A federal judge has ruled against the proposed acquisition of the health insurance company Humana by its larger rival, Aetna.

The decision is a victory for former President Obama’s Justice Department, which sued Aetna last year to block the $34 billion merger, NPR’s Yuki Noguchi reported.

The suit alleged that the merger would hurt competition in the health care market, leading to higher prices for consumers and fewer services for Medicare patients.

U.S. District Judge John Bates found that to be the case, writing in his decision that, “the merger of Aetna and Humana would be likely to substantially lessen competition in markets for individual Medicare Advantage plans and health insurance sold on the public exchanges” in 364 counties.

Medicare Advantage plans are privately run but reimbursed by Medicare.

Bates also spent a considerable chunk of the 158-page decision analyzing Aetna’s decision, announced last summer, to withdraw its insurance plans from 17 counties where Aetna and Humana both sold plans on the public exchanges.

The company also pulled back from 11 of the 15 states in which it offered individual plans in 2016, as we reported.

As NPR’s Scott Hensley reported at the time:

“Aetna said the pullback was a business decision stemming from a loss in the second quarter on individual plans and uncertainty about the policy outlook for the exchanges.

“In the company’s statement, [Aetna CEO Mark] Bertolini said, ‘As a strong supporter of public exchanges as a means to meet the needs of the uninsured, we regret having to make this decision.’ …

“Bertolini was talking up the business potential of the exchanges as recently as April, when he said during a call with analysts and investors that the exchanges were ‘a good investment,’ despite the losses incurred.”

Bertolini and his company “have long been supporters of the public exchanges,” today’s decision noted.

But, as Scott also reported, a letter leaked to reporters last summer indicated Aetna CEO Mark Bertolini had tied his company’s decisions about participating in the exchanges to the Justice Department’s decision on the merger. In the letter to the DOJ, Bertolini wrote, “if the DOJ sues to enjoin the transaction, we will immediately take action to reduce our 2017 exchange footprint.”

The company subsequently did just that.

In his Monday decision blocking the merger, Bates found, “Aetna tried to leverage its participation in the exchanges for favorable treatment from DOJ regarding the proposed merger.”

He found Aetna had withdrawn from the 17 counties where it competed with Humana “at least in part for the purpose of improving its litigation position” in the government’s lawsuit against it.

The judge concluded that Aetna would be likely to do business in the future in those 17 counties, and that, as a result, “The merger would also be likely to substantially lessen competition on the public exchanges in three Florida counties” that were among the 17.

Yuki reported Aetna said it was reviewing the opinion and is considering an appeal.

“Meanwhile, the same court is considering another case brought by the Justice Department’s antitrust division against the proposed merger of Anthem and Cigna,” she reported. “A decision in that case is also expected soon.”

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NPR’s Robert Siegel talks with Virginia Gov. Terry McAuliffe, a Democrat, about President Trump’s proposal to convert Medicaid to block grants, whereby states would receive a set amount of money to cover health care for its poorest residents.

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As Congressional Republicans begin work on repealing the Affordable Care Act, many of the nation’s governors want to make sure that their state budgets don’t take a hit during the dismantling process.

They’re most concerned about Medicaid, the health insurance program for the poor that’s run jointly by the states and federal government. As a result of a Supreme Court decision, states were allowed to decide whether they would expand Medicaid under the ACA. 14 million people have gained health insurance coverage through Medicaid since eligibility for the program was expanded.

While 19 states declined the expansion, primarily due to the opposition of Republican governors and lawmakers, several Republican governors did choose to expand the program. Now they’re lobbying to keep their citizens covered and billions of dollars of federal Medicaid money flowing.

Among them is Ohio Gov. John Kasich who, along with several other Republican governors, met with GOP members of the Senate Finance Committee last week for a closed-door discussion about the healthcare law.

Kasich has been anything but quiet on the subject.

In a letter to Congressional leaders, Kasich recommended that Medicaid expansion not be repealed, while indicating he’s open to some changes, such as in income eligibility. Kasich urged Congress in an op-ed on Time.com to pass an Obamacare replacement at the same time as a repeal.

“For the millions of Americans who have gained health coverage since 2010, it’s safe to assume that their idea of fixing Obamacare does not involve ripping away their own health care coverage without a responsible alternative in place,” wrote Kasich.

‘If I had to pay for my medical costs, I wouldn’t be taking no medicine’

Evelyn Johnson is among those who would be affected were the ACA repeal to also roll back the Medicaid. She sat in the back of the cafeteria at a social services drop-in center in Cleveland last week as a pair of healthcare navigators made calls to help people sign up for Medicaid.

“So far I’ve got a pair of glasses. They’re going to do my teeth,” she said of the benefits she’s received since getting health insurance.

Johnson, who lives with a friend, does not have children and works as a babysitter, would not have been eligible for state-backed insurance before the Medicaid expansion, when it was limited largely to low-income children, parents and people with disabilities.

Now, anyone whose income is at or below 138 percent of the federal poverty line, about $16,000 a year for a single person, is eligible.

Without insurance, Johnson said she would not able to afford the prescription drugs she needs.

“If I had to pay for my medical costs, I wouldn’t be taking no medicine,” she said. “There’s no way. I take too many pills.”

Around 700,000 Ohioans have signed up for expanded Medicaid since January 2014. Since the Affordable Care Act came into effect, Ohio’s uninsured rate has fallen to 6.5 percent from 15 percent in 2012.

Unpopular position with Republicans

Kasich’s decision to expand Medicaid was unpopular with Republicans. He fought his own party and sidestepped the state legislature to get the expansion done.

At an event with business leaders earlier this month, Kasich argued it’s been a good deal for the state.

“If they don’t get coverage, they end up in the emergency room, they end up sicker, more expensive. I mean, we pay one way or the other,” Kasich said. “And so this has been a good thing for Ohio.”

Also defending their decisions to expand Medicaid are such Republican governors as Rick Snyder of Michigan, Brian Sandoval of Nevada and Gary Herbert of Utah.

“So if all of a sudden, that goes away, what do we tell these 700,000 people? We’re closed? Can’t do that,” Kasich said at the business event.

Medicaid covers about one in four people here in Ohio. If the expansion is rolled back, it will mean fewer payments to doctors and hospitals.

“You pull on one thread, you topple the whole tower,” said John Corlett, who ran the Medicaid program in Ohio under the previous Democratic governor.

“There’s nothing to say that the program can’t be improved, that it can’t be made better,” Corlett, who now runs a think tank in Cleveland called the Center for Community Solutions said. “But just to say we’re going to get rid of all of it, and then we’ll figure out how to make it better, I think would be really disruptive. It’d be disruptive to healthcare providers, to patients, to insurance companies.”

Changes coming?

Even if the Medicaid expansion remains, the new Trump administration may make major changes to it in the future.

Last year, Ohio asked the federal government to require beneficiaries to pay into health savings accounts, a request the federal government denied.

“I think that with the constellation in Washington the way that it is, that there’s going to be an awful lot of opportunities,” said Greg Lawson, a senior policy analyst with the Buckeye Institute, a conservative think tank in Ohio that opposed expansion.

Lawson would like to see limits on federal spending per state, and hopes Ohio will be able to add a work requirement for some beneficiaries.

“I don’t think you’re going to see the light switch probably just get turned, and one day it’s all going to just disappear,” he said. “I think what you’re more likely to see is major structural changes to the program that over time that will have budgetary impacts.”

But it’s not clear yet what shape those changes will take—or whether the governor who expanded Medicaid here will support them.

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When Ali Andrew Li was born on Jan. 7, he was gently placed on his mother’s chest, where doctors cleaned and examined him and covered him with a warm blanket.

“I just loved it,” his mother, Salma Shabaik, a family physician who lives in Los Angeles, says. “It was really nice to have the baby right there beneath my eyes where I could feel him, touch him, kiss him.”

That was different than the birth of her son Elias two years ago; he was whisked away to a bassinet to be examined. And unlike Elias, who cried a lot after delivery, Shabaik says Ali stopped crying “within seconds” after being placed on her chest.

Kangaroo mother care has been widely used worldwide to care for premature babies, and it’s gaining popularity in caring for healthy full term babies like Ali as well. It is as it sounds: Like a kangaroo’s pouch, mothers hold their naked newborns on their bare chest for the first few hours of life.

At Ronald Reagan UCLA Medical Center where Ali was born, the technique is routinely practiced for healthy mothers and newborns. The baby gets to know their mother immediately, says Dr. Larry Gray, behavioral and developmental pediatrician at Comer Children’s Hospital, University of Chicago Medicine. “The baby gets landed in a trusting environment,” he says, reassuring them that life outside the womb can also be “soft, comfortable and warm.”

The benefits are many, according to Dr. Lydia Kyung-Min Lee, an ob-gyn at UCLA. Not only is the baby happier, she says, but his or her vitals are more stable. Body temperature, heart and breathing rate normalize more quickly. The close contact also allows the baby to be exposed to the same bacteria as the mother, which can protect against allergies and infection in the future. Infants who receive kangaroo care breast feed more easily, Lee says, and their mothers tend to breast feed for longer periods of time, which is “all good.”

Babies also seem to suffer less pain. Almost 20 years ago, Gray studied how babies respond to a heel prick to draw blood, a procedure that screens newborns for genetic disorders. He found that when healthy newborns had kangaroo care, there was less facial grimacing and crying suggesting pain, compared to babies who had been swaddled and had the procedure in their bassinets, “sort of alone.”

One of the first places to show how this technique can help preemies was Colombia in the 1990s. There, hospitals with no access to incubators and other equipment often sent home preemies with no expectation that they would live. But doctors were surprised to see that babies whose mothers carried them close, skin to skin, not only survived but thrived.

This was a “serendipitous magical finding,” says Gray, suggesting that skin-to-skin contact acted something like a “natural incubator.”

Gray also points to the work of Myron Hofer, a psychiatrist with Columbia University Medical Center who studies attachment between mother and infants. Hofer coined the term “hidden regulators” that pass between mother and baby. It’s not just that mother and baby are together, Gray says, but also that the mother is in some way “programming the baby, the breathing, temperature and heart rate.”

That “magic” can also happen between baby and father, too, says Gray, if there’s skin-to-skin contact. And if mothers or babies are very sick and have to be isolated, Gray suggests mothers take any opportunity to hold their infant skin to skin. Even a little bit of kangaroo contact, he says, can be beneficial.

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Republicans plan to turn control of Medicaid over to the states as part of their replacement for the Affordable Care Act, according to an adviser to President Donald Trump.

Kellyanne Conway, a counselor to Trump, told NBC News’s Sunday Today with Willie Geist, that the health care law that will replace Obamacare will turn Medicaid — a joint state-federal health insurance program for the poor — into a block grant program. The change would mean the federal government would give money to the states to implement Medicaid as they see fit.

“Those who are closest to the people in need will be administering it,” Conway said in the interview, which was recorded the Thursday and Sunday. “You really cut out the fraud, waste and abuse, and you get the help directly to them.”

Medicaid is now funded by the federal government and states together and it has an open-ended funding stream, meaning it pays for all health costs to which its beneficiaries are entitled under the law.

Conservatives who are concerned about the impact the growth in health care spending will have on the federal and state budgets have advocated block grants as a way to cut the Medicaid costs.

But many health policy analysts say that block grants could lead to reductions in care. “A Medicaid block grant program would institute deep cuts to federal funding … and threaten benefits for tens of millions of low-income families,” said Edwin Park, vice president for Health Policy at the Center for Budget and Policy Priorities, in a report on the group’s website.

Block grants can take several forms. Under one scenario, the federal government would offer a fixed sum of money to each state, which would grow with inflation. Since the rate of overall inflation is typically lower than inflation in the health care sector that leads to an erosion of spending over time. And such a fixed block grant means less money is available when the economy is suffering and more people qualify for Medicaid benefits.

Another scenario offers states an allowance for each beneficiary. Under such a plan, spending would increase in bad economic times to cover the additional people who need care. However, overall benefits could still fall over time, depending on how the program accounts for rising health care costs.

Conway didn’t give details about how a block grant program would be structured.

Medicaid grew under former President Barack Obama, who gave states the option of expanding eligibility for the program to millions of people who live above the poverty line. Thirty-one states and the District of Columbia have expanded their programs.

Republicans who are advocating repeal of the Affordable Care Act haven’t said whether they will force those states to roll back their Medicaid programs.

Conway also reiterated Trump’s promise that “everybody” will have insurance coverage under his Obamacare alternative.

“President Trump has said that people will not go without coverage. And he means that,” she said. “That is certainly part of the official plans that are being worked on.”

However, she said that health care for all didn’t mean the president advocates universal coverage or a single-payer health plan.

“What he means is that no one will go without coverage,” Conway said. “There will be ways for people to access affordable, quality health insurance if they’d like to get it.”

Conway said voters can also expect an Obamacare replacement to include wider use of health savings accounts, which allow people to save money tax-free to help pay for their medical costs.

Critics say such accounts don’t help low-income people who struggle to pay health insurance premiums because many don’t have extra money to put aside. Also, they often pay little or no income tax, so such an account doesn’t give them a boost.

Health savings accounts, depending on how they’re structured, can help wealthy people however. That’s because they allow people with high incomes and who pay a high rate of high tax to shelter more of their money from federal taxes.

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Since it opened 50 years ago, the Haight Ashbury Free Medical Clinic has been a refuge — for everyone from flower children to famous rock stars to Vietnam War veterans returning home addicted to heroin.

Strolling through the clinic halls in San Francisco, Dr. David Smith, the medical organization’s founder, points to a large collage that decorates a wall of an exam room affectionately referred to as the Psychedelic Wall of Fame. The 1967 relic shows a kaleidoscope of images of Jefferson Airplane and other legendary counterculture bands floating in a dreamscape of creatures, nude goddesses, peace symbols and large loopy letters.

“That was made by a woman who had just taken LSD,” Smith says. “She stayed here for a very long time and put all that up. It lasted as long as her LSD trip.” He continues on to what was once called the “bad trip” room, where clinic staff would talk clients down during acid trips gone awry.

Fundamentally, Smith and others say, the organization has remained true to its roots in counterculture, still offering free care in a deliberately nonjudgmental atmosphere.

But it is also drastically different: It is now the Haight Ashbury Free Clinics — plural — and part of a multi-million-dollar conglomerate with the decidedly un-hippie name of HealthRIGHT360.

All told, HealthRIGHT 360 serves approximately 40,000 patients each year via a wide range of programs, including reentry services to ease the transition of formerly incarcerated adults and teens into life outside jail, residential and outpatient drug treatment, mental health care and medical and dental care. In 2014, it purchased a 50,000-square-foot building at 1563 Mission Street in San Francisco as additional space, to offer all of these services under one roof. The organization also serves patients in neighboring San Mateo and Santa Clara counties.

It’s been a long journey from Smith’s early days running a standalone clinic.

When his clinic first opened, it operated 24 hours a day with an army of volunteer physicians from the University of California, San Francisco, and Stanford University. The one paid staffer was a nurse. The first year’s budget was her salary: $25,000.

The clinic had what Smith describes as a “guerilla pharmacy.” Pharmaceutical representatives, he says, would load up their trunks with medication samples and drop them off at the clinic, where a team of UCSF volunteer pharmacists bottled up the medication and shelved it.

“Our first exam table was my kitchen table,” he recalls. Decisions were made by consensus. Even the janitor weighed in, Smith says.

Back then, iconic music promoter Bill Graham organized benefit rock concerts — featuring performances by George Harrison and Janis Joplin — to help keep the clinic afloat financially.

Smith remembers when Joplin overdosed on heroin, and the clinic rushed over an “overdose team” armed with naloxone, a drug that blocks the effects of opiates. “We zipped out there,” he says, “and reversed her overdose.”

Smith says he saw many Vietnam veterans returning from the war in the early 1970s who were addicted to heroin. They felt ostracized, he says, by what was then called the Veterans Administration, and headed to San Francisco’s Haight Ashbury and its clinic, which by then offered comprehensive medical care and a drug detox program.

The influx of veterans led to federal grants to Smith’s clinic from the Special Action Office on Drug Abuse Prevention. “That began the government funding era in the 1970s and ensured our survival,” Smith says.

In the 1980s, a young woman named Vitka Eisen came to the Haight Ashbury clinic struggling with heroin addiction, and learned firsthand the value of the personal attention the clinic offered.

“I went there for detox at least nine times,” she says. “I never felt shamed or judged. They always acted like they were glad to see me.”

Her trust in the staff, she says, led her to kick her heroin habit and return to school. She eventually earned a doctorate in education from Harvard University.

Today Eisen is CEO of HealthRIGHT360.

By 2011, like many recession-era nonprofits, the organization Smith helped start in the 1960s was deeply in debt. So it merged with Walden House, a respected San Francisco-based addiction and mental health treatment program, which wanted to offer comprehensive medical care to its patients. The merged nonprofit adopted the name HealthRIGHT360.

By joining forces, Eisen says, Walden House and the Haight Ashbury Free Clinics were able to weather the extraordinary financial expense of shifting their organizations to electronic health records, a requirement of the Affordable Care Act.

With the network in place, she says, it’s been easier to train and add new providers as HealthRight360 has expanded. The merger also allowed the Haight Ashbury Free Clinics to erase its debt in a year.

Between 2011 and last July — when the organization merged with Prototypes, a Southern California women’s drug treatment center — HealthRIGHT360 acquired five other community clinics in Northern California and now offers treatment at 40 sites up and down the state.

Ben Avey, assistant director of external affairs at the California Primary Care Association, says such mergers aren’t new, but they have accelerated under the Affordable Care Act.

At the individual clinics that comprise health systems like HealthRIGHT360, “they speak your language, know your culture, understand the situation you’re coming from,” Avey adds.

As CEO, Eisen led the consolidation that streamlined HealthRIGHT 360.

“We have one board, one human resources department, one finance department, one payroll department and one executive,” she says. The annual revenue is $110 million. Medi-Cal, the city, county, state and federal governments all reimburse HealthRIGHT 360 for providing patient services, as do commercial health insurers.

But ties to the early days remain. The early treatment of concertgoers evolved into San Francisco-based Rock Medicine, which is now part of HealthRight360. Staff members set up medical clinics on-site at rock concerts, circuses and fairs in the San Francisco Bay Area and Los Angeles, providing medical treatment that garners $1,038,000 annually from the venues.

The nonjudgmental attitude of the Haight Ashbury Free Clinics’ staff toward patients also continues to this day, according to 61-year-old David Smith, (no relation to the clinic founder), who has been coming to the clinic since the 1980s and says he’s always felt welcomed and accepted.

This was true, Smith says, even when he was homeless in the early 2000s.

“It didn’t matter if I was dirty,” he says. “I didn’t have to feel like I couldn’t come in here because I wasn’t in the proper state of cleanliness — which was, unfortunately, the case for quite a bit of time.”

Kaiser Health News, is an editorially independent part of the Henry J. Kaiser Family Foundation and is not affiliated with Kaiser Permanente. Laurie Udesky is an award-winning freelance journalist based in San Francisco. On Twitter: @laurieudesky.

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President Donald Trump, fulfilling a campaign promise to start to repeal Obamacare on Day 1, signed an order directing federal agencies to waive enforcement of large swaths of the law.

The one-page order allows the head of the Department of Health and Human Services or any other agency with authority under the law, not to enforce regulations that impose a financial burden on a state, company or individual.

It’s so broad it could allow many of the law’s provisions, including many of taxes it imposes on insurers and the requirement that individuals buy insurance, to die from lack of enforcement.

The order is an important political act for Trump, who pledged throughout his campaign that he would act quickly to roll back the health care law. Its reach, however, depends upon exactly which provisions he decides to target.

The order comes as Trump’s pick to lead the Department of Health and Human Services, Rep. Tom Price, R-Ga., is awaiting his confirmation hearing and vote, which could come within days or weeks.

It’s unclear how much of this order could be carried out before Price, if he’s confirmed, is installed at HHS.

Trump’s order also pushes one of his favorite health care ideas — to allow insurance companies to sell policies across state lines — by encouraging “the development of a free and open market in interstate commerce for the offering of healthcare services and health insurance, with the goal of achieving and preserving maximum options for patients and consumers.”

It lands just as members of Congress are working to repeal and replace the Affordable Care Act.

Trump and Republican lawmakers have promised that any repeal would be followed immediately by a replacement for the law and they’ve said that anyone who has insurance through the ACA will not lose it in the transition.

“While President Trump may have promised a smooth transition, the Executive Order does the opposite, threatening disruption for health providers and patients,” said Leslie Dach, director of the Protect our Care Coalition, a group of organizations trying to save the Affordable Care Act.

Health policy analysts have warned that repealing the unpopular parts of the law such as the taxes or individual mandate could lead to the collapse of the individual health insurance market. This executive order could allow those provisions to be rolled back before a replacement bill is ready.

Republicans in Congress have laid out a number of broad road maps for a new health care law but have yet to reveal a specific bill that would show how many people will get insurance coverage or how much it might cost.

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As promised, President Trump got to work on Day One, spending some time in the Oval Office in between the inaugural parade and a trio of formal balls.

Trump signed an executive order Friday night directing government agencies to “ease the burdens” of Obamacare while the new administration and Congress work toward repealing and replacing the Affordable Care Act.

White House Chief of Staff Reince Priebus presented Trump with the order, which he described as: “An executive order minimizing the economic burden of the Patient Protection and Affordable Care Act pending repeal.”

It’s not clear what kind of relief the executive order envisions.

Trump also signed paperwork authorizing the elevation of two new Cabinet secretaries. The Senate voted this evening to confirm Trump’s nominees for defense secretary, James Mattis, and homeland security secretary, John Kelly.

Trump called his first day in office “busy, but good.”

“A beautiful day,” he added, before changing into formal wear for a round of celebratory balls.

Also Friday evening, Priebus was preparing a memo for all federal agencies, ordering a freeze on government regulations. It was not immediately clear whether that order would apply retroactively to regulations in the pipeline from the outgoing Obama administration.

Trump was joined in the Oval Office this evening by his national security adviser, Mike Flynn; son-in-law and senior adviser, Jared Kushner, and campaign manager turned counselor Kellyanne Conway.

The new president is already putting his mark on the workspace. Crimson drapes in the Oval Office have been replaced with gold. Obama’s rug, featuring inspirational quotes such as, “The arc of the moral universe is long but it bends towards justice,” has been swapped for a new floor covering. And a bust of Winston Churchill once again occupies a place of honor. The Churchill bust had been removed during the Obama years, replaced by a bust of Martin Luther King Jr. That bust is still there.

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