President-elect Donald Trump has promised over and over in recent months that he will repeal and replace the Affordable Care Act, also called Obamacare, when he reaches the White House.

“Obamacare is a disaster. You know it. We all know it,” Trump said at a debate last month. “We have to repeal it and replace it with something absolutely much less expensive.”

Now that Trump will move into the Oval Office in January, the question is whether he’ll be able to completely repeal the six-year-old law that has had an impact on every aspect of the U.S. health care system.

“It’s a challenge for a Trump presidency,” says Jack Hoadley, a research professor at Georgetown University’s Health Policy Institute. “To get a true repeal and replace through, he needs 60 votes in the Senate.” That’s the minimum number of votes needed to overcome a filibuster in the Senate.

“Repeal of the law is absolutely going to come up, and the only potential defense against that would be a Democratic filibuster — if Republicans even allow a filibuster,” says Austin Frakt, a health economist who runs the blog The Incidental Economist.

But even if Trump can’t repeal the Affordable Care Act in its entirety, there’s a lot he can do through rule-making and smaller legislative changes to weaken the law and mold it more to his liking.

“They are probably, practically speaking, talking about leaving the ACA, as is, in place,” Hoadley says. “Then he can change the ACA to have it showcase the kinds of plans he wants to see in place.”

During his campaign, Trump proposed a series of measures that he said will allow people to buy affordable health insurance policies outside of the Obamacare exchanges.

Those measures include promoting tax-free health savings accounts that might help individuals save money to pay for health care costs and allowing people to deduct the cost of their premiums on their personal income tax returns. Trump has said he also wants to allow insurers to sell policies across state lines to boost competition.

Trump could alter the Obamacare exchanges to promote high-deductible health plans and health savings accounts to get a result similar to what he’s looking for.

“He could change the details of how the marketplaces work,” Hoadley says. “It’s all worked out through regulation. You could just suspend the regulations.”

Alternatively, Trump could embrace the health care plan promoted by House Speaker Paul Ryan, which starts with repealing the Affordable Care Act. It includes many of the same principles as Trump’s plan, but has more details.

One of the biggest challenges Trump faces is that about about 20 million people today have health coverage because of the Affordable Care Act, according to the Department of Health and Human Services. The uninsured rate hit an all-time low of 8.9 percent this year, according to the Centers for Disease Control and Prevention.

An analysis of Trump’s plan by The Commonwealth Fund estimates it would increase the number of people who lack health insurance by as many as 25 million, and increase the federal budget by as much as $41 billion. That’s because much of Trump’s plan involves giving tax breaks to encourage people to buy insurance while taking away the requirement to buy insurance — a mandate embedded in Obamacare.

Even if Trump fails to repeal the law, Frakt says, he could easily destroy it from within by refusing to fund it through the budget process.

“The only thing stopping that is, it’s a big deal to throw millions of people off insurance without offering something in return,” Frakt says.

If Trump is right that his health savings accounts are a good enough replacement, then he’ll be able to get rid of Obamacare through a vote or through neglect.

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While Donald Trump campaigned for the presidency, he repeatedly said he would get rid of the Affordable Care Act. What will happen to Obamacare? Also, we monitor how financial markets are doing.

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A federal district court in Mississippi has issued an injunction blocking a new rule that would preserve the right of patients and their families to sue nursing homes over quality-of-care disputes.

The rule, announced in September by the Centers for Medicare & Medicaid Services, would ban so-called pre-dispute binding arbitration clauses in nursing home contracts, which require patients and families to settle any dispute over care through arbitration, rather than the court system.

The rule was supposed to take effect Nov. 28, but the American Health Care Association, an industry group that represents most nursing homes in the U.S., filed a lawsuit in October to block the rule, which it called “arbitrary and capricious.”

The acting administrator for the Centers for Medicare & Medicaid Services argued in a September blog post that the rule improved the “care and safety of the nearly 1.5 million residents in the more than 15,000 long-term care facilities that participate in the Medicare and Medicaid programs.”

As we have reported, the rule applies to facilities that receive money from Medicare or Medicaid — which is nearly all of them.

The lawsuit by the AHCA also contests the authority of the Centers for Medicare & Medicaid Services to regulate how nursing homes handle disputes, saying that authority lies solely with Congress.

On Monday, a federal district court granted the injunction, even as it acknowledged that “nursing home arbitration litigation suffers from fundamental defects.”

The reason for granting the injunction, the court explained in its order, is that it believes the new rule represents “incremental ‘creep’ of federal agency authority” — in this case the Centers for Medicare & Medicaid Services — “beyond that envisioned by the U.S. Constitution.”

The decision indefinitely postpones the rule from taking effect until the lawsuit is settled.

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Since the mid-1800s, laughing gas been used for pain relief, but these days it’s usually associated with a visit to the dentist.

In the early 20th century, women used laughing gas to ease the pain of labor, but its use declined in favor of more potent analgesia. Now a small band of midwives is helping to revive its use in the U.S.

One hospital in Rhode Island, South County Hospital in North Kingstown, has just added nitrous oxide, the formal name for laughing gas, to its menu of pain relief options for labor.

Amy Marks jumped at the chance to use it because she wanted to avoid an epidural — an injection in the fluid around the spinal cord that blocks feeling below the waist. Now she sits with her son, Ethan Thomas, barely a day old, snug in the crook of her arm.

“When the contractions started getting pretty intense, I was like, wow, this is pretty bad,” says Marks, who is 31 and lives in Wakefield, R.I. “So they brought it in and it really took the edge off.”

If you’ve been through labor, you know it hurts. Is taking “the edge off” really enough? It was for Marks, once she got the hang of breathing in the gas through a face mask, timing it to anticipate the peak pain of a contraction by 15 to 30 seconds.

“You’re going through the contraction, you’re breathing in and out, maybe do five, six breaths, get to the peak of the contraction, and I kind of didn’t really need any more, I could bear the rest of the contraction,” she says. “I was giggly. But only for like 15 to 30 seconds.”

Marks’ nurse-midwife, Cynthia Voytas, says Marks was breathing a mixture of 50 percent nitrous oxide and 50 percent oxygen.

“It gives you this euphoria that helps you sort of forget about the pain for a little bit,” Voytas says.

“Absolutely. That’s exactly what happened,” says Marks.

Voytas shows me a little cart stocked with two gas tanks. It’s mobile, so nurses can roll it up to the woman’s bedside. There’s a hose with a breathing mask. When she wants a little gas, a woman can just pick up the mask and breathe. Voytas says it gives a mom more control over her pain relief.

Until 2011, only a couple of hospitals in the United States offered nitrous oxide to women in labor. Today, it’s in hundreds, according to the two main manufacturers of nitrous oxide systems. One of those manufacturers, Porter Instrument, maker of Nitronox, says nearly 300 hospitals and birth centers use the option for pain management.

Michelle Collins, a professor and director of nurse midwifery at Vanderbilt University School of Nursing, is helping lead the charge to bring back nitrous oxide as one of several options women should be offered for pain relief during childbirth. She sees the effort as being in line with what midwives have always done: advocating for women to have more control of the experience of giving birth.

Prior to the 1950s, Collins says, nitrous oxide was commonly used in labor. But then doctors started using more powerful anesthetics. Women would go to the hospital, be completely knocked out, and wake up with a baby in their arms. Epidural anesthesia, which came on the scene in the 1970s, gave women the possibility of a pain-free labor while awake. But it came with trade-offs: epidurals can make it difficult to move around, and can prolong the second stage of labor.

Women want more options, Collins says. They want to be more involved in the birth of their baby. “Now women are more informed, and they’re demanding that their voices be heard, which is a really great thing in my book,” she says.

Nitrous oxide has continued to be used regularly in Europe for labor pain, so there’s data that shows it’s safe, especially in smaller doses. It doesn’t reduce pain, like an epidural. Rather, it induces a sense of euphoria or relaxation.

“For some women, the epidural is going to be their number one choice. For other women, they want to be unmedicated and have nothing and that’s their choice. For other women, nitrous oxide is a viable choice,” Collins says. “It’s seen somewhat like a menu and for everything that’s safe, it should be on that menu and available to the woman.”

Another leader of this mini-revolution, retired nurse midwife and epidemiologist Judith Rooks, says the gas leaves the body in seconds.

“It does pass the placenta and go into the fetal circulation, but as soon as the baby takes a breath or two, it’s gone,” Rooks says.

The American College of Nurse Midwives came out with a position paper in 2011, saying it’s important for midwives be aware of nitrous oxide as a good option for women in labor and get trained in how to administer it.

Obstetricians don’t have an official position on use of nitrous oxide, says Dr. Laura Goetzl, a professor at Temple University’s Lewis Katz School of Medicine in Philadelphia and a member of the American College of Obstetricians and Gynecologists. She helped draft the College’s 2002 guidance about analgesia for labor, which, she says, “did not discuss nitrous oxide as an option since its use in the U.S. was exceedingly rare at the time.” She adds, “However, I can speak as an expert on obstetrical analgesia that it is a safe and reasonable option. We are actually currently trying to add a service to our hospital.”

The American Society of Anesthesiologists reviewed research on nitrous oxide in May 2011, and said that there needs to be more studies, and more rigorous studies, on its safety and effectiveness — much of the research is decades old. They also warn that facilities should have a good system for capturing any gas that escapes into the air, so those nearby don’t breathe it in. But they also say its use in Europe shows “good safety outcomes for both mother and child.”

Nitrous oxide is less expensive than an epidural by hundreds, sometimes thousands of dollars. Collins says the disposable patient breathing circuit and mask cost about $25 and the gas alone might cost about 50 cents an hour. Porter Instruments, which manufacturers the Nitronox system, says the equipment itself will cost a hospital or facility just under $5,000. An anesthesiologist does not need to administer it — that can be done by a nurse midwife or other trained medical staff. Though hospitals are having a hard time figuring out the billing because it’s so new, says Collins.

“The interesting thing is that there’s not a charge code for this particular use of nitrous oxide in labor,” she says. “So places around the country are being very creative in how they’re approaching the charge portion of it.”

One insurer in Rhode Island covers it as it would another painkiller. Some hospitals, says Collins, just swipe a patient’s credit card, or don’t charge at all.

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

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The Justice Department is investigating the pricing practices of several generic drug manufacturers because the list prices of many older medications have risen in lockstep in recent years.

That investigation could lead to an antitrust lawsuit alleging price-fixing by the end of this year, according to a report by Bloomberg News. Bloomberg cited anonymous sources familiar with the probe.

The Justice Department declined to comment on the reported investigation for this story.

Many of the companies, including Teva, Mylan, Lannett Co., and Impax Laboratories, have disclosed in public securities filings that they are under investigation by the Justice Department and Connecticut Attorney General George Jepsen. Jepsen spokeswoman Jaclyn Falkowski declined to comment for this story.

Mylan’s disclosure said the following:

“Mylan N.V. received a subpoena from the Antitrust Division of the U.S. Department of Justice (“DOJ”) seeking information relating to the marketing, pricing and sale of our generic Doxycycline products and any communications with competitors about such products. The company is fully cooperating with DOJ’s inquiry.”

An antibiotic, doxycycline is used to treat bacterial infections, including acne, and sometimes used to prevent malaria. The drug’s price rose more than 8,000 percent from Oct. 2013 to April 2014, according to a report that was part of a congressional inquiry.

“Mylan is and has always been committed to cooperating with the Antitrust Division’s investigation,” said spokeswoman Nina Devlin in an emailed statement. “To date, we know of no evidence that Mylan participated in price fixing.”

The other companies’ disclosures were similar, often with different medications such as digoxin, a heart failure treatment, named. The price of digoxin rose more than 800 percent to $1.10 a tablet between 2012 and 2014, according to the Congressional report. It has since declined, according to GoodRx.

Teva spokeswoman Denise Bradley said in a statement, “Teva is not aware of any facts that would give rise to an exposure to the Company with respect to these subpoenas.”

Lannett’s CEO said on a conference call that his company did nothing wrong.

The Bloomberg report comes on the same day that Sen. Bernie Sanders, (I-Vt.), and Rep. Elijah Cummings (D-Md.) sent a letter to the Justice Department asking it to investigate possible antitrust violations in the pricing of insulin. The lawmakers said the price of insulin products tripled from 2002 to 1013.

“Not only have these pharmaceutical companies raised insulin prices significantly – sometimes by double digits overnight,” the lawmakers wrote in their letter. “In many instances the prices have increased in tandem.”

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For years, medical interns have been limited to working no more than 16 hours without a break to minimize the chances they would make mistakes while fatigued. But that restriction could soon be eased.

The group that sets the rules for medical residents proposed scrapping the 16-hour limit for interns, doctors in their first year of on-the-job training after finishing medical school. The new rule would let these new doctors work for as many as 28 hours at a stretch.

The Accreditation Council for Graduate Medical Education proposed the change based on research that found that the relaxed rule wouldn’t increase risks for patients, officials say. In fact, the ACGME says, the longer work hours could make patient care safer and would also improve medical training by giving young doctors more realistic experience.

“Just as drivers learn to drive under supervision in real life on the road, residents must prepare in real patient-care settings for the situations they will encounter after graduation,” said Dr. Thomas Nasca, ACGME’s chief executive officer, in a written statement announcing the proposed change.

The longer shifts could improve patient care by minimizing the number of times interns have to pass their patients onto someone else to continue their treatment, the council says. Mistakes can occur as a result of those hand-offs, the group says.

The new rules would limit interns to working no more than 24 hours at a stretch plus four hours to “manage transitions in care, promoting professionalism, empathy and commitment,” according to the announcement.

“Training to become a practicing physician can be compared to training for a marathon,” Nasca says. “You must learn how to pace yourself, take care of yourself and recognize your limits.”

But the proposal is controversial. Critics argue it would be put patient safety at risk because the first-year residents would become too fatigued.

“Study after study shows that sleep-deprived resident physicians are a danger to themselves, their patients and the public,” says Dr. Michael Carome, director of Public Citizen’s Health Research Group. “It’s disheartening to see the ACGME cave to pressure from organized medicine and let their misguided wishes trump public health.”

The rules will continue to limit interns to working no more than 80 hours per week averaged over four weeks.

Some specialties, such as emergency medicine, anesthesiology and internal medicine, would continue to have more restrictive rules, according to ACGME.

The group will take public comments on the proposal for 45 days before making any changes final.

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San Francisco Bay Area companies say Sutter Health is strong-arming them into a contract that would help the hospital system secure its power over prices and potentially raise the cost of medical care for their employees in the future.

Dozens of companies have received a letter, via their insurance administrators, asking them to waive their rights to sue Sutter. If they don’t, a fact sheet included in the letter says, the companies’ employees who get care through Sutter’s network of hospitals, doctors and medical services will no longer have access to discounted in-network prices.

“In both choices, Castlight and our employees lose,” says Jennifer Chaloemtiarana, general counsel for Castlight Health, a tech company in San Francisco that received one of these letters this spring. She thought it was strange.

Castlight is self-insured, meaning it hires an insurance company — in this case, Anthem Blue Cross — to manage the administrative details of its health coverage. But when an employee gets sick, Castlight pays the bill, not Anthem. Anthem basically functions as a middleman, including negotiating discounted prices with providers like Sutter.

“We don’t have a direct relationship with Sutter Health,” Chaloemtiarana says. “So the letter was unusual in that regard, because it asked us to make certain legal agreements with Sutter.”

The letter is from Anthem Blue Cross, but it says if Castlight has any disputes with Sutter, Castlight has to agree to arbitrate with Sutter Health. Castlight can’t sue. And if it doesn’t agree, Castlight’s employees will lose their in-network medical rates.

This makes Chaloemtiarana uncomfortable. She’s heard from her counterparts at several other companies who also don’t know what to do.

“Everyone’s struggling with it,” Chaloemtiarana says. “Nobody has signed it happily and thought it was fine.”

As an employer that pays its employees’ medical claims, Castlight doesn’t like the idea that it will never be able to challenge Sutter over its prices in open court. To Chaloemtiarana, waiving that right would only help strengthen the power of Sutter’s “already dominant” provider network.

Sutter is the largest medical system in Northern California, with roughly 30 percent market share of the hospitals, surgical centers and doctors’ groups, according to a data analysis by Christopher Whaley, a research economist at the University of California, Berkeley. In comparison, Whaley says, the largest medical system in the Los Angeles area has 5 percent market share.

Economists have long argued that Sutter uses this power to charge more for its services. Sutter’s hospital prices are about 25 percent higher than other hospitals around the state, according to a recent study from the University of Southern California.

“Having a very strong, dominant provider system will reduce choice for our employees,” Chaloemtiarana says. “We want them, over the long term, to have choices in high-quality, low-cost providers.”

Refusing to agree to the arbitration clause, she says, allows her company to “maintain our flexibility in fighting against what we consider to be difficult, anti-consumer provisions in provider networks.”

Sutter rejects these claims and the research findings.

“Recent academic studies have been one-sided and misrepresent the competitive environment of Northern California,” said Bill Gleeson, vice president of communications for Sutter, adding that the studies “unjustly inflate the so-called market share of Sutter. There’s competition all around.”

Castlight and the other self-insured companies believe they’re being asked to agree to the arbitration clause because of a lawsuit Sutter is facing from UFCW & Employers Benefit Trust which funds health coverage for 60,000 members of a grocery workers’ union. UEBT is alleging that Sutter uses unfair business practices to maintain its power over prices.

“They’ve put a stranglehold on the competitive process in the Northern California health care market,” said Richard Grossman, UEBT’s attorney. “And therefore they’re free to raise prices without limit, and they have.”

Sutter rejects these claims, too, and argues that UEBT should have to arbitrate its disputes behind closed doors. The company says the arbitration agreement Sutter has with Blue Shield, UEBT’s insurance administrator, also applies to UEBT. But the judge in the case disagreed and so did an appeals court.

“My client had never agreed to arbitration, had never seen a contract that included an arbitration clause. And so we opposed that,” says Grossman. “The judge agreed with us and said, ‘Sutter, you cannot force them into arbitration.'”

Grossman says that’s why Sutter now wants other self-insured companies like Castlight to actively sign the arbitration agreement and give up any future right to sue over prices or to claim anti-competitive practices in open court. Again, if they don’t, their employees will have to pay higher out-of-network rates at Sutter hospitals and doctors’ offices.

“They want to force any disputes into confidential arbitration so their misdeeds cannot be exposed in a public courtroom,” Grossman says.

Sutter says the goal of the arbitration agreement is “transparency.”

“We’ve taken a very proactive, very transparent approach, to making sure that the health plans provide these important clients of theirs with all the key terms of their agreements,” says Gleeson. “And that includes rates.”

Pressed to comment on the decision Sutter is asking self-insured companies to make — to give up their right to sue or give up their lower prices for medical care — Gleeson says companies “can’t accept deep discounts and make up their own rules.”

Castlight has until mid-November to sign the agreement, or face the consequences. Chaloemtiarana says she’s going to try to negotiate with her insurer over the Sutter arbitration agreement. But she’s not sure how things will turn out.

Castlight itself is in the business of trying to make health care more transparent — it makes a software platform where employees get information about their health benefits, service costs and quality, so they can make better decisions about their care. Chaloemtiarana says, out of principle, and for the long-term mission of improving health care, Castlight must “stand up against” Sutter.

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Last year, the Texas legislature approved a $350 million cut in Medicaid reimbursement rates to early childhood intervention therapists and providers. The cuts, made to help balance a billion dollars in property tax relief, affect the most vulnerable Texas children — those born extremely prematurely or with Down syndrome or other genetic conditions that put them at risk for developmental delay.

For months, providers of in-home physical, speech and occupational therapies have continued to serve children who have disabilities, despite mounting financial losses. Now some have had to shut their doors, curtail services or halt their home-visit programs, leaving many children without treatments their parents feel are crucial to the kids’ well-being.

That’s what’s happened to 2-year-old Haylee Crouse, who lives with her three brothers and sisters in the small town of Whitehouse, in East Texas. When she was just 8 days old, Haylee contracted newborn meningitis. It left her with some mental and physical deficits, and she started having periodic seizures.

But at the age of 9 months, Haylee started getting home visits and treatments from physical, occupational and speech therapists, several days a week. The therapists worked for the non-profit Andrews Center, in Tyler, Texas. Amanda Crouse, Haylee’s mother, said the therapists have made all the difference in the world for her baby girl.

“They were a lifesaver to her and to our family,” Crouse said. “They worked her hard. For example, she was not rolling over. They taught her how to roll over. They then taught her how to crawl, pull up on the couch and then, finally, she learned how to walk.”

Today, Haylee walks and laughs and is learning to talk. But all this progress is now at risk, her mother says. The state’s cuts to its Texas Medicaid Acute Care Therapy Programs have meant that the one provider of early childhood intervention treatment in Tyler — which has provided in-home therapy to hundreds of families in five East Texas counties — can no longer do so. And so, that’s it.

On the 2-year-old’s last day of therapy, Crouse said, “her therapist actually cried. Gave her a hug, said goodbye. We took a picture, just to kind of document that moment. And it was an emotional day.”

As news of the cuts became public, parents and grandparents of children who have disabilities flocked to Austin in March to implore the state Senate not to do this. Mothers wept in frustration as they testified before the Texas Senate Finance Committee about the vital these early interventions play in their children’s quality of life.

“This is Elijah,” Mary Castro told the committee members that day, holding up a photo of her 2-year-old son. “When my son was born, my husband and I found out eight days later that he has Down syndrome. He’s medically fragile and developmentally delayed.”

Without the support of early childhood intervention therapists that Medicaid provided, Castro told the lawmakers, “Elijah would not be walking, signing, doing word approximations, dancing to music, or interacting with his peers. With that said he is delayed. Quite delayed. But we love him, and he loves people.”

Republican Sen. Jane Nelson, who heads the Texas Senate’s finance committee, tried to reassure Castro and other anguished parents that the state would make sure there would be no interruption of services, whatsoever.

“Every eligible child for these services will continue to receive them,” she told the parents. “And we’re going to monitor it and we’re going to make sure that happens.”

But that’s been a promise the state has not been able to keep, and it’s in the rural parts of Texas where collapse of service has already begun.

“Sometimes you need to come out to these rural areas and see how things are done — and how they have to be done — and even talk to some of the parents before you just decide to cut a program,” said Waymon Stewart, the executive director of the Andrews Center in Tyler.

Stewart predicts that children with profound disabilities will suffer most from the closure of his program and others like it, especially in rural regions. It’s not uncommon for early childhood intervention therapists to have to drive an hour each way to get to far-flung patients. For children who are prone to seizures, or who have to be connected to machines for daily living, long trips in the car several days a week for treatment in other clinics are simply not going to happen, he says.

The cuts made in the state capital took a $312,000 bite out of his center’s budget, forcing him to terminate 20 employees.

“It really hit us hard,” Stewart said. So we were really digging into reserves to try to make this program last, and we did for a year.”

But after that, he said, “we just decided to give our notice. We couldn’t continue to do it unless the rates were changed.”

In Wichita Falls, 235 miles away, the same thing has transpired at the North Texas Rehabilitation Center, which serves 10 North Texas counties. Mike Castles, the center’s president, said they hung on for a year, but it cost them more than $200,000 in losses. So, after 30 years of service to thousands of North Texas families, that’s it for them too.

“It’s all about money,” he said, “and it created some internal problems financially with our other programs as well. There’s just so much money to make this all work. We tried to for a year; it got worse instead of better with even more bad news coming for this fiscal year.”

The state is actively hunting for new therapy providers. But the trick is finding new providers who can make work the same difficult financial circumstances that drove previous health providers out of the program.

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As customers this week begin shopping for 2017 health insurance on HealthCare.gov and state exchanges, which is a better buy, overall: a bronze plan, or silver? And will the IRS go after taxpayers next year who don’t repay the subsidies they got — but didn’t ultimately qualify for — in 2016? Here are the answers to some recent questions from readers.

I know that silver plans are the most popular type of coverage on the marketplace, but bronze plans are often a lot cheaper. Are there circumstances when I should consider buying bronze?

Bronze plans may make sense for some people, including those who are healthy and don’t expect to use much health care, as well as those who are sick and expect to use a lot of it. While the out-of-pocket spending limit for both bronze and silver plans is often similar, the monthly premium for bronze plans is generally significantly lower.

Look carefully at the total amount you might be responsible for paying out of pocket with each type of plan, in addition to the specifics of coverage and provider networks.

If you typically use minimal health care services, you may be willing to risk the higher deductible of a bronze plan, which is likely to top $5,700, compared with about $3,000 for a silver plan. (Overall, bronze plans pay 60 percent of health care expenses, on average, while silver plans pay 70 percent.)

And if you have an expensive condition and know you’re likely to blow through your deductible and hit your out-of-pocket spending limit for the year anyway, a bronze plan may also make financial sense.

In 2016, the average maximum out-of-pocket spending limit for bronze plans has been $6,631, while the average silver limit is $475 lower at $6,156, according to Avalere Health. (By law, the spending limit on any individual plan this year can be no higher than $6,850. Next year it rises to $7,150.)

Meanwhile, the average monthly premium this year for a 50-year-old is $408 for bronze plans, versus $496 for silver plans — a savings of $88 per month, or $1,056 annually, according to Avalere.

In this example, people who reach their out-of-pocket maximum during the year would each save $581, on average, if they were in a bronze plan instead of in a silver one.

“For people who have high health care spending, the bronze plan is often the cheapest out-of-pocket spending overall,” said Caroline Pearson, a senior vice president at Avalere.

There’s one important exception: If your income is less than 250 percent of the federal poverty level (about $30,000), you can qualify for a cost-sharing subsidy that reduces your deductible, copayments and out-of-pocket spending limit. But you must buy a silver plan in order to get the subsidy.

Still, Pearson says, for people who tend to have high health care costs, one potential downside of buying a cheaper plan with a higher deductible is the higher amount you’ll have to shell out up front. The plan pays 100 percent of your costs for in-network care — but only after you hit that out-of-pocket spending cap.

When I sign up for health insurance on the marketplace this year, is there any reason I shouldn’t underestimate my income to get a bigger tax credit? I thought the Internal Revenue Service couldn’t come after people for repayment.

When you apply for coverage on the marketplace you have to attest that you’re providing accurate information, otherwise you could face penalties.

Apart from that, you’re confused about a couple of things.

Most people must have health insurance or pay a penalty. This year, the penalty is the greater of $695 per adult, or 2.5 percent of income. If you don’t make that payment, the IRS can deduct it from your income tax refund, but it can’t use many other enforcement tools to collect the money.

However, tax credits for monthly health insurance premiums are handled differently. As you note, people with incomes up to 400 percent of the federal poverty level (about $47,000 for one person) can qualify for those credits to help pay for their premiums.

If you underestimate your income and receive too much in advance premium tax credits, you’ll generally have to repay the excess. If you don’t repay it, the IRS can use liens and levies to collect what it’s owed, and may charge interest and penalties to boot, says Mark Luscombe, principal federal tax analyst at Wolters Kluwer Tax and Accounting, a consulting and software provider for tax professionals.

And the exchange isn’t going to just take your word for it when you estimate your income. The marketplace will compare your estimated income to your tax filings and Social Security information — and will ask you for documentation if your estimated income for next year differs substantially from what’s on file, says Timothy Jost, an emeritus professor at Washington and Lee University School of Law in Virginia.

If you do get too much in tax credits, your repayment is generally capped at between $300 and $2,500, if your income is less than 400 percent of the poverty level. People with higher incomes have to repay the full amount.

As of last December, 1.8 million taxpayers had filed 2014 returns that entailed excess advance premium tax credits of $1.6 billion that was required to be repaid, according to a report from the Treasury Inspector General for Tax Administration. Most people repaid what they owed; only 39,000 of those taxpayers — 2 percent of the total — had unpaid assessments at the end of the year, the report found.

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

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