NPR’s Robert Siegel talks to National Rural Health Association’s Brock Slabach about a report that people in rural areas are more likely to die from the top causes of death than those in urban areas.

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On the first day of this Congress, Rep. Steve King of Iowa introduced a bill to repeal the Affordable Care Act in its entirety. Now some Republicans say they want to wait until there’s a replacement plan. NPR’s Audie Cornish asks Rep. King why he wants to push ahead on repeal first.

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An NPR/Ipsos poll shows that almost half of Americans, including Democrats, don’t know the Affordable Care Act reduced the number of people without insurance.

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The Senate early Thursday passed a measure to take the first step forward on dismantling President Barack Obama’s health care law, responding to pressure to move quickly even as Republicans and President-elect Trump grapple with what to replace it with.

The nearly party-line 51-48 vote came on a nonbinding Republican-backed budget measure that eases the way for action on subsequent repeal legislation as soon as next month.

“We must act quickly to bring relief to the American people,” said Senate Majority Leader Mitch McConnell, R-Ky.

The House is slated to vote on the measure on Friday, though some Republicans there have misgivings about setting the repeal effort in motion without a better idea of the replacement plan.

Trump oozed confidence at a news conference on Tuesday, promising his incoming administration would soon reveal a plan to both repeal so-called Obamacare and replace it with legislation to “get health care taken care of in this country.”

“We’re going to do repeal and replace, very complicated stuff,” Trump told reporters, adding that both elements would pass virtually at the same time. That promise, however, will be almost impossible to achieve in the complicated web of Congress, where GOP leaders must navigate complex Senate rules, united Democratic opposition and substantive policy disagreements among Republicans.

Passage of Thursday’s measure would permit follow-up legislation to escape the threat of a filibuster by Senate Democrats. Republicans are not close to agreement among themselves on what any “Obamacare” replacement would look like, however.

Republicans plan to get legislation voiding Obama’s law and replacing parts of it to Trump by the end of February, House Majority Leader Kevin McCarthy, R-Calif., said Wednesday on “The Hugh Hewitt Show,” a conservative radio program. Other Republicans have said they expect the process to take longer.

The 2010 law extended health insurance to some 20 million Americans, prevented insurers from denying coverage for pre-existing conditions and steered billions of dollars to states for the Medicaid health program for the poor. Republicans fought the effort tooth and nail and voter opposition to Obamacare helped carry the party to impressive wins in 2010, 2014, and last year.

Thursday’s Senate procedural vote will set up special budget rules that will allow the repeal vote to take place with a simple majority in the 100-member Senate, instead of the 60 votes required to move most legislation.

That means Republicans, who control 52 seats, can push through repeal legislation without Democratic cooperation. They’re also discussing whether there are some elements of a replacement bill that could get through at the same time with a simple majority. But for many elements of a new health care law, Republicans are likely to need 60 votes and Democratic support, and at this point the two parties aren’t even talking.

Increasing numbers of Republicans have expressed anxiety over obliterating the law without a replacement to show voters.

Sen. Susan Collins, R-Maine, said she wants to at least see “a detailed framework” of a GOP alternative health care plan before voting on repeal. She said Republicans would risk “people falling through the cracks or causing turmoil in insurance markets” if lawmakers voided Obama’s statute without a replacement in hand.

Collins was among a handful of Republicans to occasionally break ranks to support some Democratic messaging amendments aimed at supporting such things as rural hospitals and a mandate to cover patients with pre-existing medical conditions. They were all shot down by majority Republicans anyway.

House leaders planned a Friday vote on the budget, though Republicans in that chamber also had misgivings.

Many members of the conservative House Freedom Caucus were insisting on first learning details about what a GOP substitute would look like – or putting some elements of the replacement measure in the repeal bill.

“We need to be voting for a replacement plan at the same time that we vote for repeal,” said Rep. Mark Meadows, R-N.C., an influential conservative.

Some GOP senators have discussed a phase-in of three years or longer to give lawmakers more time to replace Obama’s overhaul and make sure people now covered by that law can adjust to a new program.

Some more moderate House Republicans were unhappy, too, including Rep. Tom MacArthur, R-N.J., a leader of GOP centrists in the House Tuesday Group. He said he would oppose the budget because there was too little information about the replacement, including whether people receiving expanded Medicaid coverage or health care subsidies under the existing law would be protected.

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In fact, the Affordable Care Act brought the rate of uninsured Americans to a record low 9 percent in 2015. It’s the major achievement of the controversial health care law and one the Obama administration likes to tout whenever it can.

Health and Human Services Secretary Sylvia Burwell did just that in an interview with NPR on Tuesday.

“We have the lowest uninsured rate in the nation’s history,” Burwell said. “Twenty million Americans have insurance that didn’t have insurance before the Affordable Care Act. For many people they consider it just a basic part of their health care.”

But many of those surveyed in a new NPR/Ipsos poll got it wrong. About half believed that the number of people without insurance had increased or stayed the same, or they said they didn’t know what the law’s effect has been on insurance coverage.

That was a failure of communication on the part of the Obama Administration, says Bill Pierce, a senior director at APCO Worldwide, who advises health care companies on strategic communications.

“They needed to use the president more,” said Pierce. “If this was his number one achievement, and something he was proud of doing, it was the kind of thing that he needed to be out there and talking about all the time.”

Democrats were better informed than Republicans, with 54 percent of Democrats saying the law had reduced the number of people without insurance, compared to 41 percent of Republicans.

Pierce said one problem is that the law was passed in 2010 but didn’t go fully into effect for years. In that the time, the web site that housed the insurance exchange, the most public part of the program, failed.

“By the time they insurance rate started to fall, a lot of minds were already set,” he said.

NPR’s poll was designed to gauge the public’s knowledge of some basic aspects of the U.S. health care system. The results come as Republicans on Capitol Hill are working to repeal the law. The Senate early Thursday morning passed a measure taking the first step toward dismantling the law.

While many people in the poll were misinformed about the big picture when it comes to Obamacare, they had stronger knowledge about the details of the law.

The majority of those surveyed know that the ACA protects people with pre-existing conditions from being refused coverage and that it requires insurance companies to pay for preventive care.

However, the heated debate during the 2008 presidential race over so-called “death panels” left a mark.

About a third of those surveyed believed Obamacare places limits on end-of-life medical care and another half were not sure. Only 18 percent correctly said that no such limits exist under the law.

Beyond Obamacare, many people had a good grasp of the overall quality of the U.S. health care system.

The majority were aware that Americans generally pay more for health care than people in other countries and that even so, health care outcomes in the U.S. does not have “the best results in the world.”

The poll also reiterated findings from a separate survey from the Kaiser Family Foundation last week that showed that people are about evenly split on their view of the Affordable Care Act.

Still, most people don’t want lawmakers to repeal the law until they have a replacement plan in place. Only 14 percent favor repeal without a replacement plan.

That message seems to have gotten through to lawmakers. Earlier this month, Republican leaders in the House and Senate were advocating an immediate Obamacare repeal, with a slow phase out while they consider ways to replace the law so people who have insurance can still get it.

But many lawmakers walked those plans back this week in statements and via Twitter. Some, including President-elect Donald Trump, said they did not want to see a repeal until a replacement is ready.

“We’re going to be submitting, as soon as our secretary is approved, almost simultaneously — shortly thereafter — a plan. It will be repeal and replace. It will be, essentially simultaneously,” Trump said in a news conference Wednesday.

The poll surveyed 1,011 adults on January 4 and 5, 2017.

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The outcome of the repeal-and-replace Obamacare debate could affect more than you might think, depending on just how the GOP congressional majority pursues its goal.

Beyond the Affordable Care Act’s marquee achievements like guaranteeing health coverage for people with pre-existing conditions and allowing children to stay on parents’ plans until age 26, the roughly 2,000-page law created a host of other provisions that affect the health of nearly every American.

Some of these measures are evident every day. Some enjoy broad support, even though people often don’t always realize they spring from the statute.

Here’s a sampling of sleeper provisions that could potentially land on the cutting-room floor:

Calorie counts at restaurants and fast-food chains

Feeling hungry? The law tries to give you more information about what that burger or muffin will cost you in terms of calories, part of an effort to combat the ongoing obesity epidemic. Under the ACA, most restaurants and fast food chains with at least 20 stores must post calorie counts of their menu items. Several states, including New York, already had similar rules before the law.

Although there was some pushback, the rule had industry support, possibly because posting calories was seen as less onerous than such things as taxes on sugary foods or beverages. The final rule went into effect in December after a one-year delay.

One thing is still not clear: Does simply seeing that a particular muffin has more than 400 calories cause consumers to choose carrot sticks instead? Results are mixed. One large meta-analysis done before the law went into effect didn’t show a significant reduction in calorie consumption, although the authors concluded that menu labeling is “a relatively low-cost education strategy that may lead consumers to purchase slightly fewer calories.”

Private breast-milk pumping space at work

Breast-feeding, but going back to work? The law requires employers to provide women break time to express milk for up to a year after giving birth and provide someplace other than a restroom to do so in private. In addition, most health plans must offer breast-feeding support and equipment, such as pumps, without a patient copayment.

Limits on surprise medical bills from ER visits

If you find yourself in an emergency room, short on cash, uninsured or not sure if your insurance covers costs at that hospital, the Affordable Care Act provides some limited assistance. If you are in a hospital that is not part of your insurer’s network, the law requires all health plans to charge consumers the same copayments or co-insurance for out-of-network emergency care as they do for hospitals within their networks. Still, the hospital could “balance bill” you for its costs, including ER care, that exceed what your insurer reimburses it.

If it’s a nonprofit hospital, and about 78 percent of all hospitals are, the law requires it to post online a written financial assistance policy, spelling out whether it offers free or discounted care and the eligibility requirements for such programs. While not prescribing any particular set of eligibility requirements, the law requires hospitals to charge lower rates to patients who are eligible for their financial assistance programs. That’s compared with their gross charges, also known as chargemaster rates.

Community health support from nonprofit hospitals

The health law also requires nonprofit hospitals to justify the billions of dollars in tax exemptions they receive by documenting how they go about trying to improve the health of the community around them.

Every three years, these hospitals have to perform a community needs assessment for the area the hospital serves. They also have to develop strategies to meet these needs and update them annually. The hospitals then must provide documentation as part of their annual reporting to the Internal Revenue Service. Failure to comply could leave them liable for a $50,000 penalty.

A woman’s right to choose her OB-GYN

Most insurance plans must allow women to seek care from an obstetrician-gynecologist without having to get a referral from a primary care physician. While the majority of states already had such protections in place, those laws did not apply to self-insured plans, which are the type often offered by large employers. The health law extended the rules to all new plans. Proponents say direct access makes it easier for women to seek not only reproductive health care, but also screening for such things as high blood pressure or cholesterol.

Expanded therapy coverage for children with autism

Advocates for children with autism and people with degenerative diseases argued that many insurance plans did not provide care their families needed. That’s because insurers would cover rehabilitation to help people regain functions they had lost, such as walking again after a stroke, but not care needed to either gain functions patients never had, such as speech therapy for a child who never learned how to talk, or to maintain a patient’s current level of function. The Affordable Care Act requires plans to offer coverage for such treatments, dubbed habilitative care, as part of the essential health benefits in plans sold to individuals and small groups.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

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Abra and Matt Schultz, both 32, recently built a house in a middle class neighborhood in Pottsville, Pa. Matt works as a carpenter foreman for a construction company. He and Abra, his wife, are right in Trump’s wheelhouse — Republicans in Republican Schuylkill County.

The couple spent December trying to decide whether to buy health insurance or skip it for 2017. They voted for Trump because they were fed up with how much they are paying for health insurance.

In mid-December in the couple’s kitchen, Abra was sizing up their health insurance options. She showed off a thick notebook, along with a file folder with policy document and notes piled as high as a stack of pancakes. “Don’t touch my paperwork — don’t even try to touch it,” Abra joked to Matt. “I get so stressed out about it. I’ll not pick one until the very last minute, like that deadline day.”

Matt makes good money but he usually gets laid off in the winter when construction slows down. For the last few years, he and Abra have bought coverage on HealthCare.gov, the Affordable Care Act exchange.

But they’re in a tough spot. They make too much money to get a subsidy to help them pay for insurance. Subsidies are available only to those who make under 400 percent of poverty or about $97,000 for a family of four. But while the Schultzes don’t qualify for help, paying full price for health insurance stretches their budget to the limit.

Two years ago, when they first signed up for insurance on the exchange, Abra says they were paying $530 a month for a plan they liked. The price rose a little for 2016, but the options for 2017 went up a lot — about 30 percent on average in Pennsylvania.

“We have one for $881, one for $938, one for $984, like the deductibles are — look, these are insane,” Abra said, as she checked the exchange website for monthly premiums. “The one that we would be stuck with would be the silver. This is $881.50, and our deductible would be $7,000.”

It’s frustrating, she said, because she and her husband are relatively healthy and haven’t needed that much care. Add to that the cost of a separate partially subsidized insurance policy for their two children, and the family is expecting to pay at least $14,000 in health premiums.

Abra Schultz resented the mandate to buy health insurance from the beginning. And she liked what Trump he said about the Affordable Care Act on campaign stops, like one in King of Prussia in November, just before the election.

“Obamacare has to be replaced, and we will do it and we will do it very, very quickly,” Trump said in his speech. “It is a catastrophe.”

Abra said she wouldn’t mind being in health insurance limbo while Trump and lawmakers debate the future of Obamacare.

Larry Levitt with the Kaiser Family Foundation said he understands her frustration with the law. “These are people who are playing by the rules, and doing the right thing, and they feel like they’re getting the shaft,” he said.

No one likes higher and higher premiums, he says, but there’s a trade-off. “Before the ACA, to get insurance on your own, you had to fill out a medical questionnaire, and an insurer would only take you if you were reasonably healthy,” Leavitt said. “That kept premiums down, but it’s because sick people were excluded from the market altogether.”

Levitt said the law’s goal was to to get insurance to a point where premiums only increase slightly every year while everyone can still get coverage, no matter their preexisting condition. And he says, any replacement plan devised by Republicans will have upsides and downsides, just like the Affordable Care Act. “If this were easy, it already would have happened,” he said.

Abra said she understands the broader picture, but she needs to focus on what’s best for her family — affordable health insurance.

“[Trump] just wants to fix what needs to be fixed, which I think is wonderful news,” she says.

Abra did decide on a policy for her and her husband — she selected the plan that costs $938 a month because she wants to keep her current doctor. But if lawmakers eliminate the penalty for people who don’t get insurance, she might take a risk and drop the coverage.

This story is part of a reporting partnership with NPR, WITF’s Transforming Health project and Kaiser Health News.

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NPR’s Audie Cornish talks with outgoing Health and Human Services Secretary Sylvia Burwell about the GOP’s plan to repeal the Affordable Care Act and how Democrats are trying to defend it.

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Scientists have found the inspiration for a lifesaving tool in an unusual place — a children’s toy. The invention may soon help health care workers diagnose malaria in places where standard laboratory equipment is hard to find. Diagnosing malaria in the field isn’t all that difficult, but you need a device called a centrifuge that can spin a blood sample very quickly, causing different types of cells in blood to separate from each other.

Most centrifuges are bulky, require electricity and are expensive. Because of that, many field hospitals in developing nations don’t have easy access to the technology.

Manu Prakash, a professor of bioengineering at Stanford University who developed the new tool, saw the need firsthand during a trip to Uganda. “We were out in a primary health center talking to health care workers and we found a centrifuge used as a doorstop because there’s no electricity.” The workers said that they really needed a powerful centrifuge that they could use anywhere. And it needed to be cheap.

When he got back to California, Prakash began experimenting with all kinds of things that spin, including toys. Toys might seem like a strange place to start, but Prakash didn’t think so. Who doesn’t love toys? And, he explains, “Toys hide in them pretty profound physical phenomena that we just take for granted.”

The researchers started to experiment with yo-yos. But the yo-yos didn’t spin fast enough to work as a centrifuge. Then they stumbled upon the children’s toy known as the whirligig, or buzzer.

The toy is made of a disc that spins when a person pulls on strings that pass through the center. And it spins much faster than a yo-yo. The scientists clocked their version at 125,000 revolutions per minute. According to the authors, that’s the fastest rotational speed reported for a human-powered device. By comparison, the internal combustion engine of a Formula One race car rotates at about 15,000 rpm.

And so the paperfuge was born.

The paperfuge is made out of paper coated in a polymer film that makes it extra strong, string and PVC pipe or wood. Blood samples are attached to the center disc and pulling the strings causes the cells to separate, just like in the more expensive electrical centrifuge. The samples can then be processed and tested for parasites.

To prove that the paperfuge could work in the field, the researches took a prototype to Madagascar for a test run. It worked as advertised, allowing local health care workers to spin blood and test for parasites. Prakash and his colleagues reported their results Tuesday in Nature Biomedical Engineering.

This isn’t the first time that Prakash has invented a low-cost tool for use in resource-poor areas. A few years ago, his group also invented a $1 paper microscope called the Foldscope.

The paperfuge is inexpensive, costing just 20 cents apiece to make. They can be made by hand or by machine, and the spinning disc can be made of paper or plastic. Using a desktop 3-D printer, the study authors printed over 100 paperfuges in one day. That means if the paperfuge catches on, it could be relatively easy to make and distribute to resource-poor areas.

Now that Prakash’s group has shown that it’s effective in identifying malaria, they are working on developing different variations of the paperfuge that could help diagnose other diseases.

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Darlene Hawes lost her health insurance about a year after her husband died in 2012.

Hawes, 55, is from Charlotte, N.C. She ended up going without insurance for a few years, but in 2015 she bought coverage on HealthCare.gov, the Affordable Care Act marketplace, with the help of a big subsidy.

“I was born with heart trouble and I also had, in 2003, open-heart surgery,” she says. “I had breast-cancer surgery. I have a lot of medical conditions, so I needed insurance badly.”

After the results of the 2016 election came in, she was scared she’d lose her insurance immediately. For years, Republicans have vowed to scrap the health care law. The new Congress is already working on a plan to undo the Affordable Care Act. But they have not settled on how to replace the health care structure that Obamacare set up.

Hawes is one of about 550,000 North Carolinians who relies on the Obamacare marketplace for health insurance. She was relieved after she talked with an enrollment specialist last month who told her she can renew her policy for 2017.

“And I’m like, ‘Oh my Lord, did she just say that?’ ” Hawes asks with a laugh. “It’s just like a whole load of burdens just fell off of my back because all the years I haven’t been covered since my husband passed away — I don’t want to be sad again. I was very sad.”

Most health care researchers and policy analysts agree not much is likely to change in 2017.

“Even the Republican Congress in one of their most recent bills to repeal it, they put in a two-year transition period, so that the premium subsidies and the other provisions of the law that are fundamental wouldn’t be repealed for a couple of years,” says Sabrina Corlette, a research professor at Georgetown University’s.

Some Republican leaders say repeal should happen immediately with a transition period to come up with a replacement.

Still, the CEO of HealthCare.gov, Kevin Counihan, says he can’t guarantee coverage will remain. “It’s not my place to promise anything about a new administration,” he says. “But what I can tell you is not only are we moving forward, but our enrollment is higher than expected.”

At the end of 2016, enrollment for 2017 plans spiked and as of the end of December, North Carolina has the third-highest enrollment for 2017 plans among states using HealthCare.gov.

Julieanne Taylor with Legal Services of Southern Piedmont is helping people sign up. She says about a third of them have asked about the election.

“But generally when we’re calling, people are really excited to have their appointment and come in and look at the plans for 2017,” she says. “I think they’re mostly interested in how much they’re going to be paying.”

In some ways, North Carolina is in tough shape. Premiums are going up and insurance companies have dropped out, leaving Blue Cross Blue Shield of North Carolina as the only insurer in 95 percent of the state.

Blue Cross actuary Brian Tajlili says it’s simply an expensive market that has older, sicker people who cost more to cover.

“There is continuing demand for services and continuing high utilization within this block of business,” he says.

What he calls “this block of business” means the customers who buy insurance on the exchange. It’s a small slice of the overall health insurance market, because most people are covered through work or Medicare. The overwhelming majority of consumers who buy coverage on the exchange get federal subsidies that greatly reduce what they pay.

Still, it’s been a turbulent market for consumers and insurers. Over the past two years, Blue Cross has lost $400 million in North Carolina on that part of its business.

Amid the post-election uncertainty, Tajlili says Blue Cross is committed to offering plans in 2017.

“2017 will be another pivotal year for us as we look at the individual market,” he says.

One of Blue Cross’ new customers will be Sara Kelly Jones, 46, who works at Letty’s restaurant in Charlotte, N.C. She recognizes Obamacare isn’t perfect. But before the law, health insurance was a financial vise that kept tightening on her.

“I could not afford it at all,” she says. “Every year it was going up $100 to $120, $150 a month. It got to the point where it was going to be at least $200 more a month than my mortgage.”

But under Obamacare, Jones qualifies for a subsidy. Her premium will go up with Blue Cross, but she says she can afford it with that help.

Jones says the political debate over the law ignores people like her.

“I’m terrified,” she says. She’s worried about the Republican Congress’ pledge to scrap and replace Obamacare without presenting a detailed proposal. “If there had been any plan outlined that wasn’t just some vague, ‘We’re going to replace it with something awesome,’ ” she says she’d rest easier. “They have no plan! What on Earth are you going to do with all these people, myself included, that are counting on this?”

This story is part of a reporting partnership with NPR, WFAE and Kaiser Health News. You can follow Michael Tomsic on Twitter: @michaeltomsic.

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