A Massachusetts Institute of Technology economist and Harvard oncologist have a proposal to get highly effective but prohibitively expensive drugs into consumers’ hands: health care installment loans.

In the journal Science Translational Medicine, the academics liken drug loans to mortgages, noting that both can enable consumers to buy big-ticket items requiring a hefty upfront payment that they couldn’t otherwise afford.

Some consumer advocates and health insurance experts see it completely differently.

“Isn’t this why we have health insurance?” asked Mark Rukavina, a Boston-based health care consultant whose work has focused on affordability and medical debt. “Insurance used to protect people from financial ruin for these unpredictable, costly occurrences. Now, with large deductibles, we’ve got coverage for preventive care but not for treatment.”

Andrew Lo, a professor of finance at MIT’s Sloan School of Management, and Dr. David Weinstock, an oncologist at the Harvard-affiliated Dana-Farber Cancer Institute, agree that insurance would be a better option. But for many consumers that isn’t enough protection these days. Even patients with insurance can face high deductibles or an uncapped share of drug costs under coinsurance instead of copayments.

“This is a private sector stopgap way to deal with something right now,” said Lo.

Their proposal calls for the loans to be financed by a pool of investors who would buy bonds and equities issued by an organization that makes the loans to consumers.

While it may be “distasteful” to talk about patients mortgaging their lives for treatment, Lo said, they hope the proposal will spur change.

The health care installment loans that Lo, Weinstock and their co-author Vahid Montazerhodjat, a former MIT doctoral student who was working with Lo, propose would be aimed at helping people afford “transformative” therapies that cure potentially fatal conditions, such as cancer or hepatitis C.

They’re not designed to pay for maintenance drugs that help people deal with chronic illness. It’s easier for insurers to cover maintenance drugs because they’re purchased over an extended period of time, they said.

In contrast, breakthrough hepatitis C drugs Sovaldi and Harvoni, for example, can cure people of the liver-destroying disease in a few months, but the price tag of $84,000 or more has led many insurers to limit coverage to people whose disease has significantly progressed to show signs of liver damage.

“There are miraculous treatments like Harvoni, but they’re out of reach” for many people, said Lo.

Someone who wanted that Harvoni treatment might take out a health care loan with a nine-year term at an annual interest rate of about 9 percent, the authors suggest. In a twist on conventional loans, if a therapy doesn’t work or the patient relapses or dies, the patient isn’t obligated to repay the loan.

Are sick patients good loan prospects? Lenders might want to assess not only loan applicants’ creditworthiness but also their health to determine whether the applicant is likely to live long enough to pay it off.

The study authors say that requiring repayment only if the treatment works will protect patients and provide an incentive for the development of more effective drugs.

That’s a wrongheaded approach, said Dr. A. Mark Fendrick, director of the University of Michigan Center for Value-Based Insurance Design.

Medical treatment isn’t always straightforward. Even highly transformative drugs such as Sovaldi aren’t guaranteed to work, Fendrick said, and other factors come into play. For example, about 10 percent of people who were prescribed Sovaldi for hepatitis C didn’t finish their course of treatment, Fendrick said, referring to an analysis by the CVS Health Research Institute.

“In this situation, the person who does the right thing and gets the good outcome is penalized and has to pay the money back,” he said. Instead, he argued, patients who follow their doctor’s recommendations and “do what you’re supposed to do” should not be held liable for the loan.

The proposal doesn’t address drug prices, except to say that the potential for increases due to higher demand for previously unaffordable therapies needs to be addressed.

Price increases are a real concern, said Paul Ginsburg, director of public policy at the University of Southern California’s Schaeffer Center for Health Policy and Economics. The health law has made it easier for people to afford expensive drugs. It expanded Medicaid coverage to millions of lower income adults and capped at roughly $7,000 the amount consumers generally spend out-of-pocket for care.

“It’s helped people, but it’s also driven prices higher,” he said. From a drug company’s perspective, “It just means that more people can afford this drug, so we can charge more for it.”

Lo said the MIT Laboratory for Financial Engineering and the Dana-Farber Cancer Institute will host a conference this winter to bring together drug manufacturers, insurers, patient advocates, financial engineers and others to discuss strategies to make expensive drug therapies more affordable. Health care loans will be on the agenda, he said.

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

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How do you fix a problem if you don’t know its size?

Many states — including some that have been hardest hit by the opioid crisis — don’t know how many of their youngest residents each year are born physically dependent on those drugs. They rely on estimates.

Pennsylvania is one of those states. Ted Dallas, head of Pennsylvania’s Department of Human Services, calls the information he’s working with “reasonably good.”

“Data is never pristine when you’re dealing with 2.7 million people,” he says. “Do I think it gives you a good picture of the issues that are out there? Yes.”

Between 2013 and 2014 in Pennsylvania, Dallas says, about 3,700 of the babies on Medicaid, the government’s health insurance for the poor and disabled, were born with neonatal abstinence syndrome. Statistics show that 31 died before their first birthday — and neonatal abstinence syndrome likely played a role in some of those deaths.

Still, it’s not all the data Dallas would like to have. The statistics are two years old, he says, and only count babies who are covered by Medicaid. That’s just a slice of Pennsylvania’s nearly 13 million people. More comprehensive, statewide numbers would have to come from Pennsylvania’s Department of Health — and that agency isn’t keeping track.

With more complete information, Dallas says, the state would be able to better deploy resources as it tries to solve a health problem that’s getting worse. With the right resources, there is an upside to this aspect of the opioid crisis: Babies with neonatal abstinence syndrome who get the right care usually do recover. But their care is expensive, and takes time.

“These babies are very work-intensive,” says Dr. David Wolf, who works in the neonatal intensive care unit in PinnacleHealth’s Harrisburg Hospital. “Our nurses are on the front lines. They have to deal with the minute-to-minute symptoms.”

Cuddling or rocking the babies nearly nonstop is key to successful treatment, Wolf says, along with adjusting medication doses frequently in the first 48 hours of the child’s life, to start the process of weaning these newborns off opioids.

Each infant’s stay in the hospital can stretch past two or three weeks, and can cost $10,000 or much more. Then the babies need follow-up visits.

Pediatricians say that if the right agencies get real-time information, the babies are likely to get better care, and it’s more likely that hidden roots of the epidemic can be identified and addressed.

To make good decisions, health officials need basic information: Which infants are affected? How many, where, and why?

Pennsylvania might look to Tennessee’s tracking efforts. Tennessee reacted quickly when doctors started seeing a lot more cases of neonatal abstinence syndrome in 2012, recalls Dr. Michael Warren, a pediatrician and public health specialist with Tennessee’s Department of Health.

“We were hearing from hospitals across the state, that they were really, really full,” he says, “and in some cases, bursting at the seams.”

It’s now mandatory for doctors and hospitals to report cases of neonatal abstinence syndrome within 30 days, and Tennessee made it simple for them to do so.

“If you’ve ordered from Amazon or an online service and you’ve been able to do that, you can navigate this system with ease,” Warren says. “And truly, at the end of it, you click ‘submit’ and that case is reported to us at the Department of Health.”

The data that started rolling in shattered a number of stereotypes.

“I think sometimes there’s a tendency to say these are just those moms who are using illicit drugs or buying those drugs on the street,” Warren says. “But what the surveillance system has actually allowed us to see is that — in the majority of our cases — Mom is getting at least one substance that is prescribed to her by a health care provider.”

As a result, the state alerted doctors to the issue, recommending they try to change their prescribing habits, and offer alternatives to opioids, especially to pregnant patients. The evidence-based shift in prescribing recommendations only came about because health officials had solid data they could share.

When a public health crisis emerges, real-time data are especially important. Policymakers can use the information just as Tennessee did — to tailor solutions to the root causes. Otherwise solutions may miss the mark, or, if the data are old, come after the problem has festered and grown.

According to a 2014 report by the Association of State and Territorial Health Officials, at least a handful of other states have taken steps to get better, systematic data on babies born with neonatal abstinence syndrome.

Pennsylvania Department of Human Services Secretary Ted Dallas acknowledges his state is missing out.

“If we had better data generally, my theory would be we could make better decisions,” he says.

Just as I was wrapping up this story, the Pennsylvania Department of Health department called. Starting in July, officials there plan to start collecting data about all babies who are born dependent on opioids.

The system to collect the information is still being developed, officials there say, but neonatal abstinence syndrome will be added to the Pennsylvania’s list of reportable diseases, meaning that every time doctors diagnose a baby with the condition, they’ll be required to notify the state.

This story is the fourth of a four-part series Treating the Tiniest Opioid Patients, produced by NPR’s National and Science Desks, local member stations, and Kaiser Health News.

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Carolyn Rossi has been a registered nurse for 27 years, and she’s been fiercely protective of infants in her intensive care unit — babies born too soon, babies born with physical and cognitive abnormalities and, increasingly, babies born dependent on opioids.

As clinical manager of the nurseries at the Hospital of Central Connecticut, Rossi works in the neonatal intensive care unit. Like many hospitals across the country, the facility near Hartford has seen a dramatic rise in recent years in the number of babies born with neonatal abstinence syndrome. The National Institute of Drug Abuse reports that more than 21,000 infants born in the U.S. in 2012 (the most recent year for which data are available) experienced symptoms of opioid withdrawal. The hospital says each such baby in its care costs roughly $50,000 to treat.

These fragile and fitful newborns present new challenges for hospitals. Some research suggests the children do best when they can be held for hours at a time, preferably by their mothers, in quiet, private rooms, as they go through the process of being weaned off the drugs.

But delivering care that way requires changing the attitudes of many doctors and nurses about addiction.

Rossi, for example, says her initial training in the best ways to care for newborns in withdrawal was very different from what the research now suggests.

“You know, we looked at it like, ‘They are drug addicts and the baby is born a drug addict and we’re trying to protect the baby from the mother,’ ” Rossi says. “Like we were going to cure the baby, but not cure the mother and the family. So it was a lot about taking babies away from moms.”

That turns out not to be a useful strategy if you’re hoping to engage the help and support of a mother who already feels stigmatized by her drug habit, says Kate Sims, who directs women’s and children’s services at the hospital.

“She’s feeling guilt herself,” Sims says. “And then [she] comes in here and, unfortunately, as best as we are as providers and nurses, we’re also judgmental. And so it’s felt.”

A lack of trust between mother and a nurse makes treating the baby even harder, Sims says.

So the hospital is now trying to make sure everyone in patient care sees the addicted mother first as a mom. In some cases that means getting care providers to understand that addiction isn’t a moral failure, and that many people who are addicted come from a lifetime of trauma. Rossi says it’s been hard for nurses who have been trained to be baby specialists to become mom specialists, too.

“It’s a big culture change for me personally, and I know for the NICU nurses that are in here,” she says. “You really do believe you’re doing the right thing until something like this comes along.”

The hospital’s approach to caring for these infants is changing, in other ways, too. Dr. Annmarie Golioto, chief of pediatrics and the head of the hospital’s nursery, says a bright, loud and bustling intensive care unit is a hard environment for a baby going through withdrawal. So she’s gotten approval to use a few rooms just outside the intensive care unit as a quiet, monitored space for a baby and mother to stay for as long as the baby needs it.

“We’ve had to figure out: ‘How can we use our rooms differently?’ ” says Golioto. “How can we use our space differently? And how we can partner with mom differently to have that relationship with her, to say, ‘We expect you to stay here with your baby and take care of the baby after you’ve been discharged.’ “

Golioto hopes the new setting will shorten recovery times for the children and decrease the amount of morphine a baby needs to ease withdrawal. She’s also hopeful these moves will inspire some mothers to think differently about their newborns.

“The thinking was, ‘My baby is being taken care of. There are nurses there. There are doctors there. I don’t need to be here. They’re getting everything they need,’ ” says Golioto. “We’re trying to change the thinking — ‘no, they’re not getting everything they need if you’re not here. Because they need you.’ “

Rossi says she recognized the value in this new nursing approach the very first time she saw it in action. It was last December, she recalls. Rossi gave a mother a hospital room to stay in for more than a month while her baby went through withdrawal.

“She was just thrilled,” Rossi says. Though the mother couldn’t be at the hospital 24/7, “she was here as much as she could be,” the nurse says, “and just knowing that she had the flexibility helped me understand that she is a mom. She is a great mom. She wants to be a better mom.”

Nearly every aspect of the opioid epidemic worsened in 2014, according to the federal government’s latest figures. And even though the Hospital of Central Connecticut’s programs are just a few months old, health care workers there hope the changes they’ve made in their culture of care will, at the very least, give vulnerable moms and babies a better start.

This story is second in our four-part series Treating the Tiniest Opioid Patients, a collaboration produced by NPR’s National & Science Desks, local member stations and Kaiser Health News.

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This story is first in our four-part series Treating the Tiniest Opioid Patients, a collaboration produced by NPR’s National & Science Desks, local member stations and Kaiser Health News.

Swaddled in soft hospital blankets, Lexi is 2 weeks old and weighs 6 pounds. She’s been at Women and Infants Hospital in Providence, Rhode Island since she was born, and is experiencing symptoms of opioid withdrawal. Her mother took methadone to wean herself from heroin when she got pregnant, just as doctors advised. But now the hospital team has to wean newborn Lexi from the methadone.

As rates of opioid addiction have continued to climb in the U.S., the number of babies born with neonatal abstinence syndrome has gone up, too — by five-fold from 2000 to 2012, according to the National Institute of Drug Abuse.

It can be a painful way to enter the world, abruptly cut off from the powerful drug in the mother’s system. The baby is usually born with some level of circulating opioids. As drug levels decline in the first 72 hours, various withdrawal symptoms may appear — such as trembling, vomiting, diarrhea or seizures.

At some point, if symptoms mount in number or severity, doctors will begin giving medication to help ease them. The idea is to give the baby just enough opioid to reduce those symptoms, and then slowly, over days or weeks, decrease that dose to zero.

A doctor comes to check on Lexi and her mother, Carrie. To protect her family’s privacy, Carrie asked us not to use the family name.

“So, hi, Peanut!” the doctor says to the baby. “Any concerns?” she asks Carrie.

“Coming down has been catching up with her,” says Carrie.

“Do you feel like she’s jittery?” the doctor asks.

“She didn’t want to be put down last night — like [she had] the shakes,” Carrie says.

Lexi has neonatal abstinence syndrome, and has been getting methadone treatments for it. She is getting better — most babies do — but even with treatment, she’s had tremors, diarrhea, and she’s cried and cried. Her little arms and legs tighten up, her fingers and toes clenched. She’s been feverish, her mother says.

“I know what she’s feeling,” Carrie says. “And that is the worst part.”

Carrie was addicted to heroin herself and knows withdrawal is miserable. She’s been off heroin — with help from methadone — since she found out she was pregnant, she says. The small dose of methadone keeps a low level of opioid in her system so she doesn’t go into withdrawal, but it doesn’t get her high. For Carrie and thousands like her, methadone is a lifesaver — helping them quit a heroin or oxycodone or other opioid habit for good.

But getting pregnant posed a dilemma: If Carrie stopped taking opioids altogether, she risked relapse or miscarriage. Yet, if she continued to take any opioid — including methadone — there would be a 60 to 80 percent chance that her baby would be born with neonatal abstinence syndrome, the doctors told her.

“It’s hard to watch, as her mother,” Carrie says, “because you’re helpless and there’s really nothing you can do. You are a lot of the reason why she’s going through what she’s going through.”

Babies going through withdrawal spend weeks — even months — in hospital nurseries like this one.

“Their cry is very different,” says Cindy Robin, a registered nurse at the Providence hospital, who has been caring for mothers and newborns for more than 30 years. “It’s a more distressed cry,” she says, “and it really pulls at your heartstrings to have to listen to them.”

Robin says babies with mild symptoms of the withdrawal syndrome will sneeze and sniffle. They have trouble settling down. Babies who have a more severe case can have seizures and dangerously high fevers. Robin says nurses have to dim the lights, and swaddle the newborns tightly to help keep them calm.

“They just need to be held in a nice, quiet spot,” she says. “We have nice quiet music playing, and try to keep them as comfortable as possible.”

Nurses with special training check on the babies every couple of hours.

“So these are the things that we look for … and what we teach the parents,” she says: “Is the baby crying excessively? Is it a high pitched cry? Is it just a continuous cry? How do they sleep after they eat?”

Medication, which is gradually decreased, can help ease this constellation of symptoms.

“The American Academy of Pediatrics and others recommend an opioid for the babies, because you’re giving them back what they’re withdrawing from,” explains Dr. Jonathan Davis, a neonatologist and chief of newborn medicine at Tufts’ Medical Center. “Morphine and methadone are the two most common.”

But Davis says no one’s really done the research to figure out which drug works better for babies, and doctors are left to figure that out by trial and error, case by case. Though the Food and Drug Administration hasn’t officially approved morphine or methadone for use in newborns, doctors prescribe these drugs to the children anyway, in smaller doses than they give adults.

“As I spoke to people around the country, everyone would have their own approach and a very different way of treating these babies,” Davis says. “And we thought that quite odd.”

So he and a colleague, Brown University developmental psychologist Barry Lester, have launched a major study to sort out what works best. The two are hoping to enroll 180 babies in their double-blind, randomized, controlled trial — no one will know which newborns are getting methadone, and which are getting morphine, for example, until the study’s end. And they’re taking the research further: No study yet has looked at the long-term effects of the drugs, so Davis and Lester will continue to follow-up with measures of cognitive and physical development until the children are 18 months old.

“It may be,” Davis says, “that one agent is safer short-term, but when we look longer-term it may actually be more dangerous.” Teasing out long-term effects of a drug isn’t easy, Lester says; many factors can influence a baby’s development.

“If you’re drug-exposed and you’re growing up in an inadequate environment — which may not be poverty, it may be inadequate parenting — that’s a double whammy,” he says. “Those are going to be your worst case scenarios.”

Despite many remaining unknowns, doctors have consistently found that treatment with morphine or methadone enables most babies to get through withdrawal in about six to eight weeks.

“It can be heartbreaking,” says Robin, who has helped shepherd many kids through dark days. “But at the end, it is also rewarding,” she says, “because you see them get better and you see them go home.”

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Eliza Catchings has been seeing doctors at the Christie Clinic in central Illinois since 1957. But just after receiving this year’s WellCare Medicare Advantage member card, the insurer told her the clinic was leaving WellCare’s provider network and she would have to choose new doctors.

“I was terrified,” said Catchings, 79, who gets care for diabetes and heart problems. But she was helped by a little-noticed change in federal policy.

Medicare Advantage plans sold by private insurers are an alternative to traditional Medicare, but they cover services only from doctors, hospitals and other providers that are in the insurer’s network. Although providers are allowed to drop out of the plans any time, members can usually change only during the annual sign-up period in the fall. There are exceptions, but until recently losing a provider was not among them.

After insurers dropped hundreds of providers in 2013, the Centers for Medicare and Medicaid Services issued rules giving people a “special enrollment period” to change plans or join regular Medicare if there was a “significant” change in their provider network. The policy took effect in 2015 and applies only to Medicare Advantage members, not to the plans CMS oversees in the health law’s marketplaces.

Yet officials didn’t explain what they considered significant or what would trigger the option.

In the past eight months, Medicare officials have quietly granted the special enrollment periods to more than 15,000 Medicare Advantage members in seven states, the District of Columbia and Puerto Rico based on provider cuts. These decisions offer important details about how members can get permission to follow their doctors who leave their plans.

The number of beneficiaries affected has ranged from 344 members who lost access to 125 physicians and hospitals (3 percent of the network) in a New West Health Services plan in southwestern Montana to 7,830 members of MMM Healthcare and PMC Medicare Choice, which dropped 268 providers (about 5 percent) in Puerto Rico. Richard Shinto, president and CEO of InnovaCare, which runs both Puerto Rican plans, said poorly performing doctors were dropped so that the plans could improve their star ratings from CMS.

Those insurers notified CMS about the changes, as required by the government, to make sure the smaller network met minimum standards and members’ needs.

But Medicare Deputy Administrator Sean Cavanaugh said beneficiaries can also call the government’s help line (800-Medicare) to request permission to leave their plans because they lost their doctors. In rare situations, Cavanaugh said, individual beneficiaries have been allowed to switch plans.

“What we’re looking for is whether their selection of a plan was based on a network and the presence of certain physicians and that their selection would’ve been different” without those physicians, he said.

Yet Medicare doesn’t publicize the option, and few beneficiaries may know about it. Representatives who answered calls earlier in March to Medicare’s toll-free number said nothing could be done.

Catchings sought help from Jen Tayabji of the Champaign County Health Care Consumers advocacy group, who then contacted Erin Weir at Age Options, the Area Agency on Aging in suburban Chicago.

They took examples of five Wellcare members who could not find new doctors to CMS, which then granted a special enrollment period to several hundred Christie Clinic patients and told WellCare to send them letters.

Miguel Torres, WellCare’s senior director for Illinois field sales and marketing, said Christie Clinic terminated its WellCare contract in three rural counties and the company is still trying to replace the 100 doctors the insurer lost. Creating “a competitive network” is a constant focus, he said, “to ensure that our members get the care closest to their homes.”

Now Catchings can stay with her long-time doctors at the Christie Clinic. “Everything’s the same,” she said, except one thing — she has a Medicare Advantage plan from Coventry.

KHN’s coverage of aging and long-term care issues is supported in part by a grant from The SCAN Foundation.

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When California’s aid-in-dying law takes effect this June, terminally ill patients who decide to end their lives could be faced with a hefty bill for the lethal medication. It retails for more than $3,000.

Valeant Pharmaceuticals, the company that makes the drug most commonly used in physician-assisted suicide, doubled the drug’s price last year, one month after California lawmakers proposed legalizing the practice.

“It’s just pharmaceutical company greed,” said David Grube, a family doctor in Oregon, where physician-assisted death has been legal for 20 years.

The drug is Seconal, or secobarbital, its generic name. Originally developed in the 1930s as a sleeping pill, it fell out of favor when people died from taking too much, or from taking it in combination with alcohol. But when intended as a lethal medication to hasten the death of someone suffering from a terminal disease, Seconal is the drug of choice.

“It works very quickly and very gently,” Grube says. “People fall asleep with no complications. It’s a very gentle passing.”

In 2009, Grube remembers the price of a lethal dose of Seconal — 100 capsules — was less than $200. Over the next six years, it shot up to $1,500, according to drug price databases Medi-Span and First Databank. Then Valeant bought Seconal last February and immediately doubled the price to $3,000.

Most drug companies justify such hikes by pointing to high research costs. But Grube says that’s not the case with Seconal. It’s been around for 80 years.

“It’s not a complicated thing to make, there’s no research being done on it, there’s no development,” he says. “That to me is unconscionable.”

Valeant bought several other drugs at the same time it bought Seconal, raising some of those prices as much as 500 percent. That sparked a congressional investigation into its pricing practices. (The CEO resigned Monday amid an accounting controversy).

“Valeant sets prices for drugs based on a number of factors,” the company said in a statement, including the cost of developing or acquiring the drug, the availability of generics and the benefits of the drug compared with costly alternative treatments. “When possible, we offer patient assistance programs to mitigate the effects of price adjustments and keep out-of-pocket costs affordable for patients.”

The most likely explanation for raising the price of Seconal is the lack of generics, says Mick Kolassa, founding partner of Medical Marketing Economics, a firm that advises drug companies on how to price and market their drugs.

Seconal went off patent in the early 1990s. There were some generics for a while, but then demand shrank and manufacturers abandoned them.

“So that meant when the current company bought it, they didn’t have any generic competition, simply because the market got so small that it left,” Kolassa said. “So in situations like that, a company can acquire it and raise the price.”

Kolassa says it’s also possible that the demand for even the brand-name drug is so low that it’s hard to recoup the costs of making and selling it.

“Here’s a company that said, well, we can raise the price, keep it on the market and make some money with it,” he said. “Or we can walk away and the product goes away.”

Whatever the explanation, what cancer patients like Elizabeth Wallner see is a drug company taking advantage. She has one word to describe the pharmaceutical executive who decided to double the price of Seconal: “Scumbag.”

Wallner, who lives in Sacramento, Calif., was diagnosed with stage 4 colon cancer five years ago. It spread to her liver and lungs. She always thought that if her suffering became too unbearable, she would consider ending her life. But she never thought about the price tag of the lethal drug.

“You’re going to make money off my death,” she said.

She’s most worried about her son.

“You are literally, at that point, taking the money from children,” said Wallner, who is 52. “Everything I have, if I’m going to die tomorrow, everything I have will be left to my son who will be 20 years old and almost 100 percent on his own.”

Under the California aid-in-dying law, it is optional for health insurance companies to cover the costs of the practice. Most private insurers plan to do so, according to the California Association of Health Plans. So does the state’s Medicaid program.

But for patients who aren’t covered, there is a cheaper alternative: a three-part drug cocktail that can be mixed by a compounding pharmacy for about $400.

Grube says the cocktail works just as well, but doctors usually don’t prescribe it because of the hassle some patients have to go through to get it. Seconal, on the other hand, is a ready-made pill, routinely available at most retail drugstores.

He says advocacy groups like Compassion & Choices are working on campaigns to reduce drug costs and to educate doctors and patients about the law.

“My dream is that any Californian who will choose aid in dying would have few burdens or barriers to jump through,” Grube said.

Katie Orr contributed reporting from Sacramento. This story was first published on KQED’s blog State of Health.

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On the sixth anniversary of the enactment of the Affordable Care Act, the federal health law was back before a seemingly divided Supreme Court Wednesday.

At stake this time is the controversial requirement that most health insurance plans provide women with access to contraceptives at no additional out-of-pocket cost. Specifically at issue is whether a special accommodation the Obama administration has provided for religiously affiliated employers (such as universities or hospitals) still violates a federal law protecting the free exercise of religion.

Under the rules issued by the Obama administration in 2014, religious nonprofit organizations don’t have to provide contraceptive coverage, but they do have to either fill out a government form or write a letter stating that they object and telling the government who their insurer is so the government can arrange for contraceptive coverage to be provided.

The current case, Zubik v. Burwell, is actually seven cases being considered together. The plaintiffs, led by the bishop of the Roman Catholic Diocese of Pittsburgh, argue that even the act of writing a letter makes them “complicit in sin” by enabling employees to obtain birth control coverage.

“My clients would like to be conscientious objectors,” attorney Paul Clement told the justices. “But the government is insisting they be conscientious collaborators.”

The liberal members of the court made it clear that they agreed with the lower-court rulings in the cases, all of which found that the requirements do not pose a “substantial burden” on the exercise of religion under the Religious Freedom Restoration Act.

“It’s not a substantial burden if someone else is going to do the action you object to,” said Justice Sonia Sotomayor.

Conservatives, however, seemed less convinced.

“Their objection is the government is hijacking their insurance plans,” said Chief Justice John Roberts. Even though the religious employers do not have to pay for or directly arrange for the coverage, he said, the employers’ insurance plans are “being used by the government to provide these services.”

If the court deadlocks in a 4-4 tie, as seems possible, it could order the case to be argued again whenever there is a ninth justice to replace the late Antonin Scalia. Or it could issue a split decision that would uphold the appeals court rulings in question, but set no national precedent.

This is not only the fourth time in five years the court has been asked to rule on a key aspect of the health law, it is the second time in three years it has taken up the so-called contraceptive mandate.

In 2014, the court ruled 5-4 that the craft store chain Hobby Lobby and other closely held for-profit companies didn’t have to provide contraception as part of their health insurance plans if they had a religious objection.

The current case comes in the midst of an election campaign that could be affected by efforts to limit women’s access to contraception and abortion.

Poll results released Wednesday by the Kaiser Family Foundation show that more than a third of those surveyed (and 40 percent of women) said there is “a wide-scale effort to limit women’s reproductive health choices and services.” (Kaiser Health News is an editorially independent program of the foundation.)

Not surprisingly, Democratic women were more likely than Republican women to say there is a widescale effort (56 percent vs. 25 percent) and far more likely to say that they are “personally concerned” about women’s reproductive health choices (52 percent vs. 18 percent).

The contraceptive case comes only weeks after the court heard a case from Texas that could limit women’s access to abortion.

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

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