Amid growing questions over the future of Obamacare exchanges, the head of California’s marketplace said the nation’s largest private health insurer should take responsibility for nearly $1 billion in losses and stop blaming the federal health law.

In a blistering critique, Covered California’s executive director, Peter Lee, said UnitedHealth Group Inc. made a series of blunders on rates and networks that led to a $475 million loss in 2015 on individual policies across the country. The company estimates a similar exchange-related loss of $500 million in 2016.

“Instead of saying, ‘We screwed up,’ they said, ‘Obamacare is the problem and we may not play anymore,’ ” Lee said in an interview with California Healthline. “It was giving an excuse to Wall Street and throwing the Affordable Care Act under the bus.”

Lee, a staunch defender of the health law and a former official in the Obama administration, has tangled with UnitedHealth in the past. He knocked the company for sitting out the launch of Obamacare in 2014, then welcomed UnitedHealth into Covered California for 2016.

But now, he said, the company is “driving me bonkers” because it has “fed this political frenzy that Obamacare doesn’t work. It’s total spin and unanchored in reality.”

A company spokesman declined to comment on Lee’s criticism, and referred to UnitedHealth’s previous statements on the exchange business.

During a Nov. 19 conference call with analysts, UnitedHealth’s CEO Stephen Hemsley said: “We can’t really subsidize a marketplace that doesn’t appear at the moment to be sustaining itself. … I think that basically is an industry-wide proposition.”

An Urban Institute report issued last week, however, found that some of UnitedHealth’s troubles may have been self-inflicted. The company’s premiums were substantially higher than its competitors in many of the largest U.S. markets. The insurer also offered broader provider networks that tend to attract sicker customers who incur big medical bills.

In November, UnitedHealth surprised analysts and health-policy experts with its steep losses and said it might leave the exchanges altogether, just after expanding into new states. The sudden reversal prompted questions about the sustainability of the government-run marketplaces, the linchpin of President Obama’s signature law.

UnitedHealth reiterated its dour outlook for the exchange market when it announced quarterly results Jan. 19. The company said it has seen an influx of sicker patients during special enrollment, fewer healthy people signing up and costs rising as a result.

UnitedHealth ended last year with about 500,000 customers in the public exchanges, and it expects membership to grow to about 800,000 during the recent open enrollment. It has said it will decide by mid-year whether to continue selling in Obamacare marketplaces.

Other major insurers have expressed similar concerns about doing business in the public exchanges, albeit with less red ink than UnitedHealth.

Anthem Inc., the nation’s second-largest health insurer, said last week that its exchange enrollment in California and 13 other states was running about 30 percent below expectations, but the business was still slightly profitable. Anthem ended last year with 791,000 exchange members.

On Monday, insurance giant Aetna Inc. said it lost up to $140 million, or a negative margin of 3 percent to 4 percent, on individual coverage last year. It has 1 million members with individual policies, about 75 percent of them on public exchanges. The company said it expects to break even this year, however.

“Our individual commercial business ended the year with improved results,” Aetna’s chief executive, Mark Bertolini, said Monday during an earnings conference call. “Despite our improved finish, this business remained unprofitable in 2015 and we continue to have serious concerns about the sustainability of the public exchanges.”

In response to industry criticism, the Obama administration is taking steps to prevent the misuse of special enrollment so people can’t wait to sign up until they need care. Special enrollment is designed for people who lose coverage or need to make a change because of an event in their life, such as moving, getting married or having a child.

Insurance markets can’t function properly without enough healthy customers paying premiums, which are used to cover expenses incurred by sicker policyholders. The three-month open enrollment period for the federal and state exchanges just ended Jan. 31. California extended its deadline to Feb. 6 for people who already had begun the sign-up process by Sunday.

John Holahan, a health-policy researcher at the Urban Institute, said the Obama administration does need to impose stricter rules for special enrollment. He also said concerns over affordability have hampered enrollment since some middle-class consumers and young, healthy people are put off by high premiums and large deductibles.

“But I haven’t seen anything that shows the exchanges are really in trouble,” Holahan said. “That doesn’t mean every insurer is going to make it. Some companies don’t make it, and that isn’t a sign markets are unsustainable.”

The Department of Health and Human Services expects about 10 million people to be enrolled in federal and state exchanges at the end of 2016. That’s far below previous government forecasts.

UnitedHealth sat out Covered California for the first two years before joining in several rural areas. Lee said both sides will be analyzing whether the company returns for 2017. As an active purchaser, Covered California can decide whether or not to contract with certain health plans and allow them on the state exchange.

“United will be looking at what their prospects are in California,” Lee said.
“We will be looking at United as a plan to see if they offer good value for Californians. It’s to be determined on both ends.”

This story was produced by Kaiser Health News, which publishes California Healthline, a service of the California HealthCare Foundation.

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A memo from congressional investigators sheds new light on the inner workings of Martin Shkreli’s Turing Pharmaceuticals after the company jacked up the prices of a decades-old drug used to treat AIDS patients.

The House Committee on Oversight and Investigations is looking into Turing and other drug companies’ price increases. This memo, released Tuesday, includes excerpts from the company’s internal documents and emails.

It paints a picture of the now-disgraced “pharma bro” Martin Shkreli giddily rubbing his palms together at the prospect of all the money Daraprim will generate for his fledgling company. The drug is the only cure for toxoplasmosis, a disease that strikes people, including AIDS and cancer patients, whose immune systems are suppressed.

Turing bought Daraprim last year and jacked up the price 5,000 percent, from $13.50 to $750 a pill.

Here are a few highlights from the data dump.

When Turing agreed to buy Daraprim, company officials went into celebration mode:

“Very good. Nice work as usual. $1bn here we come.” — Turing Chairman Ron Tilles email dated May 27, 2015.

“I think it will be huge. We raised the price from $1,700 per bottle to $75,000. … So 5,000 paying bottles at the new price is $375,000,000 – almost all of it is profit and I think we will get 3 years of that or more. Should be a very handsome investment for all of us.” – Martin Shkreli email dated Aug. 27, 2015.

“Another $7.2 million. Pow!” — Tina Ghorban, senior director of business analytics, reacting to a purchase order for 96 bottles at $75,000 a bottle, on Sept. 17.

The company thought it could handle blowback from AIDS activists and doctors:

“HIV patient advocacy may react to price increase … we still come out ahead if we can frame this issue within the HIV/AIDS community as a fight between a drug company and insurance companies. As long as everyone who needs Daraprim can get it as soon as they need it, regardless of ability to pay, the community should have no issue. There is no love lost between HIV/AIDS activists and insurance companies, and they certainly don’t want to be manipulated by them to fight on their behalf.”

“Cost and coverage are not obstacles to treatment today … physicians do not report high out-of-pocket costs, required prior authorizations, or other access barriers to toxo medications.”

They were wrong:

“Given your company’s recent move to raise the price of pyrimethamine over 5,000% to an incredible $750 a pill, I have decided not to meet with representatives from Turing. … I am also urging my colleagues here at UNC, as well as at Duke, ECU, Wake Forest and other clinical centers across our state to do likewise, until Turing announces a reasonable and ethical reduction in the price of this important medication — a drug we rely on most to treat toxoplasmosis.” — Associate professor at University of North Carolina, Oct. 1.

“After over a week of trying to secure Daraprim for an uninsured patient requiring Daraprim at Massachusetts General Hospital, I need immediate assistance with expediting this case. … We have been provided with inaccurate/misleading information by the dedicated Daraprim Team. … This is a critical matter, visible at the highest levels of our Infectious Disease Department.” — Doctor at Massachusetts General Hospital, Oct. 8.

So Turing went into crisis mode, trying out discount programs and struggling with PR:

“I think we are acting a little like a deer in the headlights, and need to take some action steps now. If a hospital like Mass General is having issues we are in trouble.” — Ed Painter, head of investor relations, Oct. 8.

“Is there an annual price reduction commitment that would discourage generics from entering the market? What if we headlined … Turing Pharmaceuticals commits to an out-of-pocket cost to individuals of less than $20.” — Painter, Sept. 26.

“I don’t think so. Re reductions — Think it’s best we don’t PR something like that unless its something we’re willing to commit to doing.” — Patrick Crutcher, director of business development, Sept. 26.

“FYI, we are ‘blowing through’ copay dollars very fast. … My opinion is that with the current state of affairs that we should continue to provide to patients, but we’ll need to ultimately evaluate this program and understand the effect on margin.” — Jon Haas, director of patient access, Sept. 29.

“As early as next week, the Board should remove Martin as CEO. … the price drop has to be significant and tied to something. … This cannot be seen as something that appears to be as arbitrary as the price hike in the first place.” — Outside PR consultant, Oct. 8.

On Dec. 16, Shkreli was arrested on securities fraud charges related to his tenure at another firm. He resigned the following day.

“I am confident I will prevail,” Shkreli wrote on Twitter on Dec. 19. “The allegations against me are baseless and without merit.”

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Patients suffered no additional harm when doctors training to be surgeons were allowed to work longer shifts, a study published Tuesday concludes. The findings provide fresh evidence for medical educators looking to relax the strictest limits on resident hours.

The study in the New England Journal of Medicine comes as the Accreditation Council for Graduate Medical Education is reassessing requirements that prevent residents from working extremely long stretches or back-to-back shifts. Those rules were enacted in 2003 and strengthened in 2011 amid concerns that sleep-deprived residents were more likely to make serious errors.

Since then there has been pushback from residency program directors concerned that the rules created new dangers for patients by abruptly forcing interns to leave in the middle of treating a patient or performing surgery. They also complain the rules interfere with resident education because it is harder for trainees to follow their patients.

The study released Tuesday conducted a direct experiment by tracking patient outcomes after loosening the rules for doctors in 58 surgical residency programs. It found that their patients didn’t die or suffer complications any more often than at 59 residency programs that stuck with the current rules.

“We believe the trial results say it’s safe to provide some flexibility in duty hours,” said Dr. Karl Bilimoria, the main author and a professor of surgery at the Feinberg School of Medicine at Northwestern University in Chicago.

Some previous studies had come to similar conclusions, but this one has been anticipated because of its more rigorous methods. The trial has drawn protests from Public Citizen and the American Medical Student Association, which said researchers put patients and residents at risk by waiving the rules.

The groups assert that the experiment, funded by the American Board of Surgery, the American College of Surgeons and the accreditation council, was never likely to find a significant difference in patient outcomes, since most elements of patient care — the physicians, specialists, nurses and other clinical workers — remained unchanged.

“Research on the deleterious effects of chronic sleep deprivation is just overwhelming,” said Dr. Deborah Hall, president of the medical student association. “I’m concerned we’re going to walk away from a lot of progress that’s been made without overwhelming data [showing] that residents aren’t subject to the ordinary limits of human neurobiology.”

In an editorial also published in the journal, Dr. John Birkmeyer, chief academic officer at Dartmouth-Hitchcock, a health system in New Hampshire, came to a different conclusion than Bilimoria. Birkmeyer wrote that the experiment “effectively debunks concerns that patients will suffer as a result of increased handoffs and breaks in continuity of care.”

Rather than roll back the rules on duty hours, he argued that surgeons should find safer ways to treat patients without relying on “overworked” residents.

“To many current residents and medical students, 80-hour (or even 72-hour) workweeks and 24-hour shifts probably seem long enough,” Birkmeyer wrote. “Although few surgical residents would ever acknowledge this publicly, I’m sure that many would love to hear, ‘We can take care of this without you. Go home, see your family, and come in fresh tomorrow.’ “

The research was conducted in the academic year that began in the fall of 2014. One group of residency programs followed the existing rules, while the other programs were allowed to remove several strictures.

Residents in the experimental group could stay at the hospital longer than 28 hours in a row, the current maximum. They did not have to be given at least eight hours off between shifts. Residents who worked a 24-hour shift no longer had to wait 14 hours before returning to the hospital. And first-year residents could work more than 16 hours in a row, a limit set in 2011.

After analyzing medical records for 65,849 patients in the control group and 72,842 in the experimental group, the researchers found no significant difference in death or complication rates. They also surveyed 4,330 general surgery residents and found that those with the more flexible schedules rated their overall well-being and morale no different than did those with strict rules.

“We’re very encouraged by the findings,” said Dr. Maya Babu, a neurological surgery resident at the Mayo Clinic and president of the Resident and Associate Society of the American College of Surgeons. “We feel very strongly that flexibility is important to provide opportunities to learn and to have patient ownership, to see patients from the time they’re admitted through surgery the next day.”

Seven percent of residents exempted from the duty limitations said they left during an operation at least once a month, while 13 percent of those following the rules said they left. Thirty percent of the experimental group said they missed an operation at least once a month, while 42 percent of those with standard rules said they missed one. A third of the test group said they turned a patient over to another doctor in the middle of dealing with them, while nearly half of the control group recalled doing so.

Dr. Michael Carome, director of Public Citizen’s Health Research Group, a patient safety advocacy organization, said the study should have objectively assessed the hours residents worked and the effects on their health and patients, rather than rely on surveys. He said the study also didn’t track whether residents in the control group adhered to the stricter limits on how long they could work.

“The study didn’t collect any meaningful data on resident health outcomes,” Carome said.

The most major restrictions on resident duty hours put into place in 2003, such as a maximum workweek of 80 hours a week and a minimum of one day off every seven, were not tested in the study and are expected to remain in place.

The paper was scheduled to be presented Tuesday at the Academic Surgical Congress in Jacksonville, Fla. A similar experiment, looking at internal medicine residents, is still in progress.

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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The updated childhood immunization schedule, released today from the Centers for Disease Control and Prevention, includes a couple tweaks to vaccine recommendations for older children and teens.

One officially moves the recommendation for the human papillomavirus (HPV) vaccine a few years earlier for children with a history of sexual abuse and officially recommends the HPV-9 vaccine over other HPV vaccines. Another offers all older teens the option of a meningitis vaccine previously recommended only for high-risk children.

The HPV vaccine is currently recommended for girls and boys ages 11to 12. The HPV-9 protects against nine strains of HPV, an infection that can lead to cervical and other cancers, including mouth and throat cancers. Though HPV is the most common sexually transmitted infection, it sometimes can be transmitted without sexual contact.

“More than 80 percent of the population will be infected at least once in their lifetime,” said Cody Meissner, a professor of pediatrics at Tufts University School of Medicine who was involved in discussions about the new schedule.

The new vaccination schedule recommends that 9- and 10-year-olds receive the HPV vaccine if they have a history of sexual abuse. Studies estimate that one in four girls and one in 20 boys will experience sexual abuse before age 18.

“It is an ubiquitous, tragic and unfortunate reality,” said Mark Schleiss, director of pediatric infectious diseases at the University of Minnesota in Minneapolis. Age-appropriate sexual abuse screening questions are already incorporated into well-child visits, he added.

“Perhaps this language will help remind primary care physicians that they need to be asking their patients about sexual abuse,” Schleiss said. “These perpetrators are usually someone the child knows and trusts and even loved ones, so it’s a very delicate issue, but we just have to get past the denial that these things don’t happen to young children.”

Child victims of sexual abuse have a higher risk of sexually transmitted infections for several reasons, Meissner said. They may be infected during the first assault or during continuing abuse, and they initiate sex sooner than their peers.

“If a child’s been sexually abused, she or he tends to engage in sexual activity at an earlier age and more frequently with a greater number of partners than someone who wasn’t abused,” Meissner said.

One third of child victims of sexual abuse are younger than age 9, according to the U.S. Department of Health and Human Services Children’s Bureau. But 9 is the earliest age the vaccine is licensed for, explained Anna Giuliano, director of the Center for Infection Research in Cancer at Moffitt Cancer Center in Tampa, and a researcher who led HPV vaccine clinical trials.

“They’re going as young as the license will allow them to go,” Giuliano said. “Otherwise they’re going off label, and ACIP will not allow them to go off label.” ACIP is the Advisory Committee on Immunization Practices, which makes vaccine recommendations at the CDC.

Parents might wonder how long the vaccine’s effectiveness lasts, Guiliano said, but more than 10 years of followup data from clinical trials show it has long-term staying power.

“When we look at how the antibodies have sustained, we anticipate the vaccine will protect out to 30 years or more post-vaccination,” Guiliano said. “We have no reason to believe that the protection will wane over time.”

Studies have also shown that the immune response to the HPV vaccine is better in children ages 9 to 15 than in those ages 16 to 24, said Wendy Sue Swanson, a pediatrician and executive director of digital health at Seattle Children’s Hospital.

“Every vaccine in the schedule is designed around giving it as early as it can be used so it can protect as long as possible,” she said. “You don’t get any less side effects by waiting for the vaccine, so it makes no sense to wait until they’re older.”

Yet HPV vaccine uptake has lagged — about 60 percent of girls and 42 percent of boys received at least one dose in 2014 — in part because of doctors’ hesitancy.

“We need to help providers to make a strong cancer prevention recommendation for vaccinating 11- and 12-year-old boys and girls with the HPV vaccine,” Guiliano said. “If all the pediatricians and family practice doctors were making that strong recommendation, I think we would see a strong increase in the rate of uptake in that vaccine.”

Despite finally having a vaccine that can prevent cancer, Meissner said, HPV vaccination rates fall below those of several African countries.

“It’s one of the safest vaccines we’ve got, and it’s such a shame that our uptake has been so low,” he said.

The other change adds a vaccine against serotype B of meningococcal disease, which causes meningitis, an infection of the covering of the brain and spinal cord. It is now recommended at age 10 for children with increased risk of catching or not effectively fighting the disease. That includes individuals with a missing or damaged spleen, sickle cell anemia or other problems with the body’s complement system, which helps the immune system recognize and kill bacteria, Schleiss said.

ACIP also added the meningitis serotype B vaccine as an option for teens ages 16 to 18, an unusual recommendation because it is optional but not universally recommended, unlike other vaccines on the CDC schedule.

“ACIP and CDC are saying, it should be funded, it’s safe to give, it’s effective in preventing in the short-term infections that are caused by meningitis B, but we’re leaving this decision up to the pediatrician and the parents to discuss,” Swanson said. “We don’t see significant life-threatening side effects from this vaccine, but the risk of your child getting meningitis serotype B is also really low.”

Though very rare — the U.S. had about 160 cases in 2012 — the disease is also very lethal, Swanson said: 10 to 15 percent of kids who get meningitis will die even with treatment.

“I’d recommend it for anyone who’s a parent of a teenager because this disease is so devastating,” Schleiss said.

But Meissner, a member of the CDC meningococcal vaccines working group, said the risk-benefit balance does not justify recommending the vaccine for all teens.

“The burden of diseases is so low that I don’t think that’s the way the country should be spending its money,” Meissner said. “The likelihood of having an anaphylactic reaction to the vaccine may in fact be greater than the odds of deriving benefits.”

According to a CDC study last year, a routine meningitis B vaccine recommendation for all teens would prevent approximately 15 to 29 cases and two to five deaths each year. Vaccinating all college freshmen, in light of recent outbreaks on college campuses, would prevent about nine cases and one death a year.

“To immunize an entire population would expensive and maybe overkill, but it’s a safe vaccine and it’s really effective, so we want parents and pediatricians who want it to have it,” Swanson said.

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Pharmacies across the U.S. will begin receiving shipments of a generic form of the revolutionary cancer pill Gleevec this week after the drug lost its patent protection on Monday.

The generic version of drug, known as imatinib, is likely to cost about 30 percent less than brand-name Gleevec, says Kal Sundaram, the CEO of Sun Pharmaceuticals, the Mumbai, India-based company that will make the first generic.

Specific prices will be negotiated with insurers and pharmacy wholesalers, he says.

The launch is one move in the ongoing push and pull over rising drug prices. More than a dozen major drugs are losing their patent protection this year, leaving them open to competition from generics.

Still, drug prices overall continue to climb.

When Gleevec was launched by pharmaceutical giant Novartis in 2001 to treat chronic myeloid leukemia in adults, it was a huge advance in the treatment of that disease and in cancer therapy overall. The drug has since been approved to treat other types of leukemia and blood cancers, some rare skin cancers and some gastrointestinal tumors. Sales last year reached $4.7 billion worldwide and $2.5 billion in the U.S.

While the launch of generic imatinib will undoubtedly cut the price of treatment, the effect may not be dramatic at first.

Sundaram says he expects his medication to capture about 30 percent of the U.S. market over the next six months, leaving the rest to branded Gleevec. After that, generics from other companies may go on sale, which could lead to even lower prices.

Since Gleevec was launched, Novartis has raised the price of Gleevec often, nudging it even higher in recent years. The price for one pill climbed from $92.74 in 2010 to $179.93 in 2014, according to data from Centers for Medicare and Medicaid Services, which spent almost $1 billion on Gleevec in 2014.

A price cut of 30 percent would bring down the cost of the medicine to about what it was in 2013.

Novartis spokeswoman Julie Masow says the company expects Gleevec sales to fall “in a similar manner to other major comparable products that have experienced the loss of market exclusivity.”

Sundaram says Sun is planning to support sales of its generic imatinib by appropriating many of the tactics used by makers of brand-name drug manufacturers.

The company will have a discount card to ensure patients only have to pay a $10 copay and will cover up to $700 to help patients meet their deductibles.

Drugmakers, including Novartis, offer similar discounts to help keep patients buying their branded drugs after competing medications go on sale. Insurance companies often charge patients a higher copay for brand-name drugs to help steer them to lower costs generics.

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Any day now, Ben Lecomte will plunge into the Pacific Ocean off a Tokyo beach towards San Francisco. He wants to become the first person to swim across the Pacific. He’s already the first person to free swim across the Atlantic Ocean, without a kickboard.

No one knows what the physical feat of swimming 5,500 miles will have on Lecomte’s heart, but cardiologists are anxious to find out. His swim offers a rare opportunity to study whether extreme athletic performance has a harmful effect on the heart.

After completing his swim across the Atlantic in 1998, the first words out of Ben Lecomte’s mouth were “never again.”

Now this 48-year-old, French-born American is about to embark on a swim expected to take five to six months.

“I’m not a fast swimmer,” Lecomte says. But boy is he dedicated. “Swimming is a passion,” he says. “You cannot just push it away.”

Lecomte, who lives in Austin, Texas, is diving back in the ocean to focus attention on environmental problems. He’s worried about the future for his kids. During the swim he will collect data on the Pacific, including the microbes and trash he encounters. People can follow along on his Facebook page, The Longest Swim.

And he will also collect data on himself, including how his heart holds up for eight hours of freestyle every single day. This data will go to Benjamin Levine, a cardiologist at UT Southwestern Medical Center and director of the Institute of Exercise and Environmental Medicine at Texas Health Resources.

“My question has always been, how much exercise do you need to do to injure the heart?” Levine says. “Since Ben was planning to swim across the Pacific Ocean, we thought ‘Hey, this might be a good opportunity.’ “

After all, we’re told more exercise is better — and generally, it is. Yet several studies of extreme endurance athletes have called that idea into question.

People who run marathons or do triathlons can have some scarring or fibrosis in the center of the heart, says Paul Thompson, chief of cardiology at Hartford Hospital in Connecticut. “Right where the two sides of the heart join each other — the septum.”

This scarring at the septum is worrisome, Thompson says, particularly for people who have an underlying genetic condition that weakens the heart muscle.

And there’s a second area of concern. “It’s been shown in a couple of studies now that people who are lifelong endurance athletes have more coronary artery calcification than you would expect for their risk factors,” Thompson says.

Calcification, meaning a buildup of calcium in the heart, is not something you’d expect to find in people swimming long distances, running ultramarathons or tackling Ironman competitions. There could be a genetic explanation to both the calcium issue and the scarring, Thompson says. So he advises people to study up on their family history and see if there have been cases of sudden death, then weigh the benefits and risks of extreme exercise.

“We don’t think that long-term exercise is dangerous, because long-term endurance athletes live longer than other people,” Thompson says. But Thompson does wants to figure out what’s going on.

Which brings us back to Ben Lecomte and the tricky task of monitoring his heart from the middle of the ocean.

Using technology that NASA uses for monitoring astronauts on the International Space Station, UT Southwestern’s Levine will be able to monitor Lecomte’s heart during his swim. It’s a small echo machine, like an ultrasound for the heart, that will be on the support boat traveling with Lecomte. Once a month, while resting on the boat, Lecomte will turn the machine on and use a satellite phone to call the Johnson Space Center.

Someone there will tell Lecomte how to position the probe to give himself an echocardiogram.

From his desk in Dallas, Levine will see images of how fast Lecomte’s heart is contracting, how quickly the blood flows in and out of the valves, and any stress where the two sides of the heart meet.

His prediction?

“I think when he comes back he’ll have signs of a little inflammation or irritation right where the right and left ventricle connect,” Levine says. “That’s what we see in some other of these elite long endurance athletes, and I think that’s what we’ll see in Ben.”

For most people this inflammation is really of no consequence, Levine says. But for some people, for example those who have pulmonary hypertension or other kinds of heart disease, it could cause problems.

He hopes studying Lecomte’s heart will help reveal why extreme exercise changes the heart and determine whether there’s a limit to how much exercise the human heart can handle.

Ben Lecomte is not worried. He thinks his heart can handle the enormous ocean, some 20-foot-high waves and the occasional shark.

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There’s football season, hunting season, and the holiday season. Overlapping all of these is something decidedly less fun and sexy: open enrollment season for health insurance.

“We’ve been busy this past month,” says Iris Galvez, a health insurance navigator with the Houston social services agency Change Happens!

Galvez helps people navigate the Healthcare.gov website and enroll in health plans offered through the Affordable Care Act marketplace.

“It’s the holidays, that makes it hard. Because people are like ‘Well, we’ll just put it off,’ ” Galvez says with a laugh. “But now we’re getting very busy.”

Earlier this month, Galvez helped Elisia and Cipriano Saenz, a couple from north Houston, select a plan with Molina.

“You’ll have to pay this much per month to Molina,” Galvez explains in Spanish, before handing over a summary sheet listing the couple’s monthly premium payment ($363), the federal subsidy ($691), deductible ($2,000), and copays ($20 for the primary care doctor, $55 for a specialist).

“They’re pretty good, reasonable,” Saenz says of the amounts. “We’ll be able to afford it.”

Elisia Saenz thanks Galvez for her assistance.

“You made our day,” she says. “Because we were having a hard time getting in to it.”

Last year, her husband Cipriano Saenz did try to sign the couple up, but he was confused, and then suspicious when a government worker requested more paperwork and asked him to confirm his Social Security number.

“Sometimes we have to be careful who we talk to, give our Social Security, ID number,” Saenz explains. “He told them ‘I’m very sorry. I can’t give my information to you all through phone.’ “

Elisia Saenz says he never followed up, and the insurance lapsed.

“Something had gone wrong, or maybe he didn’t understand,” she says.

Signing up can be a chore. You need to gather financial documents and set aside money for the monthly premium. Not only that, it’s just unpleasant to think about risk and injury and disease.

Galvez noted that some of her returning clients were angry this year because the insurance networks had become narrower. Almost all the coverage plans on the exchange in Houston are now HMOs.

“This year they have taken away the PPO. So a lot of people are not pleased with that,” Galvez said.

That means they have fewer choices of doctors and hospitals. Still, she tries to focus on the positives – not only avoiding the federal tax penalty for not being covered (which is either $695 for each adult without coverage or 2.5% of household income), but also the peace of mind that insurance will bring.

“You never know, you know? You fall and slip and break your leg, that’s a big bill from the hospital,” she says.

Elisia Saenz is 56 and Cipriano Saenz is 62. They work as janitors at a charter school, where Elisia also works in the kitchen. She says they can’t afford the insurance offered at the school.

“It’s been years that I haven’t been to a doctor,” Elisia says. “Thank God that I haven’t gotten sick. Now I can just go and get a whole physical, and he can do the same. So we’re happy that we got this.”

The Obama administration has increased its outreach this year to Hispanics, running special ads and targeting cities like Houston, Miami and Dallas with big Hispanic populations.

Across the country, 20.9 percent of Hispanics are uninsured in the U.S., compared to 12.7 percent of blacks and 9.1 percent of whites, according to the Kaiser Family Foundation.

There are lots of reasons why. Hispanics are more likely to work in jobs that don’t offer health benefits. Many are ineligible for the Affordable Care Act, or just don’t know about the options available.

Of the three states with the biggest Hispanic populations, only one, California, has chosen to expand Medicaid to low-income, uninsured adults. Florida and Texas have not expanded Medicaid, and that’s affected many low-income Hispanic adults.

In surveys, Hispanics explain the main reason they are uninsured is cost. Health coverage just seems too expensive to fit into a budget.

“They don’t make enough money where they work, or they work self-employed, cutting yards and stuff,” says Elisia Saenz, describing some of her neighbors.

“Sometimes they can barely, probably make it to pay the rent, feed their kids, clothe them. I know it’s kind of hard for them, if it’s just one person working in the household.”

Federal officials counter that’s an outdated perception for some Hispanics – because under the new law, many would qualify for subsidies to buy insurance, just like the Saenzs did.

Enrollment in most states for 2016 ends Sunday.

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

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There are different ways to reach voters. Vermont Senator Bernie Sanders delivers fiery speeches that fill concert halls and arenas. But generally speaking, people don’t leave Hillary Clinton events ready to start a political revolution. Big speeches and soaring rhetoric really aren’t her thing.

Instead, the former Secretary of State is trying to win voters over by being a wonk who delivers page after page of policy white papers. As Clinton makes her closing argument in Iowa, “in my plan” has to be the most oft repeated phrase in her stump speech.

Autism is not the kind of thing that dominates televised debates or tops polls as a leading issue facing the nation. But Hillary Clinton has a white paper on it, the “Plan To Support Children, Youth and Adults Living With Autism, and Their Families“. She’s also got plans for Alzheimer’s, drug addiction and elder care too.

In total, the Clinton campaign has more than two dozen policy papers — more than 50,000 words of them, many heavy on footnotes.

For Clinton campaign volunteer Abby Walker, 19, the autism plan was a big deal. That’s because her older brother has autism.

“So when Hillary came out with her plan, I just saw this and I just knew right away I needed to keep knocking on doors even more,” Walker said.

Walker goes to college in Missouri, but drives more than an hour home to Ottomwu, Iowa to convince others to caucus for Clinton.

“Ever since I got back to school, I’ve been going home like pretty much every weekend because I’ve just realized how important it is once she released her autism plan,” Walker said.

Walker and her mom attended one of Clinton’s small listening tour events during the summer. According to Walker, her mother talked to Clinton about autism.

“My mom just told her a little bit about my brother and how much he needs, services and stuff like that,” Walker said.

When Clinton’s plan was released, Walker’s mother posted it on Facebook. And she wasn’t alone.

The plan showed up in the Facebook feeds of people and organizations who don’t typically talk about presidential politics. That includes the Autistic Self Advocacy Network run by Ari Ne’eman, one of many advocates Clinton’s policy team consulted.

Ne’eman said his group would likely not even be talking about the presidential candidate without this plan and hopes to get all the presidential candidates to develop similar autism plans.

“Certainly not to the same degree and certainly not in the same way,” Ne’eman said. “It resonates and it reaches. The fact that it’s done in a well-considered way and the fact that it’s done by consulting with autistic adults ourselves really matters.”

Clinton campaign press secretary Brian Fallon said when voters have shared their concerns with Clinton, she wants to be able to offer proposals to address those issues.

“It is Hillary Clinton’s idea of fun to take a thick briefing binder home at night to her hotel, if she is on the road, and study it and to give feedback to the staff that is providing her with a menu of options for different policy prescriptions on any given issue. She loves to engage on that,” Fallon said.

But is being a wonk in a time when voters feel uneasy and even angry really a recipe for victory? It’s certainly a way to micro-target voters and meet them where they live.

Margie Omero, a Democratic pollster at Purple Strategies, says many of Clinton’s proposals fall into the category of caregiving.

“Those are huge issues facing a lot of every day Americans in their daily life, far more I might add than the things we talk about a lot in Washington. The enormous amount of pressure that women feel caring for everyone in their family, it can really not be overstated,” Omero said.

The question is whether Clinton’s many plans to address these concerns will drive the people who care passionately about them to caucus Feb 1.

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