Kids with chronic conditions are especially vulnerable to health insurance changes, relying as they often do on specialists and medications that may not be covered if they switch plans. A recent study finds that these transitions can leave kids and their families financially vulnerable as well.

The research, published in the April issue of Health Affairs, examines the spending impact of shifting chronically ill kids from the Children’s Health Insurance Program (CHIP) to policies offered on the marketplaces established under the federal health law. The out-of-pocket costs to these children’s families would likely rise — in some cases dramatically — following a change to marketplace coverage, the study finds.

The research comes at a time when health insurance issues are on the front burner in Congress. Republican lawmakers are pushing for fundamental changes to the marketplaces and to the Medicaid program. At the same time, Congress must soon decide whether to extend CHIP when its funding ends in September.

Together the state-federal Medicaid and CHIP programs insure 46 million low-income children. CHIP covers kids whose family income is low, but too high to qualify for Medicaid.

The eligibility levels vary by state. Half of states set the upper income eligibility limit at 255 percent of the federal poverty level or higher (about $52,000 for a family of three). Both programs provide comprehensive coverage for children with little or no out-of-pocket cost to families.

Since passage of the Affordable Care Act in 2010, some policy analysts have advocated moving children who are enrolled in CHIP into marketplace plans and dismantling the CHIP program. But earlier evaluations found, as does this study, that CHIP coverage is better and cheaper than marketplace coverage, said Joan Alker, executive director of the Georgetown Center for Children and Families.

CHIP is much smaller than Medicaid, with more than 8 million children enrolled. Roughly 2 million have one of six chronic health conditions, including asthma, attention deficit hyperactivity disorder, diabetes, epilepsy, mood disorders and developmental disorders such as autism, according to the study.

Using data compiled from state CHIP programs and marketplace plans for 2016 and health care use data from the federal Medical Expenditure Panel Surveys from 2008 to 2013, researchers simulated the annual out-of-pocket costs for children with these six chronic conditions if they were enrolled in CHIP versus one of the plans sold on the marketplaces operated by the federal government.

The spending differences were stark. For every chronic condition and at every income level, cost sharing was higher for children enrolled in marketplace plans than for those in CHIP.

Take the case of asthma, the most common condition that researchers modeled. For a child with asthma, whose family income was between 100 and 150 percent of the federal poverty level (about $20,000 to $30,000 for a family of three), annual out-of-pocket spending on deductibles and copays would be $284 in a marketplace plan, compared with $27 in CHIP — a difference of $257.

At higher incomes, the out-of-pocket spending differences were greater. Families with incomes between 251 and 400 percent of the federal poverty level (about $51,000 to $81,000 for a family of three) would pay $1,227 out-of-pocket annually if they were enrolled in a marketplace plan but just $84 in the CHIP program — a difference of $1,143 for the year.

“The lowest income families were relatively well protected by cost-sharing reductions” in marketplace plans, said Amy Davidoff, who is a senior research scientist in the Department of Health Policy and Management at the Yale School of Public Health and one of the study’s co-authors.

Those cost-sharing subsidies (which reduce a plan’s deductible, copayments and coinsurance) are available to marketplace customers with incomes up to 250 percent of the federal poverty level (about $51,000 for three people).

These Obamacare subsidies are now the subject of a lawsuit, however, and their fate is unclear.

As family income rises, the gap between the out-of-pocket costs for the two different types of coverage increases and becomes quite substantial, Davidoff said. “For these families, it would be huge barrier,” she said.

The deductible — the amount that people have to pay on their own before insurance covers most services — was a significant factor in the cost differences. The average deductible in marketplace plans for families with incomes between 251 and 400 percent of poverty was $3,126. None of the CHIP programs for families at that income level had deductibles, the study found.

Noting that CHIP has a history of strong bipartisan support, Alker said she is hopeful that federal lawmakers will extend the program.

“I think it would be very hard for Congress to let CHIP expire,” she said, “and put those children into the marketplace, when according to their leaders it’s about to fold.”

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

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Four out of five older Americans with hearing loss just ignore it, in part because a hearing aid is an unwelcome sign of aging. But what if hearing aids looked like stylish fashion accessories and could be bought at your local pharmacy like reading glasses?

That’s the vision of Kristen “KR” Liu, who’s the director of accessibility and advocacy for Doppler Labs, a company marketing one of these devices. She thinks a hearing aid could be “something that’s hip and cool and people have multiple pairs and it’s fashionable.”

Liu, who has severe hearing loss herself, helped design a device designed to let people with hearing loss blend in. One person may be using the technology to stream music or take a phone call, she says. Another may be wearing it to amplify speech and hear the conversation. “And no one is going to know the difference,” Liu says. “So you’re wearing technology in your ear, proudly.”

The device is a small circular instrument that fits snugly in the ear. It can be adjusted to individual hearing using a smartphone app to control volume, cut out background noise or turn up the sound in a theater. “It’s pretty much a hearing aid,” says Liu, except the company isn’t allowed to call it that.

That’s because the Food and Drug Administration, which regulates medical devices, doesn’t allow hearing aids to be sold over the counter. So devices sold directly to consumers are marketed as “personal sound amplification products,” or PSAPs. They range in price from about $250 to $350 and are considerably cheaper than hearing aids, which can cost up to $6,000 and are typically not covered by Medicare or most private insurance companies. Hearing aids are customized by a hearing specialist such as an audiologist, following a hearing test.

PSAPs can only be marketed as sound amplifiers for people with normal hearing who want to make things louder, like music or the sounds of birds chirping. Hearing loss advocates believe this means people with mild to moderate hearing loss who could benefit from the devices don’t know about them. There are dozens of the devices on the market, but their quality varies wildly, as an analysis of 11 of them last year for hearing care professionals shows. And there’s no easy way for potential purchasers to figure out which work best.

The Hearing Loss Association of America, a consumer group, wants Congress to create a new category of aids for people with mild to moderate hearing loss by passing the Over-the-Counter Hearing Aid Act of 2017. (People with severe hearing loss would still need to be seen by a medical professional.) The bill would direct the FDA to come up with safety and effectiveness standards for these new hearing aids.

The FDA is already moving in that direction, and in December said it would no longer require adults to be medically evaluated before buying a hearing aid. Proponents of direct-to-consumer sales hope congressional action would get the FDA moving faster. A 2016 report from the National Academies of Sciences also endorsed allowing over-the-counter sales.

This could be life-changing for people with hearing loss, says Richard Einhorn, a composer of modern classical music who is on the board of the Hearing Loss Association of America.

Early one morning in 2010, he woke up with his ears ringing — a loud, piercing hiss. “I hit the panic button,” Einhorn says. “I jumped out of bed and immediately fell over onto the floor.”

An inner ear infection, likely a virus, had caused him to lose his balance. He went deaf in his right ear. He already had some hearing loss in his left ear. His hearing aids cost $5,000 and were not covered by insurance.

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Composer Richard Einhorn, who says paying for hearing aids was a struggle on a musician’s income, supports efforts to gain FDA approval for cheaper devices.

Kevin Rivoli/AP

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Kevin Rivoli/AP

“I’m a composer, for goodness sake,” Einhorn says. “This is not an easy purchase to scrounge up the money for.”

Opening up the hearing aid market would foster competition and drive prices down, says Einhorn.

It would also encourage companies to come up with new and better products, says Liu. She envisions a future that solves one of the biggest problems for many people — hearing in a noisy environment, like a party or a busy restaurant. She wants a hearing aid that would automatically adjust to different sound environments, so she could hear the person talking to her and not the background distraction.

“Nothing like that exists today,” Liu says. “But I very much see something like that down the road.”

Some audio specialists support rolling back regulations, while others are skeptical.

Hearing loss is complex, says Neil DiSarno, chief staff officer for audiology at the American Speech-Language-Hearing Association. This makes it difficult for consumers to “self-evaluate, self-treat and self-monitor,” he says. If people buy their hearing aids directly over the counter, they’ll miss out on all the skills audiologists can teach them, like how to lip read and how to distinguish high frequency sounds, he says.

The market for over-the-counter hearing aids could be huge. More than 35 million Americans have some degree of hearing loss. And for older Americans, not dealing with the problem can have a big impact on age-related cognitive decline, says Dr. Frank Lin, associate professor of otolaryngology at Johns Hopkins University School of Medicine. Lin has done studies looking at the link between hearing loss and cognitive decline.

“The greater the hearing loss, the greater the risk of loss of thinking and memory abilities over time,” he says, which can lead to feelings of insecurity and social isolation — a known risk factor for dementia.

Lin says his findings should serve as a “wake-up call” for policymakers. If people have easier access to more affordable hearing aids, he says, that could lead to benefits that go far beyond hearing.

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