High deductible health plans are the new normal.

Just over half of employees this year have a health insurance policy with a deductible of at least $1,000, according to a survey of employers from the Kaiser Family Foundation.

It’s the continuation of a multiyear trend of companies passing more of the costs of employee health care back onto workers.

Overall, health insurance premiums for a family covered by an employer health plan rose an average 3 percent this year to $18,142. Of that, employees pay an average of $5,277.

Historically, that’s not much of an increase. But it still outpaces the rate of inflation, so it takes a larger chunk of worker income and employer profits.

“There’s been a gradual sea change in what insurance is for most Americans, from more comprehensive coverage to skimpier coverage,” says Drew Altman, president of the Kaiser Family Foundation.

Covenant Care, a Pensacola, Fla.-based hospice and home health care nonprofit, is one organization that has made the switch. About 450 of its 600 workers now have high-deductible health plans.

“At Covenant, we pay 80 percent of the costs of the plan and even at that point, there are some business decisions that need to be made regarding what we can afford to do,” says Pat Holtman, senior manager of human resources.

She says the company offsets some of that deductible by putting cash into accounts that workers can use for health care costs. And if employees participate in wellness programs, they get points to pay even more.

That includes doing a health risk assessment at the beginning of the year. “If they go online and do a wellness assessment, they can accrue points that way,” Holtman says. “If they’re non-tobacco users there are a certain number of points that are accrued there.”

Premiums have risen 20 percent since 2011, the Kaiser survey released Wednesday shows. They rose 31 percent in the previous five years and 63 percent in the five years before that.

With the continuous increases, companies like Covenant are getting creative, Altman says.

“Your typical employer is using everything in the toolkit to control their premiums,” he says. They use those wellness programs. They try to help workers manage their chronic illnesses.

“But if you want to bring down the premium increase quickly in any given year, the immediate step you can take is to increase deductibles and other forms of cost sharing,” Altman says.

Employers can lop about 20 percent off insurance premiums simply by raising deductibles from $200 to $1,000, says Dave Anderson, CEO of HealthNow Inc., which runs BlueCross BlueShield of Western New York.

Anderson says companies do think hard before they bump up deductibles because employees don’t like it.

“I would say no one goes there lightly,” he says. “Many employers have felt like they just had to go in that direction. They had to fix premium costs in some way.”

BlueCross BlueShield of Western New York offers its own employees a high deductible plan. And like Covenant in Florida, it encourages its workers to participate in wellness programs to knock down their share of the cost.

The company will pay $500 toward a $1,000 deductible if employees undergo a health risk assessment each year. Anderson says the risk assessment will help employees embrace more healthy behavior and stick with exercise and nutrition plans.

“We believe we’ll have that kind of overall reduction in our health care costs,” he says.

But Anderson says high deductibles raise troubling issues as well.

“And that is whether it is inherently disadvantageous to lower-income employees. And we struggle with that,” he says. “A $1,000 deductible if you’re making $100,000 is no big deal. If you’re making $30,000 a year, a $1,000 deductible is a big deal.”

In the future, Anderson says, he expects employers and insurance companies will have to address that inherent unfairness by offering health plans with deductibles indexed to workers’ income.

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Three years ago, Geoff Baird bought a drone. The Seattle dad and hobby plane enthusiast used the 2.5-pound quadcopter to photograph the Hawaiian coastline and film his son’s soccer and baseball games.

But his big hope is that drones will soon fly tubes of blood and other specimens to Harborview Medical Center, where he works as a clinical pathologist running the hospital’s chemistry and toxicology labs. In the near future, Baird and others say, drones could transform health care — not only in rural areas by bringing critical supplies into hard-to-reach places, but also in crowded cities where hospitals pay hefty fees to get medical samples across town during rush hour. By providing a faster, cheaper way to move test specimens, drones could speed diagnoses and save lives. “It’s superexciting to me,” Baird says.

The technology seems to be there. Drones are delivering pizza in New Zealand and taking condoms to parts of Ghana that lack reliable roads or access to birth control. Tech giants and big retailers, including Amazon and Wal-Mart, are testing drones for deliveries and pickups.

However, “blood specimens are not like a book or a shoe,” Timothy Amukele, an assistant professor of pathology at Johns Hopkins School of Medicine, said in a TED talk earlier this year. No one knew whether bumpy flights would hurt cells or otherwise make biological samples unsuitable for lab tests.

So Amukele and co-workers conducted several experiments to find out. In their first study, published in PLOS ONE last July, the team collected several hundred blood samples from healthy volunteers. They drove the samples to a flight field an hour northwest of Baltimore, packed half of them into foam containers and flew them around in a drone for up to 40 minutes. The other samples sat. All specimens went back to the lab for 33 routine tests. The results were the same for each group, suggesting samples stay intact during drone flights.

In follow-up analyses, drone transport also seemed safe for samples containing microbes and for donated blood. The microbial study was published in August in the Journal of Clinical Microbiology; a manuscript on the blood products study is under review. (Videos of each experiment can be found here.)

“The results don’t surprise me,” says Bill Remillard, chief technical officer at TriCore Reference Laboratories in Albuquerque, N.M. “But until you do the science, you just don’t know.”

TriCore handles nearly three-quarters of New Mexico’s clinical lab testing. And in a sparsely populated state, moving samples over large distances is expensive. TriCore spends $3.5 million per year. So after Remillard heard the results of Amukele’s first drone experiment at a meeting last summer, the two started discussing a possible pilot study using drones to transport lab samples in New Mexico.

While Amukele’s experiments show it’s feasible to move lab specimens with drones, pilot studies in real clinical settings are still needed to work out logistics. Questions include how to request a drone, where it would land, who would pick up the samples and how often a drone would need new batteries.

Safety is another concern. Some drones drop cargo with parachutes or other release mechanisms, making it harder for people to tamper with the vehicles. But as far as how safe drones are, “those data don’t yet exist,” Amukele says. Though millions of drones have been sold worldwide, “we don’t know how many crashes happen and how many are due to operator error,” he says. The Federal Aviation Administration is starting to collect this data.

It’s a promising development for an industry where legislation has lagged behind the fast-advancing technology. For years, the FAA had imposed a near-ban on commercial drones, only allowing them to fly if businesses applied for an exemption. But in June the agency announced a set of rules for companies to operate drones in the United States, and on Aug. 29 those regulations took effect. The FAA expects the number of registered commercial drones to jump 30-fold, from 20,000 to 600,000, within months.

“The rules had not been well defined. This is an attempt to define them,” says Lawrence Williams, who heads business development at Zipline, a Silicon Valley startup making drones for medical applications. Zipline is focusing much of its effort in Rwanda, where less crowded skies, relative to the U.S., make it easier to negotiate drone delivery of blood samples.

Another drone startup, Vayu, whose CEO is a co-author on the PLOS ONE drone study, is also dipping into the international arena. In July, the Michigan-based company did a demo flight in Madagascar, carrying specimens from a remote village to a lab for testing. Vayu makes a quadricopter plane capable of vertical takeoff — an appealing feature for hospitals with limited landing space.

While it’s easy to see how drones could improve health care in poor countries, Amukele thinks medical drone delivery could make a bigger splash in the U.S. Compared to Africa and developing countries, the U.S. does much more testing per person, he says, and many of the country’s 200,000 medical labs are collection-only sites that rely on central labs for testing. So “there are likely to be more [medical drone users] in the U.S. than anywhere else,” Amukele says.

As Zipline prepares to launch blood delivery drones in Rwanda, the company is also seeking regulatory approval for three projects using drones to bring medical supplies to underserved communities in the U.S.

One project would integrate drone delivery of medications with telemedicine appointments at a small clinic in rural Maryland. Another would use Zipline drones to link a large health care distribution center to hospitals and tribal clinics around Reno, Nev. And for the third project, the company would partner with a regional blood bank in Washington state, creating a plan to distribute blood to various hospitals and clinics in the event of earthquakes and other natural disasters.

Johns Hopkins was initially skeptical of Amukele’s experiments — the review board thought his first proposal was a joke — but now the university is giving the pathologist space and funds to hire a drone engineer and continue researching medical delivery drones.

In Seattle, Baird is working with Amukele and aeronautical engineers at the University of Washington on their own drone proposal. Ideally their test flights would take samples from Seattle Children’s to Harborview, a bustling facility that runs thousands of tests each day. However, that flight path would violate the FAA rule requiring drones to stay within the pilot’s line of sight. So the initial plan is to run 2-mile line-of-sight flights between the children’s hospital and UW Medical Center, Baird says.

Drones could be a huge help in poison emergencies, Baird says. In a typical scenario, a child gets rushed to the emergency room after accidentally swallowing some pills. Though routine tests can rule out some things, clinics often send samples to a centralized toxicology lab for confirmation and further testing. This can take hours. A drone could zip samples downtown in five to 10 minutes, Baird says, helping a child get diagnosed and receive medications more quickly.

He also envisions drones collecting samples from patients’ homes and taking them to the hospital. You could prick your finger and rub the blood onto a card that a drone could fly back to the lab for testing, Baird says.

In the meantime, though, Zipline’s U.S. projects remain on hold, awaiting the regulatory go-ahead, and the Seattle team continues studying maps and sketching flight routes for the small drone test it hopes to launch. The team has presented the plan to grant agencies and gotten positive responses — but no funding yet.

Like other technological advances, Baird suspects drones for medicine will “wait, wait, wait and then go very quickly.”

Esther Landhuis is a freelance science journalist in the San Francisco Bay Area. Follow her at @elandhuis.

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For the first time in her life, 26-year-old freelance designer Susannah Lohr had to shop for health insurance this year.

She called up a major insurer in the St. Louis area where she lives, and it offered her a plan with a hefty $6,000 deductible — that’s the amount she’d have to cover herself before the insurance kicks in.

When she balked, the salesman on the phone suggested that she could buy a “gap plan,” a separate policy for $50 a month to cover her deductible.

“After I got off the phone with him, I realized: That’s actually just insurance for my insurance,” she laughs.

Gap plans, used to cover out-of-pocket expenses like high deductibles, are becoming increasingly popular among consumers and businesses.

The rising price of insurance is driving the trend, explains insurance broker Ryan Hillenbrand, president of the Missouri Association of Health Underwriters.

“People see the prices of individual insurance and they say, ‘Boy, a $6,000 deductible seems really high, I don’t want something that gives me that much risk,'” Hillenbrand says. “That’s why [the gap insurance] market is heating up a little bit more.”

Gap insurance is in a category of insurance known as “limited benefit.” No matter how bad a person’s situation, the plan will only pay out a certain amount of money. “Mini-med” policies, now illegal under the Affordable Care Act, are another example of a limited benefit plan

Now, there’s renewed interest in gap plans. With monthly premiums on health insurance going up, more people are choosing cheaper, high-deductible options. In 2016, more than 90 percent of people buying insurance under the ACA chose plans with an average deductible of $3,000 or higher.

Next year, the cost of one of the most popular plans available under the Affordable Care Act could increase by 10 percent on average across the country. That comes on top of a 5 percent jump the year before.

When consumers see those prices, Hillenbrand says, “they get sticker shock.”

“If you don’t qualify for a subsidy, you’re bearing the brunt of all that cost,” Hillenbrand says. “And here come the gap plans.”

About 8 in 10 people qualify for some form of subsidy on the Obamacare exchanges, helping to make insurance more affordable for consumers.

Businesses, on the other hand, are facing those costs on their own. And for some businesses, especially smaller firms, gap plans can make a lot sense, says Alex Forrest, an insurance broker in South Carolina.

“The cost of health insurance is going up and businesses have been forced to deal with that by raising their deductibles or increasing out-of-pocket costs for their employees,” he says. “That stinks.”

With a gap plan, he says, companies can offer a package of health benefits that keeps out-of-pocket-expenses for employees down. And they still spend less than they would with higher-priced plans with lower deductibles.

Forrest says he’s seen more gap insurance products for businesses come to market in the past few years. They’re being marketed as a way to keep out-of-pocket expenses low for employees. This video explaining a plan called the “Premium Saver” boasts: “The only thing that’s really different for you is, now, you have two [insurance] cards instead of one.”

St. Louis footwear company Diba Imports, for example, purchases both a high-deductible health plan and a type of gap plan called ‘hospital indemnity insurance’ for its roughly 30 employees.

“It basically reimburses most of your deductible if you have an illness or injury that puts you in the hospital,” says Diane Butrus, the company’s COO.

Butrus says that Diba used to pay the deductibles directly for its employees, but as those deductibles started rising, eventually up to $3,000, “we couldn’t afford to do that anymore.”

The unpredictability was especially hard for a small company like Diba. The cost of covering employee deductibles swung widely year to year, hitting $25,000 one year when several employees needed serious care.

The hospital indemnity plan only costs the company just under $50 a month per employee – not exactly cheap at about $18,000 per year for the company – but at least Diba knows exactly how much it will spend on insurance every year.

“It’s been very good,” says Butrus.

Not everyone is bullish about gap plans, however, especially for individual buyers.

Health economist Deborah Chollet of Mathematica Policy Research, an independent research firm, says the insurance reforms in the Affordable Care Act were designed “basically to drive these kinds of creative insurance arrangements out of the market.”

Because gap plans aren’t major medical insurance, Chollet explains, they’re not regulated by the health care law and can avoid complying with consumer protections built into the law. So the companies providing gap insurance, she says, “can ask you about your health status, they can deny you coverage, they can do all of the kinds of things that the Affordable Care Act prohibits.”

Chollet says individuals might be better off getting an Obamacare plan through their state exchange, or at least checking to see if they qualify for subsidies, as 80 percent of consumers on the exchanges do.

That’s what Susannah Lohr ended up doing. It took her three full days on HealthCare.gov to find the best plan, but after her tax credit, her monthly premium is about $200 and her deductible is just $600.

“[It’s] a much better plan,” she says.

For people who are intimidated, overwhelmed or find the whole process of choosing a plan unmanageable, there are dozens of free health insurance navigators in each state—people you can talk to who will help you choose your coverage. It’s something Susannah Lohr wishes she had known about when she started searching for a plan.

Editor’s note at 5:20 p.m. ET: It should have been noted when this story was broadcast and published that until early this summer, Susannah Lohr was an employee of St. Louis Public Radio, which like KBIA is licensed by the University of Missouri. She and reporter Bram Sable-Smith have not worked together.

This story is part of a reporting partnership with NPR, Side Effects Public Media and Kaiser Health News.

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Gap health insurance plans are meant to cover one-time events. When the health care law required some form of major medical insurance, it was thought the need for gap coverage would disappear.

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The nation’s opioid problem comes with staggering physical and emotional costs to patients and families. But the financial burden on the health system has been harder to peg.

A report set to be released Tuesday shows a more than thirteenfold increase in spending by health insurers in a four-year period on patients with a diagnosis of opioid dependence or abuse.

From 2011 to 2015, insurers’ payments to hospitals, laboratories, treatment centers and other medical providers for these patients grew from $32 million to $446 million.

While the latest figure represents a small portion of the overall spending on medical care in the United States, the rapid rise is cause for concern, says Robin Gelburd, president of Fair Health, a nonprofit databank that provides cost information to the health industry and consumers.

“That really shows the stress on the health system and the impact on the individuals,” said Gelburd.

The Fair Health study found a sharp difference in how much insurers spend on individual patients with such a diagnosis.

On average, insurers spend $3,435 a year on an individual patient, but for those with an opioid dependence or abuse diagnosis, that amount jumps to $19,333. Those numbers reflect what insurers actually paid. The report also includes data on what providers charged, amounts that are lowered by their contracts with insurers.

The study, out Monday, builds on a study Fair Health released in early August that found a thirtyfold increase in the volume of insurance claims related to opioid dependence diagnoses between 2007 and 2014.

The latest study by Fair Health — part of a series — looked at amounts associated with claims billed by providers and paid by insurers for the types of medical services used.

Both studies use de-identified claims data from insurers representing more than 150 million insured Americans who either have insurance through work or buy coverage on their own.

There have been other efforts by several researchers to quantify the cost of the opioid problem on the overall economy, estimated in the tens of billions of dollars.

The new report adds to the available data “that it’s not just the human cost associated with the opioid crisis that is enormous, but also that the economic costs are staggering,” said Dr. Andrew Kolodny, senior scientist at Brandeis University. He didn’t work on the study.

The surge in spending on patients with opioid diagnoses is likely a combination of factors, the report notes. As media attention focuses on drug dependency, more people may be seeking treatment. At the same time, prescription and illegal use of narcotics may also be increasing.

The study found that emergency room visits and laboratory tests accounted for much of the spending.

Based on claims volume, the fastest-growing set of services in terms of utilization were for alcohol or drug therapy. Lab tests, including checks for barbiturate or opioid use, weren’t far behind.

Researchers didn’t use 2015 data for lab test costs, noting that a change in billing codes was made that increased the number of categories — and, in some cases, appear to generate higher charges by insurers. It is too early to estimate the long-term effects of the change, Gelburd said.

The report gives some examples of the changes, however. For example, one billing code for a test on opiate use commonly brought in a $31 payment from insurers prior to the change. The two billing codes that replaced it now are commonly paid at $78 and $156.

The new billing codes may reflect new technology in testing, said Gelburd. She said some observers speculate that the rapid increase in lab spending might reflect that, with more patients in therapy, the tests are being used to ensure they are taking their proper medications and not abusing narcotics.

But the spending might also reflect a growing use of very expensive urine and blood tests when less expensive ones would be sufficient, said Kolodny.

“I worry about profiteering,” said Kolodny. “We do need tests, but not the expensive ones. A lot of clinics are making extra money off these lab tests.”

The overall increase in spending across all types of medical services “is a societal issue,” said Gelburd, who says policymakers need to ensure that changes are made to address the problem.

“Are medical school curricula adjusting to recognize the growing need for these services? Are insurers increasing the number of providers in their networks to ensure sufficient access? Are consumers being educated? It’s an issue that has to be dealt with in all quadrants.”

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Julie Appleby is on Twitter: @Julie_appleby.

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Jessica Stefonik is grinning. She’s got a bounce in her step. Her cheeks are a little puffy and her speech is a bit thick.

“It feels weird right now, but I’ll get used to it,” she says.

What she’s trying to get used to is the feeling of having teeth.

On the day we met, Stefonik, a mom of three from Mosinee, Wis., got a set of dentures to replace all of her upper teeth, which she lost over many years to disease and decay.

Stefonik is just 31 years old.

She’s one of millions of people who are poor and live in rural America and have little to no access to dental care.

A study by the Federal Reserve found that a quarter of Americans went without dental care they needed in 2014 because they couldn’t afford it.

For those in rural areas, the problem is far worse. A 2015 report by the Pew Charitable Trusts found that people in rural areas are poorer and less likely to have dental insurance than their urban counterparts. They’re also less likely to have fluoridated water, and more likely to live in an area where dentists are in short supply. Those dentists that are there probably don’t take Medicaid, government health insurance for the poor.

“You’ve got a double whammy if you’re on Medicaid and you’re living in a rural area,” says Jane Koppelman, research director for the Pew Charitable Trusts’ dental campaign.

For years, Stefonik lived in pain from her cracked and decaying teeth. If she got to a dentist at all, they’d usually just pull one tooth and tell her to take better care of the rest.

She was on Medicaid, and in Wisconsin that included dental insurance. Wisconsin’s comprehensive dental benefit is considered one of the best in the nation. According to the National Academy for State Health Policy, four states don’t offer any dental insurance to Medicaid beneficiaries, and another 15 offer only emergency care.

Still, most dentists in Wisconsin, and across the country, don’t accept patients on Medicaid because they say the reimbursement rates are too low. The Wisconsin Dental Association says Medicaid pays only about 35 percent of the dentists’ costs.

“My teeth were pretty much rotting out to where I couldn’t brush them,” Stefonik says.

She tried to just gut it out, hiding her pain from her children so they wouldn’t worry about her and living with the gaping holes in her mouth. She ate only soft foods because anything else hurt too much.

“I’m hiding my smile, I’m hiding my pain and I’m trying to be happy, but I just found myself depressed,” she says.

Earlier this year she heard about the dental center run by the Marshfield Clinic. It’s about 40 miles from her home, takes all comers, and gives them comprehensive dental care for whatever they, or their insurance, can pay.

They pulled all the remaining top teeth in Stefonik’s mouth and fitted her for dentures. She paid nothing. The care was paid for by Medicaid.

Jessica Stefonik’s story isn’t unusual.

John O’Brien, a dentist and the clinic’s director of dental operations, says he sees about four or five new patients every day, and at least one of them needs more than half their teeth pulled.

When he told a 40-year-old hunter and fisherman at the clinic in Rhinelander Wis., that his periodontal disease was so bad that he needed all his teeth pulled, “He just broke down in tears,” says O’Brien.

“He couldn’t find someone in 20 years to care for his teeth,” O’Brien says. “There are just not enough dentists, so they can pick and choose who they want to treat.”

But that’s changing. Over the past 12 years, the Marshfield Clinic has opened 10 state-of-the-art dental centers to serve the rural poor.

The clinics are the brainchild of Greg Nycz, executive director of Family Health Center of Marshfield, a string of medical clinics for the poor run by the Marshfield Clinic, a major medical center in central Wisconsin. Through that work, Nycz says, he saw people in pain with broken and missing teeth all the time. And he got calls from desperate people looking for help. One from a young mother haunts him to this day.

“Her child was screaming in pain, alternately screaming and sobbing in the background,” he recalls on a recent afternoon.

Nycz talked at length with the mom and learned this had been going on for weeks. She couldn’t find a dentist to help.

“As we talked it became very clear that she was viewing herself as a failure as a mother because she couldn’t take that pain away from that child, and other mothers could,” Nycz says, choking back a sob at the memory. “And I said, ‘No more. We’re going to fix this.’ “

That was in 2002. A year later, the Marshfield Clinic opened its first dental center in Ladysmith, Wis.

Nycz underplays the difficulty in getting this job done. He tells me that state lawmakers were on board because they too got calls like the one he described. So were members of his board, who knew that access to dental care was a crisis in the region.

He has lobbied successfully for changes in laws, for federal grants, and even for low-interest loans from the Department of Agriculture’s rural development program. “We’ve been very lucky to have a supportive Congress,” he says.

One key to the clinics’ survival is a law that allows community health centers like those the Marshfield Clinic runs to be reimbursed their full costs for caring for Medicaid patients, on the condition that they also care for people who have no insurance.

But Nycz’s relentless drive is also a key. “There are a lot of hoops we have to jump through to do this work,” he says.

The Marshfield Clinic centers aren’t unique. Federal law requires community health centers that get certain types of government support to offer dental care. But the scale of Marshfield’s operation is unusual. Its 10 clinics employ 45 dentists, three oral surgeons and 41 hygienists. They have a budget of nearly $44 million and can serve 60,000 patients a year.

Mary Kate Scott, a management consultant who has done extensive research on dental centers that cater to the poor, says Marshfield is ahead of the curve. But she says more states are seeing high-quality dental centers that serve the poor open up, in part because of the expansion of Medicaid under the Affordable Care Act.

Nycz grew up outside Milwaukee. His family didn’t have much money. “McDonald’s back in the day — 15-cent hamburgers — that was a big treat for us,” he says.

He’s not your typical hospital executive. His hair is a bit too long. He’s big, with a quiet demeanor that barely tames what is a missionary-like zeal to ensure that the poor get quality health care — and dental care is included in that calculation.

His office is piled high with papers. Stacks 1 to 2 feet high cover his desk and extend to the floor. He has a dog-eared copy of a 16-year-old surgeon general’s report on the sorry state of oral health in America. Its pages are highlighted and marked with Post-its. He actually had it signed by the author, and grins when he shows me the inscription.

That first dental clinic in Ladysmith was supposed to be a modest affair. They’d work with a dentist who was already in town and put up money so he could care for those who couldn’t pay. Maybe they’d add a chair and bring in one more dentist.

The plan was to announce the endeavor just after Labor Day 2002. “On Monday a tornado hit Ladysmith. Rendered his dental facility nonfunctional,” Nycz recalls.

It could have been a disaster, but Nycz saw an opportunity. First he and his staff set up a makeshift clinic in a church. Operations manager Terri Kleutsch, who runs all 10 dental clinics, called it a MASH unit.

Then Nycz went to the Family Health Center’s board and asked for more money. A lot more. “If we put a big chunk of our reserves into this effort, we could build a state-of-the-art facility that the community can be proud of,” he told them.

The board agreed and committed a large chunk of its reserves to the effort, and the state gave them a grant as well.

A year later, a clinic with 17 treatment rooms, big enough to accommodate five dentists and five hygienists, opened on Miner Street in Ladysmith.

In that first year, people came from across Wisconsin, from 42 different counties. Some drove four hours to get there. Some arrived by the busload.

And that’s still happening. Anyone who walks in the door of any of the 10 clinics is welcome and gets high-quality care.

“We don’t leave vets behind, we don’t leave people with HIV/AIDS behind, the disabled, exceptionally heavy people. We want everybody to have access,” Nycz says.

“Greg is a visionary,” says Jane Koppelman of Pew. “He’s taking what we know about science and he’s applying it to practice.”

What we know is that oral health is closely tied to overall health. Research shows bad teeth are linked to a host of problems, including heart disease and premature birth. They can aggravate diabetes and spread infection to the heart.

“When you treat the gum disease, there are fewer complications and lower costs in treating people like diabetics and people with heart disease,” Koppelman says.

At the Marshfield Clinic centers, dental care is treated as another part of general health care. Dental and medical records are combined. Patients who come to the dentist get their blood pressure and blood sugar checked. Patients who are there for a filling may end up being sent to the hospital for a stress test or diabetes followup.

And doctors at the health centers routinely look into patients’ mouths. If there’s a problem, they refer them to the dentist.

Nycz and his colleagues think that providing dental care not only makes people healthier, it can also make them more financially secure. That’s because, very simply, bad teeth can make it hard to get a job.

“You’ve got a mouthful of broken, cracked and decaying teeth, your ability to contribute to society is impaired, and your options are impaired,” Nycz says.

In rural Wisconsin, many manufacturing jobs have disappeared and been replaced with service jobs that often aren’t open to people with rotten or missing teeth. The Marshfield Clinic dental centers work with job placement programs to ensure that if someone has an interview and needs dental work to be ready, they will fit the person in and get the work done in time.

For Jessica Stefonik, just the ability to smile again and enjoy normal social events may be enough.

“I haven’t smiled in probably eight years. I mean a good smile,” she says. “And I’m very excited to be able to go out to eat with my family and not have soup,” she adds with a laugh.

Armed with her new teeth and a paper bag carrying denture adhesive and a new toothbrush, she walks to the lobby to see her daughter, Kylie.

“Hey, Kylie. Did you see my teeth? Do you like ’em?” Stefonik asks the blond girl sitting quietly in a corner chair.

The little girl whispers back. “They’re awesome.”

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What if you had cavities and gum disease and couldn’t find a dentist to treat you? That’s the reality for millions of poor people who live in rural areas and have little or no access to dental care.

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When it comes to navigating the intricacies of health insurance, Cassie Ray considers herself a pro. She actually reads her policy, including the fine print.

So when the 57-year-old from Fairfield, Calif., needed routine follow-up surgery after a mastectomy, she did her homework. “I looked up on my insurer’s network and made sure the outpatient facility that I was being referred to was in my network,” Ray says.

A month later, she received an unwelcome surprise: a $580 bill for an out-of-network anesthesiologist.

“I called the facility back, and at first, I felt like, this has to be a mistake. They’ll fix it,” Ray says.

Instead, the clinic said her only option was to negotiate the bill directly with the doctor. Ray’s experience illustrates the surprise of balance billing.

The unexpected charged come when patients are treated by an out-of-network provider at an in-network facility.

After several failed attempts in recent years, the California legislature last week passed AB-72, which aims to protect patients’ pocketbooks when they’re hit by these surprise bills. Gov. Jerry Brown has until the end of September to sign or veto the legislation. He is expected to sign it into law.

A 2015 Consumers Union survey suggests the surprise bill phenomenon is fairly common. It found nearly 1 in 4 Californians who’d had hospital visits or surgery in the prior two years reported receiving an unexpected bill from an out-of-network provider.

“They can range in price from a hundred dollars to many thousands,” says Betsy Imholz, special projects director for Consumers Union. “So it’s a big financial burden on consumers.”

In Ray’s case, she says she tried to speak with a manager at the outpatient clinic, but no one returned her repeated calls. Then the bills stopped coming, so she figured all was resolved. Soon after, however, her bill was sent to collections.

“I was so frustrated,” she recalls. “I was just in tears as I was dealing with it.”

Ray says it took about seven months of wrangling before her insurance company finally paid the bill and she was able to clean up her credit rating.

“My immediate response was, there does need to be a law to fix this,” says Ray. “This is so wrong.”

The legislation, by Assemblyman Rob Bonta (D-Oakland) and six colleagues, would limit a patient’s financial obligation to no more than what he would have owed if the provider had been in-network.

While agreeing that “patients should never have surprise bills,” Dr. Karen Sibert, president-elect of the California Society of Anesthesiologists, says her organization and a number of other specialty medical groups oppose AB-72.

At issue, Sibert says, is the bill’s formula for paying doctors who fill the gap left when insurance companies don’t have enough providers in their networks. The legislation would set the payment rate at either the amount the insurer normally pays a doctor on contract for such services or 125 percent of the Medicare rate, whichever is greater.

That’s insufficient, argues Sibert. “It’s a problem because it removes any incentive for insurance companies to reach fair contracts with physicians.”

Without such an incentive, she says, insurance companies will continue to stick consumers with inadequate provider networks.

The powerful California Medical Association agrees with Sibert about the bill’s payment formula, but it has shifted its position on AB-72 from opposed to neutral, says Janus Norman, the Association’s vice president of governmental affairs.

There are a few reasons for the change of heart, he says. First, the bill would create stricter oversight of how in-patient services are delivered, and it would allow for tougher regulations on insurers if the state finds their provider networks to be inadequate.

The provision regarding tougher regulations, “is one improvement that AB-72 included that prior legislation did not,” he says.

In addition, the measure would give out-of-network doctors the chance to appeal payment disputes with insurers through an independent third party, and the decision would be binding, another important change from previous versions of the bill, Norman says.

The California Association of Health Plans and the Association of California Life and Health Insurance Companies don’t have a formal position on AB-72, according to an analysis by the Assembly Health Committee. Instead, they have expressed “concerns” about the measure, the committee said.

“While they laud the authors’ efforts to protect consumers from balance billing,” the analysis says, the insurer groups worry that the legislation might lead to higher premiums and cost-sharing, and that the bill’s dispute resolution process might spark more lawsuits between providers and health insurance firms.

Anthony Wright, executive director of Health Access California, a consumer health care advocacy coalition, says Gov. Brown took an interest in the legislation.

“The governor’s office did provide input during the negotiation process and we are hopeful that he will sign it,” he says.

Consumers Union’s Imholz says the California Medical Association’s neutral position on the legislation was key in getting AB-72 across the finish line.

She predicts that if Brown signs the measure, a number of other states now considering similar protections against surprise bills will likely follow suit next year.

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

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Almost half of all Americans take prescription painkillers, tranquilizers, stimulants or sedatives, according to results of a federal survey released Thursday. The prevalent use of these drugs could help explain why millions of Americans end up misusing or abusing them.

Last year, for the first time, the government’s National Survey on Drug Use decided to ask the people it interviewed about all uses of prescription medicines, not just inappropriate use. The survey found that 119 million Americans age 12 and over took prescription psychotherapeutic drugs. That’s 45 percent of the population.

Of those, about 19 million Americans didn’t follow a prescription. Most misuse involved people who acquired the drugs from friends or family. More than a third had a prescription but took those drugs excessively. And about 5 percent bought drugs from a dealer or stranger.

All told, 16 percent of all prescription drug use was actually misuse, according to the report.

There’s no question that these drugs help alleviate pain and suffering for millions of Americans. But it’s also clear that the system encourages overuse.

“Any of us go to the doctor and feel like we don’t get our money’s worth if we don’t come out with a prescription, right?” Kim Johnson told Shots. She is director of the Center for Substance Abuse Treatment at the federal Substance Abuse and Mental Health Services Administration.

“Just like any drug, the more it’s out there, the more it’s available, the more likely it is to be abused,” she said. And many of these drugs pose an additional risk because of their physical effects, including in some cases their addictive properties.

The Centers for Disease Control and Prevention is trying to reform prescribing practices, particularly for opioid drugs, to reduce the overuse of these pain medications. The new survey also documents the dire need for affordable and accessible treatment options.

“One in 12 people aged 12 or over needed treatment for substance use disorder, yet nearly 90 percent of those people didn’t get specialty treatment that could have helped them toward recovery,” said Kana Enomoto, SAMHSA’s principal deputy administrator, at a news conference.

That need for treatment pertains not just to prescription drug abuse but to street drugs such as heroin.

“We need to expand access to treatment and we need to do it now,” said Michael Botticelli, director of the White House Office of National Drug Control Policy. “Because, like every other disease, people who want treatment should be able to get it. And it should not be dependent on where they live or how much money they have.”

President Obama’s budget for fiscal year 2017 called for more than $1 billion to expand access to drug treatment, but Congress has not acted on it.

You can email correspondent Richard Harris.

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Rising concerns about spending on prescription drugs that treat rare diseases are overblown, according to an analysis published Wednesday in the journal Health Affairs.

“We wanted to focus on the true impact of orphan drugs,” said Victoria Divino, a senior consultant at IMS Health and an author of the study. Researchers at IMS Health, a health care analytics firm, and drugmaker Celgene Corp. looked at U.S. pharmaceutical spending from 2007 to 2013 on more than 300 drugs that had orphan approval under the 1983 Orphan Drug Act.

The Orphan Drug Act has long been considered a success for encouraging the production of hundreds of drugs for rare diseases. But the law’s very success has raised economic concerns as the number of high-priced drugs for rare diseases has grown.

The review found that orphan drug spending in the United States totaled $15 billion in 2007 and $30 billion in 2013, an increase from 4.8 percent of total pharmaceutical spending to 8.9 percent. The current study projects orphan drug spending will remain fairly stable as a proportion of total drug spending. That stands in contrast to other published reports that estimate orphan drugs will account for 20 percent of worldwide spending on drugs (other than generics) by 2020.

The rise in orphan drug spending since 2007, Divino said, was caused by an increase in the number of orphan drugs approved by the Food and Drug Administration. The number of orphan drug approvals increased from 16 in 2007 to 33 in 2013, the analysis’ time period.

The Health Affairs article is the latest in a growing debate about the causes of high prescription drug prices and how orphan drugs may play a role. Drugs that win orphan approval have been cited for commanding premium prices, costing up to $300,000 per year or more, according to market research reports.

The Orphan Drug Act provides a seven-year exclusivity period that blocks competition and other financial incentives to companies that develop drugs for diseases that affect fewer than 200,000 people.

The pharmaceutical industry’s interest in orphan drugs has escalated in recent years and, increasingly, doctors and researchers have raised questions about unintended consequences of the act.

Celgene has been one of the top beneficiaries of the orphan drug law. The company’s flagship drug Revlimid, which has orphan status for multiple myeloma and many other cancers, had sales of $5.8 billion in 2015. Evaluate Ltd., a London-based research firm, forecasts that Celgene will become the No. 1 orphan drug company in world, as measured by sales, in 2020.

“When those financial incentives become sort of an investment opportunity to take advantage of the Orphan Drug Act. That’s a huge, huge concern,” said Clare Krusing, a spokeswoman for America’s Health Insurance Plans, a national association for health insurance companies. AHIP released a paper in August that questioned prices on orphan drugs when they were being used outside of their approved orphan indication.

For the Health Affairs paper, Divino and her team narrowed their analysis to orphan drug spending on drugs when they were used only on the rare diseases they were approved to treat under the act. The researchers used a database estimated to represent 98 percent of overall U.S. sales.

“The number of orphan drugs is increasing but when we look at this line of the actual spending and the forecast as well … yes, there is growth but it’s a consistent linear trend,” Divino said.

Still, the authors’ write, “in a broader context, drug expenditures are minimal when considered as part of total health care expenditures.” Total orphan drug spending represented approximately 1 percent of total U.S. health care spending, according to the authors.

Divino said the study’s focus was on aggregate spending and they didn’t look at the effect of orphan drug prices on individual patients.

In an email statement, the pharmaceutical industry trade group PhRMA, said the study “reinforces that the overall impact of orphan medicines on payer budgets is relatively small and contrary to rhetoric, the percentage of medicines with both orphan and non-orphan indications is small.”

But AHIP and others say that not including the cost of orphans when they aren’t used to treat rare diseases skews the pricing issue for patients.

“It’s not really the true orphans we worry about. It’s about the other types of gaming and abusing the orphan drug act which drives up expenditures,” AHIP’s Krusing said.

Researchers at Johns Hopkins Medicine called on lawmakers last year to close loopholes in the act, saying the law’s financial incentives encouraged high prices and motivated companies to apply for orphan designation even when a drug is known to treat more common conditions.

The paper, published in the American Journal of Clinical Oncology, noted that seven of the top-10 selling drugs worldwide in 2014 had received orphan status. Those listed included popular drug such as Crestor, a cholesterol fighter, and Humira, for rheumatoid arthritis and Crohn’s disease.

“There are a lot of factors I think that have come up in pricing in general, but what people are getting a glimpse of is the sheer greed,” said Dr. Martin Makary, an author of the 2015 paper and professor of health policy at Johns Hopkins School of Public Health.

Kaiser Health News is an editorially independent news service supported by the nonpartisan Kaiser Family Foundation. Follow Sarah Jane Tribble on Twitter: @sjtribble.

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