It’s barely been two weeks since Idaho regulators said they would allow the sale of health insurance that doesn’t meet all of the Affordable Care Act’s requirements — a controversial step some experts said would likely draw legal scrutiny and, potentially, federal fines for any insurer that jumped in.

And on Wednesday, Blue Cross of Idaho unveiled a menu of new health plans that break with federal health law rules in several ways, including setting premiums based on applicants’ health.

“We’re trying to offer a choice that allows the middle class to get back into insurance coverage,” said Dave Jeppesen, the insurer’s executive vice president for consumer health care.

The insurer filed five plans to the state for approval and hopes to start selling them as soon as next month.

The Blue Cross decision ups the ante for Alex Azar, the Trump administration’s new Health and Human Services secretary. Will he use his authority under federal law to compel Idaho to follow the ACA and reject the Blues plans? Or will he allow state regulators to move forward, perhaps prompting other states to take more sweeping actions?

At a congressional hearing Wednesday, even as Blue Cross rolled out its plans, Azar faced such questions. “There are rules,” Azar said. “There is a rule of law that we need to enforce.”

However, he didn’t specifically indicate whether the federal government would step in.

Robert Laszewski, a consultant and former insurance industry executive, says it should. “If Idaho is able to do this, it will mean other … states will do the same thing,” he said. “If a state can ignore federal law on this, it can ignore federal law on everything.”

Idaho’s move stirs up more issues about the stability of individual insurance markets.

Policy analysts say that allowing lower-cost plans that don’t meet the ACA’s standards to become more widespread will pull younger and healthier people out of Obamacare, raising prices for those who remain. Supporters say that is already happening, so the lower-cost plans provide more choices for people who earn too much to qualify for subsidies to help them purchase ACA coverage.

Idaho’s move to allow such plans, announced in January, drew harsh and swift criticism.

“Crazypants illegal,” tweeted Nicholas Bagley, a law professor at the University of Michigan and former attorney with the civil division of the U.S. Department of Justice, who said that states can’t pick and choose which parts of federal law to follow. Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms, pointed out that health insurers could be liable for sharp fines if they are found to be in violation of the ACA.

But both Idaho regulators and Blue Cross officials say they aren’t worried.

Jeppesen said the ACA gives states regulatory authority “to make sure the market works and is stable,” and the insurer is simply “following what the state has given us guidance” to do.

Other insurers in Idaho are taking a much more cautious approach, telling The Wall Street Journal they aren’t stepping up immediately to offer their own plans.

Laszewski said they are likely waiting to see what legal challenges develop. “If I were running an insurance company, there’s no way I would stick my neck out until the high court has ruled in favor of this — and they’re not going to,” he said.

Jeppesen said his company has consulted with legal experts and is moving ahead with confidence. The aim is to bring people back into the market, particularly the young, the healthy and those who don’t get a tax credit subsidy and can’t afford an ACA plan.

For some people — especially younger or healthier applicants — the new plans, which the insurer has named Freedom Blue, cost less per month than policies that meet all ACA rules.

They accomplish that by limiting coverage. If they are allowed to be sold, consumers will need to weigh the lower premiums against some of the coverage restrictions and variable premiums and deductibles, policy experts say.

The plans, for example, will include a “waiting period” of up to 12 months for any pre-existing conditions if the applicant has been without coverage for more than 63 days, Jeppesen said.

Additionally, they cap total medical care coverage at $1 million annually. And premiums are based, in part, on a person’s health: The healthiest consumers get rates 50 percent below standard levels, while those deemed unhealthy would be charged 50 percent more.

All those conditions violate ACA rules, which forbid insurers from rejecting coverage of preexisting conditions or setting dollar caps on benefits or higher premiums for people with health problems.

But the rates may prove attractive to some.

Premiums for a healthy 45-year-old, for example, could be as low as $195 a month, according to a comparison issued by the insurer, while a 45-year-old with health problems could be charged $526. In that case, the 45-year old would find a lower price tag — $343 a month — for an ACA-compliant bronze plan.

While Freedom Blues plans cover many of the “essential health benefits” required under the ACA, such as hospitalization, emergency care and mental health treatment, they do not include pediatric dental or vision coverage. One of the five plans doesn’t include maternity coverage.

When compared with one of the Blues’ ACA-compliant plans — called the Bronze 5500 — the new standard Freedom Blue plan’s annual deductibles are a mixed bag.

That’s because it has two separate deductibles — one for medical care and one for drugs. If a consumer took only generic drugs, the new plan would be less expensive, according to details provided by the plan. But with a $4,000 deductible for brand-name drugs, the Freedom Blue plan requires more upfront money before full coverage kicks in than the ACA-compliant plan it was compared with.

Jeppesen said the insurer hopes to attract many of the “110,000 uninsured state residents who cannot afford [ACA] coverage.”

That’s the total number of uninsured people who earn more than 100 percent of the federal poverty level in the state, he said.

Sarah Lueck, senior policy analyst for the Center on Budget and Policy Priorities, cautioned that some of those residents might actually be eligible for subsidies under the ACA, which are available to people earning up to four times as much.

“Many … could be getting subsidies for more comprehensive coverage through the [ACA-compliant state exchange] and would be better off,” Lueck said.

Kaiser Health Newsis a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that is not affiliated with Kaiser Permanente.

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Richard Klein switched doctors last year. The new doctor put him on a new blood pressure drug.

But it didn’t help.

The failure was entirely predictable.

Klein, an associate professor at Florida International University in Miami, realized later that he had tried the same medicine unsuccessfully a few years before, but he hadn’t remembered that fact during the appointment.

It was an understandable mistake for Klein and his doctor.

Klein’s prescription history was hidden somewhere in the hundreds of pages of medical records his new doctor had to go through.

“If I had been able to go into an app sitting in his office and look through my prescription history, I would have known that, yeah, we tried that a couple years back and it didn’t work well,” he says.

A feature like that will soon be available for some patients with iPhones.

In the upcoming release of Apple’s iOS operating system for iPhones this spring, the Health app will include health records, so patients can take information about their immunizations, medications, lab results and more with them.

The feature will first be available to patients of medical providers who partnered with Apple, including Johns Hopkins Medicine; OhioHealth; Ochsner Health System in Jefferson Parish, La.; and Cedars-Sinai in Los Angeles. It won’t cost those patients anything to use this feature, assuming they’re already iPhone users.

Apple’s announcement says more medical facilities will offer this feature in the coming months.

Some doctors hail it as a big shift away from patients having to handle a big pile of paper records every time they see a new doctor. But Google offered a similar service before and it failed. The search giant shut it down in 2012.

Can Apple succeed where Google didn’t?

Dr. Jonathan Slotkin says yes; he is a medical director handling digital patient engagement at Geisinger Health System in Pennsylvania, one of Apple’s partners. Unlike even a few years ago, a lot more people now use smartphones and the phones are more secure. There’s now also a technical standard for transferring electronic medical records.

“Even if I get care at three different places and maybe they use three different electronic systems, now in one place that I possess in an encrypted way, I have all of that information at my fingertips,” he says.

He adds this will make transferring information easier for patients who have to move, or go to a specialist.

The health records feature could also change doctors’ habits in some ways, says Dr. Isaac Kohane, chair of the department of biomedical informatics at Harvard Medical School and a professor of pediatrics.

“For some reason, and I say this as a physician, most physicians, if they don’t actually know how a test was done, somehow imagine it was done wrongly, and therefore repeat a test, not only at a cost but at some pain to the patient,” Kohane says. “If you have a reliable authoritative description of the test and its results, that uncertainty goes away and that excuse to repeat tests goes away as well.”

Checking your prescription history or past medical tests should be easier soon if you have an iPhone.

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Apple

Kohane called Apple’s new feature a “tectonic shift” in a commentary for member station WBUR’s CommonHealth.

But Apple will have to address one big problem that Google had with Google Health, a similar health records service: It was popular with only a niche audience — tech-savvy patients and their caregivers, and fitness enthusiasts. The product didn’t attract a wide base of users.

This time will be different, says Dr. Ida Sim, a co-director of biomedical informatics at the University of California, San Francisco Clinical and Translational Sciences Institute. Why? Because unlike with Google Health, patients no longer have to do the heavy lifting of entering or scanning their own data. Also, the 21st Century Cures Act of 2016 pushed federal agencies and providers to use electronic health records, and now there is a data standard for personal health records, which wasn’t the case in 2011.

However, she writes in an email that wider adoption will still be an issue.

“We’ll probably see huge numbers of people getting their initial Health Records populated. The issue is, then what?… The value will come from third party apps that use Health Records to provide meaningful value to patients, and until this value is demonstrated, I think Health Records uptake will be large but retention and continued engagement of patients will be challenging.”

Alan Yu reports forThe Pulse, WHYY’s health and science show.

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The maker of OxyContin, one of the most prescribed and aggressively marketed opioid painkillers, will no longer tout the drug or any other opioids to doctors.

The announcement, made Saturday, came as drugmaker Purdue Pharma faces lawsuits for deceptive marketing brought by cities and counties across the U.S., including several in Maine. The company said it’s cutting its U.S. sales force by more than half.

Just how important are these steps against the backdrop of a raging opioid epidemic that took the lives of more than 300 Maine residents in 2016, and accounted for more than 42,000 deaths nationwide?

“They’re 20 years late to the game,” says Dr. Noah Nesin, a family physician and vice president of medical affairs at Penobscot Community Health Care.

Nesin says even after Purdue Pharma paid $600 million in fines about a decade ago for misleading doctors and regulators about the risks opioids posed for addiction and abuse, it continued marketing them.

“I think it’s similar to the tobacco industry learning they could sell tobacco without spending a lot of money on advertising. My guess is this decision is in their self-interest,” he says.

A nationwide lawsuit against Purdue Pharma for deceptive marketing continues to grow. Seven cities in Maine have joined, including Portland, Lewiston and Bangor, along with five counties, to recoup some of the costs of addressing the addiction crisis.

A spokesman for Purdue Pharma said in an email that the decision to stop marketing to prescribers is voluntary and independent of any litigation.

Nesin says that at the very least, the company’s decision to refrain from promoting opioids to doctors reinforces the need for caution when prescribing the drugs.

Maine Medical Association President Dr. Robert Schlager agrees that Purdue Phama’s move is a good, if small, step to fight the opioid epidemic. “I wouldn’t expect it to have a very large role in limiting opioids further,” he says. “Because most of us, as prescribers, do limit our information exchange with the drug representatives who have been marketing opioids.”

Since 2016, doctors in Maine have also adhered to prescribing limits enacted by the Legislature. As of December 2017, legislatures in 17 states had enacted prescribing limits and nine others had authorized other state entities to enact them.

Schlager says Purdue Pharma should go further and suspend opioid marketing worldwide. “It seems a little bit not honest to just limit it here in the United States,” he says.

In an email, Purdue Pharma’s spokesman says that the company operates only in the United States, and that an associated company, Mundipharma, has not marketed opioids in Europe since 2013.

A Los Angeles Timesinvestigation in 2016 found that the family that owns Purdue Pharma has a network of international companies that employ the same kinds of marketing practices that made OxyContin a blockbuster seller in the U.S.

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

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