Stacey McHoul left jail last summer with a history of heroin use and depression and only a few days of medicine to treat them. When the pills ran out she started thinking about hurting herself.

“Once the meds start coming out of my system, in the past, it’s always caused me to relapse,” she said. “I start self-medicating and trying to stop the crazy thoughts in my head.”

Jail officials gave her neither prescription refills nor a Medicaid card to pay for them, she said. Within days she was back on heroin — her preferred self-medication — and sleeping in abandoned homes around Baltimore’s run-down Sandtown-Winchester neighborhood.

Thousands of people leave incarceration every year without access to the coverage and care they’re entitled to, jeopardizing their own health and sometimes the public’s.

Advocates for ex-convicts held high hopes for the Affordable Care Act’s Medicaid expansion that promised to deliver insurance to previously excluded single adults starting in 2014, including almost everybody released from prisons and jails.

Many former inmates are mentally ill or struggle with drug abuse, diabetes or HIV and hepatitis C infection. Most return to poor communities such as West Baltimore’s Sandtown, which exploded in violence a year ago after Freddie Gray died from injuries sustained in police custody.

But Maryland’s prison agency, which three years ago said it was “well positioned” to enroll released inmates in Medicaid, is signing up fewer than a tenth of those who leave prisons and jails every year, according to state data. Few other states that have expanded Medicaid under the health law are doing any better, specialists say.

Officials of the Maryland Department of Public Safety and Correctional Services say they do the best they can with limited resources, enrolling the most severely ill in Medicaid while letting most ex-inmates fend for themselves.

“We are battling, every one of us,” to maximize coverage, said prison medical director Dr. Sharon Baucom, pointing to efforts to train sign-up specialists, get Medicaid insurance for hospitalized inmates and share information on mentally ill inmates with other agencies.

“There are handoffs that could be improved,” she said. “With the resources that we currently have, and the process that we have in place, we could do more — and we just need some more help.”

Coverage under Medicaid was seen as an unprecedented chance to transform care for ex-inmates by connecting them to treatment, reducing emergency room visits, controlling disease and putting them on a path to rehabilitation.

As many as 90 percent of people leaving prisons and jails are eligible for Medicaid in states such as Maryland that expanded the federally supported program for low-income residents under the health act, experts estimate. The law gave states the option of extending Medicaid coverage to all low-income adults under 65, not just the children, pregnant women and disabled adults who were mainly included before.

Sickest Inmates Are First In Line

Some 12,000 of Maryland’s 21,000 prison inmates are designated at any given time as chronically ill with behavioral problems, diabetes, HIV, asthma, high blood pressure and other conditions, according to prison officials. But given limited means and the already tall order of connecting emerging prisoners with transportation, shelter and employment, the system must focus on enrolling the very sickest, Baucom said.

“It’s a shame to have to make that call,” she said.

Dr. Rosalyn Stewart saw what happened to many chronically ill ex-offenders when she ran a recently completed pilot program to enroll former inmates in Medicaid and get them treatment and shelter.

“People frequently ran out of their medications and did not have access to the care they needed,” said Stewart, an associate professor at the Johns Hopkins University medical school.

McHoul, 40, spent two short stays last year in Baltimore’s Women’s Detention Center. The first time the facility released her without Medicaid coverage. Shortly afterwards she landed in a hospital with an inflamed esophagus. She got out after a second jail stay in August without knowing the hospital had enrolled her in Medicaid between incarcerations, she said.

At neither time did she have more than two weeks’ supply of any medication, including Depakote, a mood stabilizer, she said. For some prescriptions there was less than a week’s store.

“It was whatever was left in the blister pack,” said McHoul, who’s now in a Baltimore drug treatment program. “It’s like, ‘Here’s your supply. Sign this that we gave them to you. See you later.'”

State policy is to give exiting prisoners 30 days’ worth of medicine. But a court ordered McHoul released shortly after she was arrested the second time, which didn’t give the jail enough time to prepare medications, said a corrections spokesman.

A Burden For Emergency Departments

There are many Stacey McHouls.

“Maybe somebody needs prescription services and they’re not enrolled and they don’t know where to go,” said Traci Kodeck, interim CEO of HealthCare Access Maryland, a nonprofit that connects consumers to coverage and has worked with the prison system. “Absolutely it happens. Many of them will end up in the emergency departments if we don’t attempt to connect them to services prior to release.”

Mark Pruitt, 46, was released from a Baltimore facility in October with no Medicaid card and a craving for heroin, which he said he had used before he was incarcerated for a parole violation.

He desperately wanted to enter a drug treatment program, but signing up for Medicaid to pay for it was going to take weeks — far longer than he could wait.

“I knew what I wanted. I wanted help,” he said. “I really wanted help. But it’s a struggle when you’re broke — no money, no insurance, feeling defeated. Where do you turn?”

If administrators at a Baltimore recovery facility hadn’t gotten him enrolled in Medicaid, he said, “I think I’d be dead.”

From January 2014, when the Medicaid expansion took effect, through March of this year, Maryland released almost 16,000 people sentenced to prison or jail, according to state data. Thousands more cycle in and out of jails each year without being convicted.

But the corrections department said it enrolled only 1,337 released inmates in Medicaid from the beginning of 2014 through late March. Another 1,158 prisoners joined Medicaid over that time when they were hospitalized. (Medicaid covers inmates if they spend 24 hours as hospital inpatients; most return to prison.)

Many ex-prisoners are enrolled only when they experience a crisis and end up in an emergency room — the kind of expensive care health officials are trying to reduce. The law requires hospitals to treat emergency cases regardless of insurance coverage. They can retroactively sign those patients for Medicaid.

‘They Don’t Want To Do The Paperwork’

Monique Wright, 35, got out of Jessup Correctional Institution last fall and began suffering acute head and neck pain caused by scoliosis, a spine curvature. Without Medicaid coverage or a primary care doctor, she said she had to seek emergency care at Johns Hopkins Bayview Medical Center.

“It’s the paperwork” that keeps prison officials from making sure people like her have Medicaid upon release, Wright said. “They don’t want to do the paperwork. They don’t have the staff to do the paperwork.”

Advocates wonder why the corrections system is so poor at enrolling what, they often point out, is “literally a captive audience.”

“They’ve had them housed for the past 10, 15 years,” said a frustrated Andre Fisher, a case manager for ex-inmates at Druid Heights Community Development Corp., a nonprofit in West Baltimore. “What’s so hard about it?”

Enrolling inmates in Medicaid can take weeks, prison officials said. Sometimes the card doesn’t arrive until after they’re out. Computer problems slowed signups in late 2014.

One mistake made by Maryland and most other states is not considering inmates for Medicaid until their release dates approach, said Colleen Barry, a professor at the Johns Hopkins Bloomberg School of Public Health who has studied the process.

“It’s a bad way to do it because you’re getting a very small number” of enrollees by waiting, she said. A better alternative is to enroll inmates when they are booked, as Chicago’s Cook County Jail has demonstrated, she said. Those incarcerated are generally ineligible for Medicaid, but putting them in the system when they enter makes it easier to trigger coverage when they leave, she added.

Ex-Inmates Struggle To Get Medicaid Without Help

If it’s hard for the prison system to enroll inmates, it’s even harder for the individuals to enroll themselves. Those who emerge without Medicaid face a maze of applications, bus trips, phone calls and queues if they want to sign up. Many don’t bother.

For most leaving incarceration, “it’s up to you to go there, make sure you get your health insurance,” said Jamal McCoy, 21, who was living with family in West Baltimore on home detention before he was released. “Most people don’t go. Some people take it easy when they get home.”

Those who try often find that lack of identification is the first challenge. To prevent fraud, Maryland and other states require Medicaid applicants to show verified Social Security numbers.

But jails frequently lose inmate IDs, say prisoners and enrollment officials. Those locked up for years are non-persons for much of the system, with no credit records or driver’s licenses.

That can mean delays of many weeks when released prisoners are especially vulnerable. Gaps in coverage and care of even a few days after fragile patients leave the corrections health system can make the difference between life and death.

“If you’re the diabetic that hasn’t been compliant with your medication, you need your medication now,” said Henrietta Sampson, director of treatment coordination at Powell Recovery Center, a Baltimore addiction recovery agency that works with ex-inmates. “You can’t wait two weeks because you may drop dead.”

Compared with the rest of the population, ex-prisoners in Washington state were a dozen times more likely to die in the first two weeks after release, according to research by Dr. Ingrid Binswanger, lead researcher for Kaiser Permanente Colorado’s Institute for Health Research. Drug overdose, cardiovascular disease, homicide and suicide were the leading causes of death.

“It’s very important to manage that transition, to make sure people have continuity of care,” she said. (Kaiser Permanente has no relationship with Kaiser Health News.)

Yet in some cases the prison system has stymied outside groups trying to arrange inmates’ coverage. Stewart’s group repeatedly sought permission — “continuously, for about three years,” she said — to meet vulnerable prisoners inside the facility to get an early start on enrollment and post-release appointments. It never happened.

Baucom blamed the problem on “competing priorities” and staff turnover.

Acceptance into Medicaid by the state isn’t the end of the story. Released inmates then must enroll in a private managed care organization hired by Maryland to provide coverage. That can take weeks longer.

Even when insured, ex-inmates face the same barriers to care experienced by other low-income Baltimoreans — or worse.

Many prison inmates are infected with hepatitis C, which can cause liver damage or cancer over time. But the high cost of curing the disease has prompted Maryland’s and other Medicaid programs to limit access to treatment to those whose livers are already compromised.

“I guess I got to wait until damage is done to my liver,” said William Carter, 50, adding that prison officials initiated Medicaid enrollment when he got out last year.

Released prisoners often have no idea that some Medicaid managed-care contractors allow them to use only certain doctors and pharmacies.

“So a patient goes to Walgreens or wherever to fill something and it’s like, ‘That’ll be $150,'” because he should have gone somewhere else, said Stewart. “They don’t understand what the problem was.”

Even checking all the right boxes sometimes isn’t enough for ex-inmates, who bear the double stigma of poverty and a criminal history.

One released prisoner got an appointment to renew his mental health prescription with a facility in Carroll County, Maryland — his home — that also accepted his Medicaid card, said Baucom. After the clinic learned he had a prison record it cancelled the visit.

“It’s not enough to have a card,” Baucom said. “You’ve got to have access.”

Neighborhoods are at risk when former inmates with chronic illness return.

“You really need to think about this as a public health issue,” said Scott Nolen, director of drug treatment programs for the Open Society Institute–Baltimore, a nonprofit that works on criminal justice policy. “There is transmission of communicable diseases that happens in prison, in confined spaces. And now those folks are coming back into communities, and we want to make sure they get health care.”

In few places is the burden greater than Sandtown-Winchester. Gray, 25, died of spinal injuries that prosecutors filing manslaughter and assault charges blamed on police who arrested him.

The Justice Policy Institute, a nonprofit, called Sandtown “ground zero for the use of incarceration” in Baltimore last year, estimating that nearly one resident in 30 is in prison.

At the same time, three West Baltimore ZIP codes including Sandtown showed the highest rates of HIV infection in Maryland in 2014, according to hospital data from the Maryland Health Services Cost Review Commission obtained and analyzed by Kaiser Health News and Capital News Service.

The corrections department could use more computers, release planners and other enrollment resources, Baucom said.

“If you do the checkoff list, we’ve checked off everything we can do,” she said, noting efforts not only to increase enrollment capacity but cooperation with the Maryland motor vehicle agency to get inmates state IDs.

Jesse Jannetta, a specialist at the Urban Institute in prisoner re-entry, believes Maryland’s low signup rate “is not unusual” in other states. A study published in Health Affairs found prisons and jails nationwide had enrolled 112,520 people in Medicaid from late 2013 up to January 2015, although the authors believe the actual figure was higher.

Federal and state prisons released 636,000 people in 2014, according to the Justice Department. Millions more are estimated to cycle through jails each year.

Few independent experts expect Maryland — let alone most other states — to come anywhere close to full enrollment of emerging inmates anytime soon.

“It’s fair to say we’re just at the tip of the iceberg” in prisoner enrollment, said Johns Hopkins’ Barry, a co-author of the Health Affairs study. “Maryland is always an innovator. If Maryland is still at the cutting edge of how to do this, many areas of the country don’t have any of these types of programs in place.”

Kaiser Health News is a national health policy news service that is part of the nonpartisan Henry J. Kaiser Family Foundation.

This story came from a partnership with The Baltimore Sun and Capital News Service, which is run by the University of Maryland’s Philip Merrill College of Journalism. KHN reporter Shefali Luthra and CNS reporters Catherine Sheffo, Daniel Trielli, Naema Ahmed and Marissa Laliberte contributed.

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Some people with cancer, HIV and multiple sclerosis have better access to high-cost specialty drugs in marketplace plans this year, yet a significant proportion of these plans still place many expensive drugs in cost-sharing categories that require the highest patient out-of-pocket costs.

The report released Tuesday by Avalere Health, a consulting firm, examined how silver-level plans handled 20 classes of medications that are used to treat complex and expensive diseases such as HIV, cancer, hepatitis C and bipolar disorder.

Health plans generally place covered drugs into tiers. Generics and preferred brand-name drugs are in lower tiers with lower cost sharing, while higher-priced drugs are often placed in tiers that require patients to pay a percentage of the cost of the drug rather than a flat copayment.

The study found that for five classes of drugs — two used to treat cancer, two for HIV and one class of multiple sclerosis drugs — fewer plans in 2016 placed all the drugs in the class in the top specialty drug tier with the highest patient cost-sharing requirements or charged patients more than 40 percent of the cost for every covered drug in the class.

For example, in 2015, 57 percent of silver marketplace plans put all cancer drugs called anti-angiogenic agents (which inhibit the growth of blood vessels) in the top specialty tier. In 2016, that dropped to 50 percent. Last year, a quarter of silver plans charged patients more than 40 percent coinsurance for every drug in that class. In 2016, 15 percent of such plans did so.

Likewise, 14 percent of 2015 silver plans placed protease inhibitors, a class of HIV drugs, in the top tier, compared with 10 percent in 2016. The percentage of plans charging more than 40 percent coinsurance for those drugs dropped to 6 percent in 2016 from 9 percent the previous year.

The changes are likely driven by protests and legal challenges from patient groups and from increased regulatory oversight, said Caroline Pearson, a senior vice president at Avalere. For example, California next year will prohibit insurers from placing most or all of the drugs for a specific condition in the highest cost tier. In addition, the federal Department of Health and Human Services has signaled in guidance to insurers that placing all or most of the drugs in a high-cost tier may be discriminatory.

“There’s been a lot of discussion about discriminatory drug benefits, and that attention has moved health plans to make changes,” said Pearson.

Carl Schmid, deputy executive director at the AIDS Institute, an advocacy group, said of the study results: “It does show some progress, which we are pleased to see.”

The organization drew attention to the problem in 2014 when it filed a complaint with the Office for Civil Rights of the federal Department of Health and Human Services charging that the plan designs of four Florida health plans were discriminatory because they discouraged people with HIV/AIDS from enrolling. The Florida Office of Insurance Regulation subsequently set maximum limits on cost-sharing for HIV medications in marketplace plans.

“We can celebrate this,” Schmid said, but “our goal is zero, there should be no plans” that place all the HIV drugs in a class in the top tier and charge high coinsurance.

Please contact Kaiser Health News to send comments or ideas for future topics.

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It’s been nearly two years since the Department of Veterans Affairs came under fire for the amount of time veterans had to wait to see a doctor. The agency scrambled to find a fix, including allowing vets the option of seeing a private doctor via a program they call Veterans Choice.

But the fix isn’t working, so some VA clinics are coming up with other ideas to reduce wait times. In the city of Clarksville, Tenn., the VA clinic decided it simply couldn’t take any new patients.

The facility is so overcrowded that unused wheelchairs are being stored in the hall, and nurses are stationed in what used to be a corridor. There’s even a computer set up in what used to be a bathroom.

“This is actually a converted toilet,” says Robert Lim, who works for the Tennessee Valley VA health care system, which serves tens of thousands of veterans in Tennessee and parts of Kentucky. “We’re literally like sardine cans in here. You can’t go around any place without bumping into somebody.”

Lim oversees primary care clinics like the one in Clarksville. He’s not one to sugar coat the situation. Yes, he says, this is pretty bad.

“If you go into Clarksville, you will actually wonder: ‘How in the world did they get things done?'” Lim says.

One problem is the building just isn’t arranged well for a growing doctor’s office. There are too many hallways and not enough rooms. It opened eight years ago, and Lim says it was the best space the VA could find to lease at the time.

There are also more patients than eight years ago, because the veteran population here has been growing. It’s right next door to Fort Campbell, one of the largest military bases in the country.

So in 2014, wait times at the Clarksville clinic were rising — at a time when Congress and the VA were clamoring for clinics to see patients faster.

“Patients were calling in and we’re saying, ‘Well, you can’t get in for 90 days, 120 days,'” says Michael West, the chief medical officer at Clarksville. “It was just logistically impossible for us to take care of the patients we had, so we had to draw a line and say, ‘Look, we’ve got to do something.'”

So last March, they did.

The clinic in Clarksville decided to only see veterans who already went there. If someone new wanted an appointment, clerks were instructed to say that the site had temporarily stopped taking new patients.

Instead, veterans could go to the VA hospital in Nashville, about an hour’s drive away. They could go 35 miles north to a small clinic in Hopkinsville, Ky., or 35 miles west to an even smaller clinic in Dover, Tenn.

They could also apply for the Veterans Choice Program, which is when the VA pays for a private doctor — although that’s had many problems too.

And it’s been like this for more than a year. The clinic used to take about 50 new patients each week – about 2,500 a year – but now it’s down to just a few emergency walk-ins.

Lim says the best option right now is to not accept new patients.

“It made sense to actually take care of who we have here already, rather than continuing to take new patients and lack the ability to take care of everybody. So it was the lesser of two evils,” Lim says.

NPR found nearly a dozen VA health facilities around the country that have done something similar in the last couple of years. For example, a few clinics in Washington state are having trouble hiring enough doctors for all the patients trying to get in.

It’s hard to know for sure how common this is around the country. The national VA keeps a tally of wait times, but it doesn’t track which sites are seeing new patients and which are not.

Mike Davies, who oversees clinic access for the VA, says it’s “very common” for clinics to refer at least some patients elsewhere. But he believes this problem is inevitable in a big health care system.

“Remember, VA has 1,700 sites of care,” he says. “It’s hard to have every single clinic open for accepting new patients every single day, just because life happens, right? We have providers that get sick, we have providers that move.”

But when asked if it’s a problem that some clinics cannot take new patients, he says yes.

“And we’re doing everything we can to provide care as close to home as possible. But if we’re in one of those relatively rare situations where the clinic close to home is full, we’ll do our best to accommodate you by sending you to the closest, next-best place,” Davies says.

By some measures, that policy works pretty well. Wait times at the Clarksville clinic are now among the lowest in the state. Lim says the patients there — the ones who were already in the system — are much happier and the staff is less stressed.

But it still means that new patients – when they need a doctor—can’t get into the clinic they want. This affects people like Steve Singleton and his wife, Janet. Both are Navy veterans in their early 60s who moved to Clarksville last spring. Shortly after their move, Steve came down with bronchitis and went to the Clarksville clinic for treatment.

“I went in and I showed them my VA card, and they told me that I couldn’t be seen because they had no room for any more new patients,” he says.

He ended up paying out of pocket for a private urgent care clinic. Now, he and his wife have doctors at the VA in Nashville. They’re OK with the hour-long drive for now, he says, but “it would still be nicer if I could just drive 10 minutes from my house instead of having to drive to Nashville for my medical care.”

It also means that the other nearby clinics are now strained. Scott Cobb, the Dover clinic’s manager, estimates that about a third of his new patients are coming from Clarksville. Dover now has the highest wait times in the region, while the Hopkinsville, Ky., clinic — the other clinic where Clarksville patients are referred — comes in second.

Clarksville is hoping to squeeze in one more doctor soon, which means a couple hundred new patients can get in. But the best solution won’t come until the VA can build a brand-new clinic.

It’s working on plans for a building three times the size of the current clinic, but that won’t be ready for another year. And by the time it’s built – with more and more veterans moving into the area – even that might not be big enough.

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Tennessee’s alternative to Obamacare is faltering. Steve Inskeep talks to Knoxville’s mayor about health and political issues. Chris Green of Berea College weighs in on the area’s political leanings.

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Lowe’s home improvement company, like a growing number of large companies nationwide, offers its employees an eye-catching benefit: Certain major surgeries at prestigious hospitals are free.

How do these firms do it? With a way of paying that’s gaining steam across the health care industry, and that Medicare is now adopting for hip and knee replacements in 67 metropolitan areas, including New York, Miami and Denver.

Here’s how the program works: Lowe’s and other employers pay one flat rate for a particular procedure from any of a number of hospitals they’ve selected for its quality. And, under the agreement, the hospital handles all the treatment within a certain time frame — the surgery, the physical therapy and any complications that arise — all for that one price.

It was Bob Ihrie, senior vice president for compensation and benefits at Lowe’s, who came up with the idea in 2010. When he told managers at other companies about it, he says, “The first question was always, ‘Oh, this is just for executives, right?’ And I said no, absolutely not, this is for any Lowe’s employee in the Lowe’s health care plans.”

The program is optional for employees. They can still use their local surgeon, if they prefer, and pay out of pocket whatever their insurance doesn’t cover. But more than 700 Lowe’s employees have taken the company up on its offer, Ihrie says.

It’s a great deal for patients, he says, and for his company.

“We were able to get a bundled price, which actually enables us to save money on every single operation,” Ihrie says.

The Pacific Business Group on Health negotiates that price for Lowe’s, Walmart and a number of other large employers. Associate director Olivia Ross oversees these deals, and says her team is able to negotiate rates that are 20 to 30 percent below what the companies used to pay for the procedures.

“We’re seeing savings at the front end,” she says, because Lowe’s pays less for the surgery. And, because the hospital is responsible for all that care, the institution has a strong incentive to be careful and thorough, Ross says.

That means “huge savings on the back end,” she says, “from things like reduced re-admissions, reduced return to the O.R. and lower rates of blood clots. Those are hugely expensive, preventable complications.”

Lowe’s comes out ahead, even after paying for the patient’s travel, Ihrie confirms.

Participating hospitals win, too, by attracting more patients, says Trisha Frick, who handles such negotiations on behalf of Johns Hopkins Medicine in Baltimore.

“It’s new business for us,” Frick says. “And, for the most part, the reimbursement is acceptable; we believe that we can provide that, within that amount of money.”

Medicare, the health insurance program for people 65 and older, started using bundled rates for hip and knee replacements this month in Miami, Los Angeles and 65 other metro areas. Medicare had some early evidence from pilot programs that “the model works well,” according to Rob Lazerow, a health care consultant with The Advisory Board Company.

“Medicare is saving something like $4,000 on orthopedic cases,” he says.

Medicare’s deal is somewhat different from the one at Lowe’s. Patients may pay something out of pocket, depending on the type of Medicare policy that insures them. And while the few hospitals selected in Lowe’s program can bank on increasing their revenue and the number of surgeries they’ll get, the rates established by Medicare’s bundled payment system hold for every hospital in a participating market.

“Entire markets are selected for participating,” Lazerow explains. “If you’re in the San Francisco market or you’re in the New York market, all of the hospitals are actually participating in the program.”

But there are similarities, too, and Medicare may learn some lessons from Lowe’s experience. Lowe’s initially had trouble wrangling all a patient’s medical records from local doctors. And the company found that patients who had questions weeks or months after an operation sometimes had trouble following up with the out-of-town doctor who had performed the surgery.

“You have some setbacks, and things happen, and you just have questions,” Ihrie says. “So what we give every patient now is a little card with the doctor’s name and direct phone line and the nurse’s name and direct phone line. And all of a sudden, things were a lot better.”

Another lesson was startling, Ross says. In addition to cutting the cost of procedures, another chunk of savings to the companies came from avoiding surgeries that probably shouldn’t happen in the first place.

“We’re seeing up to 30 percent — close to 30 percent of cases — who should not be moving forward with the joint replacement,” Ross says.

What typically happens in these cases, she says, is that employees get a recommendation from a local doctor that they should have surgery, only to have physicians at the selected hospitals deem the operation inappropriate.

In some cases that may be because the employee hasn’t first tried less invasive treatments, such as physical therapy, Ross says. Or the employee may need to lose weight first, to make the surgery safer.

Ihrie says what heartens him most about his company’s program is that Lowe’s employees are now taking a more active role in decisions about their care.

“What treatment you receive is not always very black and white,” he says. “The mere fact that people now think about what they’re doing helps us control costs across the board.”

This story is part of NPR’s partnership with WFAE and Kaiser Health News.

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Updated April 20 at 1:50 ET with a statement from the American Hospital Association.

Bowing to pressure from the hospital industry and Congress, the Obama administration on Wednesday delayed releasing its new hospital quality rating measure just a day before its planned launch.

The new “overall hospital quality” star rating aimed to combine the government’s disparate efforts to measure hospital care into one easy-to-grasp metric. The Centers for Medicare & Medicaid Services now publishes more than 100 measures of aspects of hospital care, but many of these measures are technical and confusing since hospitals often do well on some and poorly on others. The new star rating boils 62 of the measures down into a unified rating of one to five stars, with five being the best.

But this month, 60 senators and 225 members of the House of Representatives signed letters urging CMS to delay releasing the star ratings. “We have heard from hospitals in our districts that they do not have the necessary data to replicate or evaluate CMS’s work to ensure that the methodology is accurate or fair,” the letter from the House members said.

In a notice sent Wednesday morning, CMS told Congress it would delay release of the star ratings on its Hospital Compare website until July. “CMS is committed to working with hospitals and associations to provide further guidance about star ratings,” the notice said. “After the star ratings go live in their first iteration, we will refine and improve the site as we work together and gain experience.”

But in a conference call with hospital representatives, CMS officials said they might delay release of the ratings past July if they are still analyzing or revising the methodology, according to people who participated in the call.

Mortality, readmissions, patient experience and safety of care metrics each accounted for 22 percent of the star rating, while measures of effectiveness of care, timeliness of care and efficient use of medical imaging made up 12 percent in total.

The hospital industry for months has been urging this delay the star ratings, arguing that many of the measures will not be relevant to patients seeking a specific service. For instance, a hospital’s death rate for Medicare patients might be irrelevant for a woman trying to decide where to give birth.

The industry’s major trade groups said in a letter to CMS that some hospitals perform poorly because their patients tend to be lower income and don’t have the support at home. Many of the nation’s most prestigious hospitals have been bracing for middling or poor ratings.

Rick Pollack, president of the American Hospital Association, said in a statement that “the delay is a necessary step as hospitals and health systems work with CMS to improve the ratings for patients, and the AHA commends CMS for their decision.”

Last year, CMS created a star rating to represent the views of patients in surveys. Two sets of researchers recently determined that hospitals with more stars in patient experience tended to have lower death and readmission rates.

Hospital Compare received 3.7 million unique page views last year, according to a paper published this month in the journal Health Affairs. The author, analyst Steve Findlay, called the traffic “not at a level commensurate with [the] stature and potential” of the federal government’s health care facility comparison sites.

Dr. Ashish Jha, a Harvard School of Public Health researcher, said consumers will be more likely to use the unified star ratings, but this specific mix of measures raises concerns. “The idea that dying and being readmitted to the hospital are equally important to patients seems funny to me,” he said.

Kaiser Health News is an editorially independent news service that is part of the nonpartisan Henry J. Kaiser Family Foundation. Jordan Rau is on Twitter: @jordanrau.

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One of the chief goals of the Affordable Care Act was to expand insurance coverage so that all Americans could have access to quality health care. How’s that working out?

According to the Department of Health and Human Services, about 20 million people have gained coverage because of the ACA — either signing up for insurance through one of the marketplaces established by the law or enrolling in Medicaid or the Children’s Health Insurance Program.

All told, the sign-ups drove the uninsured rate down from 15.7 percent in 2011 to 10.1 percent in 2014, according to the latest figures from the U.S. Census Bureau. A further decline in 2015 is anticipated, given the increased volume of people signing up for insurance last year.

But behind these positive trends lie areas of deep concern to health policy leaders. In a series of polls, NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health found that a surprising share of Americans, particularly those with low incomes, are having problems with the quality of care they receive.

We found that among people living in households with incomes of less than $25,000, 34 percent rate the quality of health care they receive as fair or poor. That compares with just 13 percent of people with higher incomes.

The significance of this finding is that low-income people are more likely to be sick than people of other incomes. Forty-one percent of low-income adults rate their health as fair or poor, versus just 18 percent of people of other incomes.

The polls are part of an in-depth study to assess the changing health care landscape in the two years since the ACA took full effect. We conducted a national survey of 1,002 people, along with seven separate state polls of approximately 1,000 people each in Florida, Kansas, New Jersey, Ohio, Oregon, Texas and Wisconsin.

Other findings show the use of emergency rooms has not declined as many had predicted prior to the ACA. The use of urgent care centers, which are often lower in cost, is rising.

As part of our series, “Perceptions of Health,” Harvard is presenting a webcast Wednesday at 12:30 p.m. ET in collaboration with NPR and the Robert Wood Johnson Foundation to discuss whether efforts to extend coverage have improved the health care experiences of Americans and narrowed the gap in access to high-quality care between low-income and other Americans.

Joe Neel, deputy senior supervising editor on NPR’s Science Desk, will moderate a discussion with:

• Robert Blendon, professor of health policy and political analysis, Harvard T.H. Chan School of Public Health and Harvard Kennedy School
• Benjamin Sommers, assistant professor of health policy and economics, Harvard T.H. Chan School of Public Health
• Katherine Hempstead, senior advisEr, Robert Wood Johnson Foundation
• Jackie Jenkins-Scott president, Wheelock College

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White women are dying at a slightly younger age than they used to. That’s according to a report released Wednesday by the Centers for Disease Control and Prevention’s National Center for Health Statistics.

The life expectancy for non-Hispanic white women in the United States declined by one month — from 81.2 years to 81.1 years — from 2013 to 2014. Though just one month may not seem like much, demographers worry — it’s the first time since the government began keeping records that white women saw their life expectancy decline, according to the report.

The numbers don’t include cause of death, but demographer Elizabeth Arias, who wrote the analysis, decided to dig deeper. She looked at cause of death among white people in the U.S. over the last 15 years. And the changes she found troubled her.

“For the age group 25 to 54, suicide went up,” she says. ” ‘Unintentional poisonings,’ which is mainly alcohol and drug poisoning, and chronic liver disease — those went up by quite a bit.”

Those underlying factors affected men and women, Arias says, but affected women more. The life expectancy of white men over the same time period did not change.

Many other causes of death declined, she says — including heart disease, cancer and stroke. But those health improvements were offset by the increases in drug overdose, suicide and chronic liver disease.

The report comes just a few months after a separate study by Princeton economists Anne Case and Angus Deaton showed that middle-age mortality among white people is on the rise. The authors of that study also said the increase in deaths was likely due to suicides, drug overdoses and alcoholism.

Ellen Meara, a professor at Dartmouth’s Institute for Health Policy and Clinical Practice, said the numbers are surprising because mortality has been in decline for so long.

“There are people for whom life expectancy is falling — and that’s happening at a time where everywhere else and for every other group we’re seeing all these amazing gains in survival,” Meara says.

The NCHS report does have some good news: The average life expectancy for non-Hispanic black men increased by about a half year — from 71.8 years to 72.2 in that same time period. Arias says that improvement seems linked to declines in cancer deaths, homicides and heart disease.

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The National Institutes of Health has suspended work in two facilities that manufacture products given to people who are enrolled in research studies, saying the facilities haven’t complied with safety standards designed to protect already-sick people from inappropriate risks.

“There is no evidence that any patients have been harmed, but a rigorous clinical review will be undertaken,” the NIH said in a statement provided to NPR Tuesday. “NIH will not enroll new patients in affected trials until the issues are resolved.”

The NIH says work has been halted in two facilities that manufacture sterile or infused products: a National Cancer Institute laboratory engaged in cell therapy production and a National Institute of Mental Health facility producing positron emission tomography materials.

The cell therapy research is run by a scientific superstar named Dr. Steven Rosenberg, chief of surgery at the National Cancer Institute. He’s spent four decades at the NIH, where he pioneered the idea of using the immune system to fight cancer. He’s also the doctor who treated President Ronald Reagan’s colon cancer.

Rosenberg did not respond to an email and a phone message left at his office. A representative of the company involved with his clinical trials, Kite Pharma, declined to provide information beyond what’s in a press release. Another company, Lion Pharmaceuticals, issued a similar statement saying that its trials were among those suspended.

The shutdowns of these facilities and research studies comes as the NIH is struggling to recover its credibility following embarrassing revelations last year that halted sterile manufacturing operations at a facility that serves the prestigious NIH Clinical Center.

The Clinical Center is a world-famous hospital where the patients are also research subjects. It’s often a place of last resort for desperately ill people who are willing to try unproven medicines.

But in April 2015, fungal contamination was discovered in two vials of the drug albumin that were manufactured by the Clinical Center’s Pharmaceutical Development Service. At least six patients received injections from that batch, but the NIH has said none have suffered any problems.

Shortly after that episode, in May 2015, the Food and Drug Administration received a complaint and conducted an unannounced inspection of the pharmaceutical service facilities. The inspection found worrisome deficiencies, such as insects in the lights of so-called clean rooms, flaws in the air-handling system, and inadequate training of staffers. In June, the NIH announced that sterile operations at the facility were suspended.

Since then, an internal investigation at the NIH revealed that this wasn’t an isolated problem but rather part of a disturbing pattern. “We learned that there was a prior history of contamination events and a systemic failure to adhere to a set of standard safety and compliance principles,” reported an NIH task force. “Instead, priority had been put on producing a high volume of products to meet the requests of intramural investigators.”

That’s why, a few months ago, the NIH put together what it is calling a red team to examine the structural and cultural issues underlying these failures. The team was also tasked with reviewing “other research activities at the Clinical Center that pose a potential risk to research participants,” including other sites at the NIH that make experimental compounds intended for administration into sick people.

The red team is scheduled to brief an advisory committee to the NIH director on Thursday afternoon.

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Insurance giant UnitedHealth Group says it will stop selling insurance on Obamacare exchanges in most states starting next year.

In a Tuesday call detailing UnitedHealth’s first quarter earnings, CEO Stephen Hemsley said the company would “remain only in a handful of states,” after losing money on the individual health plans it sold on state exchanges.

The decision won’t affect UnitedHealth customers who have insurance through the company this year. However, customers in the states that the company is leaving will likely have to shop for a new plan for 2017.

The company, which is the largest U.S. health insurer, has about 795,000 customers who bought plans for 2016 through the exchanges, which were created under the Affordable Care Act. That’s just a fraction of the 13 million people who bought Obamacare plans this year.

On Tuesday the company said it expects to lose $650 million on exchange plans this year, in part because the health status of the people who bought plans is worse than expected.

Still, UnitedHealth’s overall revenue rose 25 percent in the first quarter and profits rose 14 percent — to $1.6 billion.

UnitedHealth has already informed several states that it intends to pull out of the exchange markets in 2017. Those include Michigan, Oklahoma, Arkansas and parts of Georgia.

“We have been evaluating public exchanges on a state-by-state basis,” Hemsley said on a conference call with reporters and equity analysts. “Our own experience and performance have been unfavorable in these markets.”

Officials at the Department of Health and Human Services, which administers the Affordable Care Act and the federal HealthCare.gov insurance exchange, say UnitedHealth’s plans were priced higher than many others. In at least seven states, more than 90 percent of residents could buy plans that were cheaper than UnitedHealth’s offerings.

“As with any new market, we expect changes and adjustments in the early years with issuers both entering and exiting states,” said HHS spokesman Ben Wakana, in a prepared statement. “We have full confidence — based on data — that the marketplaces will continue to thrive for years ahead.”

The effect of the company’s withdrawal on consumers depends on where they live. An analysis released Monday by the Kaiser Family Foundation shows that premiums could increase as little as $1 a month in some counties, while in other areas they could rise by as much as $100 a month.

Residents of Oklahoma, for example, may be left with only one company offering health insurance through the exchanges unless another company enters the market, the report shows.

Nationwide, however, premiums for health plans on the exchanges would likely rise only modestly — about 1 percent on average — if UnitedHealth pulls out of the market altogether. The premium increase would amount to about $4 a month.

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