverage because of the Affordable Care Act,” he says.

Even in the face of a “very fuzzy” future, Lee says he is focusing on the present, which includes shepherding more than 300,000 Californians newly enrolled in health care into 2017 coverage. He also wants to get the word out on parts of California’s plan that can be adopted elsewhere.

“There have been some things that have not worked great with the Affordable Care Act; there are some things that have worked pretty darn well,” Lee says. “Let’s make sure the laboratory of the states is a laboratory that’s sharing the lessons of success and failure with one another.”

Stephanie O’Neill, freelance reporter based in Ojai, Calif.

New York Fears A Return To ‘$1,000 A Month For An Individual Policy’

Donna Frescatore, executive director, NY State of Health

The New York state health exchange is fielding its busiest enrollment period yet, even with the uncertainty about the health law’s future.

A repeal of the Affordable Care Act, without significant replacement, could cost 2.7 million New Yorkers their health insurance and the state $3.7 billion, according to Democratic Gov. Andrew Cuomo’s office.

“We believe that the stakes here in New York are dramatic — for consumers, for our health care delivery system and for our state budget as well,” says Donna Frescatore, executive director of NY State of Health, New York’s marketplace.

Losing “momentum” is one of Frescatore’s main concerns. Between 2013 and 2015, the uninsured rate in New York was cut in half, falling from 10 percent to 5 percent, according to the state’s health department.

“We talk to moms who are concerned because their children have pre-existing conditions and they’re afraid coverage might no longer be available. We talk to self-employed New Yorkers who fear that the premiums could increase to the 2013 levels — over $1,000 a month for an individual policy,” Frescatore says.

Without financial support from the federal government, premiums may increase.

Options may revert to health insurance plans as they were in New York before the ACA.

“New York had a number of very strong consumer protections in place before the Affordable Care Act, including guaranteed issue,” says Frescatore. “People could get insurance regardless of whether or not they had a medical condition or illness, as well as other consumer protections. We’ll maintain those protections.”

But without an individual mandate bringing enough people into the insurance pool and no financial assistance, she adds, the price of plans is “just out of reach” financially for many consumers.

For now, the New York exchange continues outreach to enroll consumers and reassure them that policies won’t be disrupted throughout 2017.

“At this point, without knowing more details about repeal or replacement, what we’re really focused on is getting people coverage that they deserve,” Frescatore says.

Karen Shakerdge, WXXI and Side Effects Public Media

Connecticut To Insurers: ‘We’re Making Changes In The Positive Direction’

Jim Wadleigh, CEO, Access Health CT

Connecticut was an early adopter of the ACA. After the law was enacted, the state expanded Medicaid ahead of schedule to cover roughly 200,000 more people a year. For this year, more than 100,000 people enrolled in coverage they found on the state-based exchange, with nearly 80 percent getting subsidies.

But while the exchange may have been attractive to many consumers, it was less appealing to insurers. Two of the four original insurance companies in the marketplace are no longer in it. Now, with an uncertain future ahead, Access Health CT CEO Jim Wadleigh says he has one hard goal in mind as he thinks beyond 2017: “What can we do to help make the business environment that our carriers are in easier for them to be more successful?”

Insurers have told Wadleigh that they lose money on customers who miss open enrollment periods and go through special enrollment — the process reserved for people with big life events or job changes that merit new insurance.

“What the carriers are telling us is, these customers are coming in … finding a reason that they have a life event because they’re sick, get services, and then drop out,” he says.

That’s an expensive pattern. This week, Wadleigh is asking his board to approve a plan to ramp up enforcement.

“If we can do a better job enforcing the special enrollment, we think we can reduce the premiums by potentially 6 percent to 10 percent,” he says.

Another way to reduce costs? Shrink provider networks. So, let’s say you live in Hartford. Do you really need to pay for a plan that covers a doctor’s visit in Danbury?

“Customers are telling us they would go with a network choice option, or a narrow network, if it was cheaper and/or had a lower deductible,” he says.

That chance, he says, could save another few percentage points in premiums.

Third, Wadleigh says he is considering changes that would push more of the cost of emergency room visits to consumers, hoping to deter frequent ER fliers.

The question is whether all of this will work. Wadleigh says he thinks it will. He already has had discussions with existing carriers that are curious whether other insurers are looking to get into the marketplace.

“So what that is telling me is that the carriers think that we’re making changes in the positive direction,” he says. “And we expect that other carriers would be interested in joining our exchange with that.”

Whether they do — and whether the exchange will even be around for them to join — is still very much unclear.

Jeff Cohen, WNPR

Massachusetts Chief Says, ‘Every Day Is a Good Day of Coverage’

Louis Gutierrez, executive director, Massachusetts Health Connector

A near record number of Massachusetts residents are signing up for coverage through the state’s online insurance market, the Health Connector. Enrollment is running 32 percent ahead of last year as the Jan. 31 deadline approaches. Around 47,000 people who didn’t have insurance through the exchange last year have purchased insurance for 2017.

So many members, physicians and others in the health care world were stunned when Louis Gutierrez, who runs the exchange, said he couldn’t guarantee coverage through the end of 2017 for the nearly 240,000 enrollees so far.

“I don’t want to be in the business of speculating or making commitments about things I can’t personally control,” Gutierrez says. “I don’t think any of us really know” what’s going to happen with the repeal of the ACA.

Gutierrez says he is not predicting precipitous changes but adds that he “can’t speak to the future. Every day is a good day of coverage.”

Health insurers, which are threatening to pull out of exchanges in some states, aren’t the main concern in Massachusetts. Gutierrez says he is hearing very little from the state’s “mature and stable market.” Most plans that sell insurance through the Health Connector are nonprofits based in the state. And they may have less reason to worry that healthy members will flee, leaving insurers to cover the high costs of ill members. Massachusetts residents would still be required to buy insurance, by state law, even if the ACA mandate is repealed.

But if federal funds shrink or disappear, it’s likely coverage would become very expensive for the 178,000 men and women who expect to receive subsidies or tax credits for insurance purchased through the exchange.

“We’re interested in maintaining broad and affordable access to coverage,” Gutierrez said, but “that will depend on the shape of any subsidies that change or happen in the new scheme.”

Many Massachusetts residents are wondering whether the state could revert to the law passed in 2006, which became a model for Obamacare. The individual mandate is still on the books, but the employer mandate and other elements were replaced with provisions in the federal law.

Martha Bebinger, WBUR

Colorado Looks Toward ‘Working Together As Western States’

Kevin Patterson, CEO, Connect for Health Colorado

The view from Kevin Patterson, the CEO of Connect for Health Colorado, might be summarized as sunny with storm clouds on the horizon. “I think we’re feeling like things are going really well,” he says.

Patterson says enrollment numbers for 2017 are running 15 percent ahead of last year. But two things are clouding the future. First, the new Trump administration and congressional Republicans are vowing to undo Obamacare.

Second, the Colorado exchange is under fire from state lawmakers. As soon as the legislative session got underway in January, Republicans unveiled a bill to repeal the exchange altogether. They are expected to zero in on a recent federal audit that found the exchange improperly spent millions in federal funds and called for refunds.

Patterson says the exchange has made many changes and disagrees with the recommendation to refund the money.

The exchange is expected to survive the legislative turmoil, but it still faces the possibility of federal subsidies disappearing under a repeal of the Affordable Care Act.

But Patterson believes the exchange could carry on. “I do think there are things that we’ve learned that could be applied in a new era or whatever post-ACA is,” he says.

Still, he worries an Obamacare repeal without a timely, adequate replacement could cause some insurers to pull out of the exchange or charge higher rates. Already consumers saw premiums go up and choice go down this year. And this is pressing — insurers have to file rate requests in Colorado in May. “So the clock is ticking,” Patterson says. “Somebody has to give us a little more guidance I think to the industry around what the new world is going to look like. And I think the sooner we do that the better it is for every consumer.”

But, beyond 2017, he says, the exchange could look to expand its other lines of business beyond the individual marketplace. That could include helping small employers and public sector employers not in the marketplace figure out insurance packages and benefits. “I think that’s somewhere where we can show some more value,” he says.

Colorado’s exchange is also flirting with the possibility of working with neighboring states, particularly those in the Mountain time zone. “We’re kind of used to working together as Western states on problems that are really unique to us,” Patterson says. “That’s where I would start.”

John Daley, Colorado Public Radio

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

Let’s block ads! (Why?)

The Trump administration has canceled the latest round of federally sponsored advertising and outreach aimed at encouraging people to sign up for health insurance under the Affordable Care Act.

The $5 million in ads was aimed at getting as many people as possible to sign up for insurance by the Jan. 31 deadline for open enrollment.

Many people wait until the last minute to sign up for insurance. The Obama administration’s goal was to get as many people enrolled as possible, especially younger, healthier people who help subsidize insurance for older and sicker people.

But Trump administration officials at the Department of Health and Human Services, which oversees implementation of the Affordable Care Act, canceled the ads. The move was first reported by Politico.

The administration, working with the Republican-controlled Congress, has vowed to repeal the health law and replace it with something else. But Republicans haven’t yet coalesced around a specific replacement plan.

“We aren’t going to continue spending millions of taxpayers’ dollars promoting a failed government program,” a senior communications adviser at HHS wrote in an email.

“Once an assessment was made, we pulled back the most expensive and least efficient part of this massive ad campaign which was set to run over the weekend,” he wrote. “Those costs savings will be returned to the U.S. Treasury.”

The decision to cancel the ads was criticized by several groups that support the law. “It’s outrageous and deeply concerning,” said Anne Filipic, president of Enroll America, in a written statement. “Americans who are hungry for information about their coverage options made available through the Affordable Care Act.”

Let’s block ads! (Why?)

Much has been written about the 20 million people who gained health insurance under the Affordable Care Act, and what could happen to these patients if the ACA is repealed without a replacement. But some people don’t realize that hospitals nationwide could take a big financial hit on several fronts, too.

First, it’s likely that fewer patients would be able to pay their hospital bills, health policy analysts say, so the institutions would be stuck with that bad debt, as they were before Obamacare.

“If the Medicaid expansion goes away wholesale, and things go back to the way they were before this expansion was in place, a lot of those hospitals would see an increase in their uncompensated care costs,” says Rachel Garfield, an analyst with the Kaiser Family Foundation. The American Hospital Association estimates that hospitals across the U.S. could lose more than $160 billion from the reduction in Medicaid revenue and the increase in unpaid medical bills.

Then there’s this: The ACA has used financial incentives to encourage hospitals to experiment with ways to improve their care of patients, while reducing health care’s cost. That sort of experimentation has included a sizable upfront investment by many hospitals.

Massachusetts General Hospital in Boston, for example, signed agreements with physicians and insurers to create accountable care organizations, in hopes of saving money in the long run. With an ACO, insurers pay doctors for making sure the patient is getting the best and most appropriate care, instead of paying for every test and procedure a doctor does.

“We have now more than 20 different programs,” says Dr. Timothy Ferris, an internist and medical director of the Mass General Physicians Organization. “Video visits, electronic consultation with specialists, home hospitalization, [and] programs for patients with diabetes and heart disease. I would be worried that a repeal of the ACA would undermine our ability to invest in services for our patients.”

Ferris acknowledges that most of those experiments haven’t yet saved money. But they need more time to work out the kinks safely, he says.

“One of the things that it’s difficult for people outside of health care to appreciate — particularly politicians — is how long it takes to make significant improvements in the delivery of care,” Ferris says. “You have to be very careful when you make changes.”

Ferris says the threatened repeal of the ACA makes him worry “that the progress we’ve made over the past five years would be threatened.”

Many other hospitals across the country have invested in accountable care organizations — often overhauling their medical records systems, hiring staff and creating new services. Dennis Keefe, head of a large hospital chain called Care New England in Rhode Island, says he, too, worries about the future of his ACO, Integra.

“I think, if there’s a real change in direction away from these alternative payment models, we will be assuming risk to care for a population,” Keefe says.”We have invested enormously to be successful in this area.”

But these seismic changes in the way hospitals do business were predicated, he adds, on long-term support from the federal government — support that might disappear if the ACA is repealed.

This story is part of NPR’s reporting partnership with NPR, Rhode Island Public Radio and Kaiser Health News. The Kaiser Family Foundation supports Kaiser Health News, an editorially independent program that produces news reports heard on NPR and published on NPR.org.

Let’s block ads! (Why?)