Butter-flavored popcorn oil is in high demand at Oasis Foods, a manufacturer of cooking oils, mayonnaise and other products that restaurants and distributors often purchase by the ton.

“We get a rush this time of year with all the movie-going at the holidays,” says Duke Gillingham, president of Oasis, at his factory in Hillside, N.J., just west of Newark Liberty Airport.

The company’s health insurance coverage is not as popular as its popcorn oil. Oasis offered health insurance to all employees for 2015, to comply with a new Affordable Care Act mandate. And while some employees did sign up for the insurance — the company doubled the number of people on its health plan over previous years — about two-thirds of the employees declined the coverage. With monthly premiums of roughly $350 for a family of four, and with a $2,500 annual deductible, it was too expensive for factory workers, many of whom earn between $10 and $15 an hour.

Gillingham says he hasn’t been able to find decent insurance much cheaper than that, and he cannot afford to significantly raise his employees’ wages.

“The sad fact is we’re in a very competitive business,” he says. “We wish we could make [insurance] more affordable, but it’s essentially what the business can bear. If we don’t watch what we’re doing, we can be high-cost, and that doesn’t serve any of the employees well.”

Companies Look To Avoid Penalties

Oasis Foods, a subsidiary of a Swedish food manufacturer, has about 180 workers. As of Jan.1, smaller firms — those that employ between 51 and 100 workers — are being phased into the same mandate that Oasis faced in 2015. Companies must offer affordable coverage to all employees, and will be subject to a penalty if their workers instead turn to the health exchange to buy subsidized coverage.

There’s no penalty for companies, it turns out, if workers qualify for Medicaid — though there could be controversy.

At firms like Oasis, low-wage workers are candidates more often for Medicaid than for the state or federal insurance exchange.

To qualify for Medicaid, applicants may earn no more than 138 percent of the federal poverty level — or roughly $16,000 for a single person and around $33,000 for a household of four.

Employers have not historically played a significant role in helping workers enroll in Medicaid. But Gillingham’s insurance broker told him about a startup called BeneStream, which is based in New York City and facilitates enrollment in the government program.

Company Shifts Insurance Costs To The Government

Founded two years ago with seed money from the Ford Foundation, BeneStream now helps more than 6,500 workers at 125 companies across the country get Medicaid. CEO Benjamin Geyerhahn says moving workers from private insurance to Medicaid helps firms shift their costs to the government.

“The savings is quite significant,” he says. “Our average is about 250 percent — so about two-and-a-half times the money you spend on us comes back to you in the form of saved premium.”

Geyerhahn says going onto Medicaid, which is nearly free for employees, is a good deal, though it lacks the generous benefits of more expensive plans. If employees make so little that they’re eligible for Medicaid, he says, they probably can’t afford regular insurance premiums, especially when combined with the high deductibles that undermine much of the benefit of insurance.

“Yes, this [level of coverage] is something that will help them if they get in a car accident or have a heart attack,” he says, “but this isn’t something that’s going to help them manage their health over the course of the year.”

Wal-Mart, McDonald’s and some large companies have drawn fire for not providing employees with health insurance, but instead relying on taxpayers to fund workers’ health needs via Medicaid.

Ken Jacobs, chair of the University of California, Berkeley’s Labor Center, says companies whose workers get Medicaid should bear some of the burden of the cost to taxpayers.

Critics Think Employers Should Pay Bigger Share

“Those employers should be paying more into the general pot that pays for health care, rather than putting those costs onto everyone else,” he says.

California legislators considered imposing a state tax penalty for companies whose workers get Medicaid, but lawmakers ultimately rejected the proposal.

Linda Blumberg, an economist at the Urban Institute, says that whether you are looking at a vast company like Wal-Mart or a modest-sized one like Oasis Foods, compensation is about trade-offs. The more you pay for people’s insurance, the less you have to put in their paychecks.

“When workers are low-income,” Blumberg says, “I would rather that we publicly finance their medical care, make it very accessible to them, have low cost-sharing so that’s not a barrier to them getting necessary care, and let them have a little bit higher wages in order to compensate.”

And even the large increases in the minimum wage currently being contemplated or phased in by several states and cities might still not be enough for those workers to afford most employer-sponsored insurance, given the high premiums and deductibles of such plans.

At Oasis, Gillingham says his company pays a lot in taxes, so getting almost-free health care for some workers amounts to a “fair deal.”

He contrasts this system to one he and his family of six experienced in England.

“My kids didn’t suffer from having a five- or six-minute checkup,” he says, compared with doctor visits in the United States — that may have been twice as long, and at much higher expense, but without any noticeable difference in results.

“We didn’t see any of the demons that people speak of when they talk about socialized medicine,” Gillingham says. “There were no lines, no poor standard-of-care.”

But despite being relatively upbeat about government healthcare, he concedes that Oasis workers so far have given Medicaid mixed reviews. Some doctors and hospitals take the insurance, but many don’t.

Still, that’s true of most health insurance, Gillingham says.

A Gallup poll last month found that 67 percent of Americans, in general, are satisfied with the country’s health care system, compared with 75 percent of people who are on Medicaid.

“I think the system is evolving,” Gillingham says. “I don’t know where it’s going to go, but I know it’s going to change, and we need to adapt and make use of the system in the best way possible.”

This story was produced as part of NPR’s partnership with WNYC and Kaiser Health News.

The U.S. is in the grips of a prescription drug epidemic, fueled in part by an explosion in opioid prescriptions over the past several decades. Roughly half of those prescriptions are written by primary care doctors. NPR’s Robert Siegel talks with Dr. Wanda Filer, president of the American Academy of Family Physicians, about her experience prescribing opioids and what doctors can do to prevent abuse.

Transcript

ROBERT SIEGEL, HOST:

According to the Centers for Disease Control and Prevention, nearly 19,000 people died from prescription opioid overdoses last year. The drug epidemic has so rattled the country, it’s become a topic on the presidential campaign trail.

New Jersey Governor Chris Christie has riveted audiences in New Hampshire and on YouTube with the story of a law school classmate of his, in Christie’s telling, a perfectly successful, healthy, happily married lawyer.

(SOUNDBITE OF ARCHIVED RECORDING)

CHRIS CHRISTIE: He was running one day in his normal routine. He hurt his back. And so he went to the doctor because he was having trouble working – really hurt. And so he said listen, we’re going to give me some treatment, whatever, but in the meantime, just to help you get you through, we’re going to give you Percocet – help numb the pain.

SIEGEL: Christie says friend became addicted. He went on to lose his family, his job, his home and finally his life.

(SOUNDBITE OF ARCHIVED RECORDING)

CHRISTIE: A year and a half ago on a Sunday morning, Mary Pat and I got the call that we’d been dreading forever -that they found him dead in a motel room with an empty bottle of Percocet and an empty quart of vodka – 52 years old.

SIEGEL: As prescriptions for opioid painkillers have soared, so have overdose deaths. The CDC will issue new prescribing guidelines next year. They’re taking public comment through mid-January. The guidelines are aimed at primary care doctors, who write roughly half of all opioid prescriptions. Doctors like Wanda Filer of York, Pa., who’s also the president of the American Academy of Family Physicians.

Dr. Filer remembers that, not long ago, the fear was not overprescribing, but underprescribing for pain.

WANDA FILER: There was a campaign back in the late 1990s and early 2000s called Pain Is The Fifth Vital Sign, and many physicians were told you’re not paying enough attention. You need to be more liberal with opioid medications. I think many of us felt a little bit indicted, quite honestly, and now we feel as though the pendulum has shifted so quickly because suddenly, we’re being told there’s too many opiods. And I suspect the truth is somewhere in between. Pain, for those people who suffer from it, is a very real issue. It’s debilitating. It’s pain, but it’s also suffering on very human term.

SIEGEL: I mean, describe the real life of a primary physician here for us. How often is the complaint that brings someone to you pain?

FILER: I had three people on Monday morning who came in with complaints of pain. One of them is a person who’s been on opioid therapy long-term. It’s allowed her to regain her life. It’s allowed her to be much more functional, and I’m managing that. And she’s been stable. We have a contract in place. We check a random urine periodically to make sure the medication, A, is showing up and B, that nothing else that I don’t want showing up is showing up.

Another one was a patient that came in with his adult child. And she said to me my father is really hurting from all of his arthritis. I think that he needs opioids. I had never seen this man before. I said – well, how long have you had pain? Oh, for about four to five months. I said, well, before we give you any kinds of medications, let’s figure out what’s going on here.

My other concern, quite honestly, is I don’t know this patient very well. He has some underlying medical conditions that make opioids particularly risky for him. And so I did not give him the prescription, and I would be inclined not to do so until I get to know him better and see if it’s even safe for him.

SIEGEL: And might you be thinking during these interviews with patients – are you thinking, is this a case for Motrin as opposed to OxyContin, a non-opioid as opposed to opioid?

FILER: Absolutely. And is this a case for ice? Is this a case for yoga? Is this a case for physical therapy? So we think about all the modalities that are able to us. And narcotic or opioid medications are really the last resort.

SIEGEL: You’re an experienced primary care physician. That’s not a euphemism. You’ve been doing this for a few years.

FILER: (Laughter) Thank you.

SIEGEL: Do you think that, let’s say, less experienced doctors, one might say…

FILER: God bless you.

SIEGEL: …Younger, would find this a very difficult area of medicine to cope with today?

FILER: It is a difficult area. It’s a skill set that we all work to master. I think we master across our career – certainly, when I first came out into practice, it makes you squirm a little bit more, not so much the science of opioid prescribing, but that dance of – how much do I accept what this patient is telling me at face value? – versus – how much I have to be a healthy skeptic? – for their safety, but also for the health of the public.

SIEGEL: Are their patients whom you treated for pain five years ago, 10 years ago, who you think if, you know, if they walked in today with the same complaint, you would you treat very differently because you’re thinking about all this, and medicine’s thinking about it has changed?

FILER: I’m certain that there are people that I would treat differently today. I think we were influenced by some of the campaigns to provide more medication years back, and I think we all do that. You go back and you think about what I might’ve done a bit differently. That’s part of the ongoing, continual lifelong learning.

SIEGEL: How important are the upcoming guidelines from the Centers for Disease Control and Prevention, and what are you looking for there?

FILER: Well, I think the guidelines will be very important once they’ve gone through their public comment period. Many of us have not had a chance to really dig into them yet, but I like the idea that the CDC is bringing a credibility factor to this. However, I’m hearing some concern across multiple medical associations about the process.

And so making sure that we strike that right balance for people with real pain – get access to medications that they need, versus protecting the health of the public and doing no harm – will be the art of the guidelines as well as the science.

SIEGEL: Dr. Filer, thanks for talking with us today.

FILER: Thank you. It was my pleasure.

SIEGEL: Dr. Wanda Filer is president of the American Academy of Family Physicians.

Copyright © 2015 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by a contractor for NPR, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of NPR’s programming is the audio.

Every once in a while a technology comes along that completely alters the way scientists do their work.

It’s hard to imagine astronomy without a telescope or high energy physics without an accelerator.

From here on in, it’s going to be impossible to imagine biology without CRISPR-Cas9.

Simply put, CRISPR-Cas9 allows scientists to make specific changes to specific genes in living cells. Such a thing was possible in the past using technques called zinc finger nucleases and Talens. But those techniques were cumbersome and weren’t widely adopted.

In the three short years since the first scientific papers appeared about CRISPR-Cas9, the technique has been “spreading like wildfire,” says Ramesh Akkina, a molecular immunologist at Colorado State University.

And for 2015, the journal Science called CRISPR the “breakthrough of the year.”

There have been lots of ethical debates about what the new gene editing technique could do, such as creating designer babies or making mutant species. But most biologists aren’t interested in making designer babies or mutant species. They just want to understand basic things like how the cells in our bodies work, or how certain genes function. They expect CRISPR-Cas 9 to be very, very helpful with those lines of inquiry.

Recently I visited Colorado State University to give a talk, but I realized it would be a great place to assess just how far and wide CRISPR-Cas9 had spread.

First, I talked with Christopher Allen, a scientist in the environmental and radiological health sciences department who studies the genes that are important for repairing DNA inside our cells.

When that repair process goes wrong, the result can be cancer. So Allen would like to be able to compare cells side by side: one that has a gene he thinks is important in the repair process, and one that is missing that gene. To do that, he has to modify the genome of a cell, something CRISPR-Cas9 will let him do easily.

Another scientist, Carol Wilusz, studies how and when genes are expressed in stem cells. She says CRISPR-Cas9 is going to make a difference in her work, “because it’s going to enable us to do experiments that we’ve been struggling to do through other approaches.”

Now, Wilusz and Allen aren’t trying to cure diseases, at least not directly, but CRISPR might be useful for that, too.

“The work we’re doing now is to use CRISPR-Cas technology to delete HIV genome from infected cells, such that the cell can be cured completely,” says Ramesh Akkina, a virologist at Colorado State. Right now he is perfecting that trick in cells in the lab, but he is working on a scheme to do it in patients as well.

CRISPR-Cas9 isn’t just useful for working organisms in the animal kingdom. It’s useful in forests and fields.

“I study diseases of plants,” says plant geneticist Jan Leach, “and my goal is to try to make plants that are resistant to different pathogens.”

She says there are a host of genes inside plant cells that turn on when the plant tries to fight invasion from bacteria or fungi. She’d like to be able modify all of them. With CRISPR-Cas9, she can.

“I’ve been working in this particular area for over 20 years, and in 20 years I’ve been able to do one or two genes,” says Allen. “With CRISPR-Cas I’ll be able to do 20 or 30.”

In two days, I spoke with nine different researchers. I asked them all the same question. “Will CRISPR-Cas9 have an impact on your work?”

Honestly, it’s stunning to witness the impact CRISPR-Cas9 has had on biology. It ranks with the most important tools invented in the past century. I wouldn’t be surprised if it wins Science magazine’s breakthrough of the year next year too.

Sarah Jackson had quit abusing drugs and had been sober for six months when she found out she had hepatitis C.

“That was weeks of not sleeping and just constant tears,” she says. “I had already put a lot of that behind me and had been moving forward with my life and this was just a major setback.”

To get rid of the infection, her doctor prescribed Harvoni, one of the new generation of highly effective hepatitis C drugs. But Jackson never started the treatment because her insurance, Indiana’s Medicaid, refused to pay for it.

“There’s nowhere else to go,” says Jackson. “The doctor tried and now I have no other place to turn.”

More than 3 million people in United States are infected with hepatitis C, a virus that can destroy the liver and cause liver cancer. The number of cases is increasing, and most new cases are attributed to injection drug abuse, according to the Centers for Disease Control and Prevention.

In the last few years, new medications have come on the market that can cure hepatitis C with a more than 90 percent success rate. But these new drugs are famously expensive. A full 12-week course of Harvoni costs about $95,000. Because of that, Medicaid in many states restricts who receives the medication.

Medicaid in at least 34 states doesn’t pay for treatment unless a patient already has liver damage, according to a report released in August. There are exceptions—for example, people who also have HIV or who have had liver transplants—but many living with chronic hepatitis C infection have to wait and worry.

“It is just not feasible to provide it to everyone,” says Matt Salo, director of the National Association of Medicaid Directors. “States have to make sure that we’re going to prioritize and that those who need it the most get priority treatment, and that’s what you’re seeing.”

States get a discount on the drugs, but Salo says even if they could cut prices in half, treating everyone with hepatitis C would still cost too much for states’ limited Medicaid budgets.

Officials in Washington state, for instance, estimate that at full price, treating everyone on Medicaid for hepatitis C would cost three times the state’s total pharmacy budget.

States are caught between the high prices and those who say that rationing care is illegal.

“If something is medically necessary, it’s medically necessary and must be covered by the Medicaid program,” says Gavin Rose, an attorney for the ACLU of Indiana.

Rose is representing Sarah Jackson in a class action lawsuit to fight the Indiana restrictions. He argues in the lawsuit that if a doctor says you need a drug, Medicaid must pay for it. The lawsuit cites a recent letter from the Centers for Medicare and Medicaid Services reminding states of the law.

Furthermore, Rose argues, treating hepatitis C early would keep the virus from spreading and actually save money in the long run. “We are talking about drugs that might prevent Medicaid from having to deal sometime in the future with treatment for liver cancer, with treatment for liver transplants,” he says.

There seems to be consensus that the new drugs for hepatitis C are too expensive. Even the U.S. Senate has criticized the pricing in a report released earlier this month. States spent $1 billion last year on Sovaldi, another commonly prescribed hepatitis C drug. A new treatment is set to come to market next year, and that competition may help bring prices down.

In the meantime Sarah Jackson will wait for her lawsuit to get resolved. “This is weighing over me every day. I have to worry about it all the time,” she says.

Despite the anxiety, she’s willing to go through it to help others like her who want to be cured.

This story is part of a reporting partnership with NPR, local member stations and Kaiser Health News.

The deadline to sign up for an Obamacare health insurance plan starting on Jan. 1 was extended until Friday because the web site was overwhelmed. Demand was up, but that might be because the penalties for not having insurance are increasing.

Transcript

ARI SHAPIRO, HOST:

One deadline to sign up for health coverage under the Affordable Care Act has just passed. It was last night. That deadline was for people who wanted coverage starting January 1. People can still sign up through the end of next month for coverage that would kick-in in a few months. By most accounts, demand has been huge because this the year penalties for not having health insurance go up. NPR health policy correspondent Alison Kodjak is here with more on the latest enrollment.

Hey Alison.

ALISON KODJAK, BYLINE: Hey Ari.

SHAPIRO: The government actually extended the enrollment period this week because the healthcare.gov website was so busy. Is this just a sign that demand is through the roof and it’s all good?

KODJAK: Well, demand is through the roof, but I’m not sure it’s all good. The demand is goosed because of these penalties you mentioned, they’re going up a lot. They’re at least doubling. It used to be the lowest penalty was about $325. Now the lowest penalty is $695 and could go up as much as $10,000.

SHAPIRO: OK. So people might’ve wanted health care but they also wanted to not pay the fines. Talk about how the website held up, especially given the history of the healthcare.gov website.

KODJAK: Well, it held up better than before, but there were some bumps. People were trying to buy insurance, and the government said they were getting 11 sign-ups per second for a couple of days last week. But the waits were getting kind of long, and on the telephone helpline, which is very popular, the waits were as long as 22 minutes earlier this week. There was – originally, the deadline was Tuesday. One of the government officials who was talking about this today said that they would’ve needed 72,000 people answering the phones to make the waits at the normal amount, you know, just to answer when people called, and that’s why they had to extend the deadline.

SHAPIRO: Although it doesn’t sound like these delays were on the scale of the epic meltdown when healthcare.gov first launched.

KODJAK: No, no. It wasn’t that bad. I mean, like I said, the waits on the website were about two minutes. You know, something like Amazon, they would’ve been able to handle the volume, which was, you know, in the 150,000 to 200,000 people shopping at one time range.

SHAPIRO: So people who still want insurance and have not yet signed up, it’s not too late for them, right? What happens at this point?

KODJAK: Well, they can still go onto healthcare.gov and find an insurance plan and sign up. They can go to the call center. They can go to what they call a navigator, somebody who helps you sign up, up through January 31. But that plan won’t go into effect until March, and they may face a penalty for missing those two months if they have no insurance for January and February.

SHAPIRO: Now, to hear Republicans in Congress and on the campaign trail talk about it, the Affordable Care Act is hugely unpopular and a failure. What do the latest numbers tell us about those claims from the Republican side?

KODJAK: Well, I think it’s a complicated picture. People are clearly buying insurance. People want insurance and need insurance. But there are definitely a lot of people who have been goosed into buying insurance because of the penalties we were talking about. And people are really complaining that some of these plans are too expensive, they have high deductibles, they have high co-pays. You can see the complaints all over our website if you look at the comments under our stories.

SHAPIRO: We’ve been hearing a lot about this huge budget bill that Congress passed last night which includes removing two taxes that were part of the Affordable Care Act. What effect will that have on the law?

KODJAK: Well, I don’t think it’s going to have any effect on people buying insurance and the marketplace specifically, but these were the taxes that were supposed to pay for the expansion of Medicaid and to pay for the subsidies that make some of these policies affordable to people. So what it’s going to do is expand the budget deficit, but in addition it opens up the law for criticism by saying yes, this law is costing taxpayers a lot of money because there are no pay-fors.

SHAPIRO: That’s Alison Kodjak, NPR’s health policy correspondent.

Thanks Alison.

KODJAK: Thanks Ari.

Copyright © 2015 NPR. All rights reserved. Visit our website terms of use and permissions pages at www.npr.org for further information.

NPR transcripts are created on a rush deadline by a contractor for NPR, and accuracy and availability may vary. This text may not be in its final form and may be updated or revised in the future. Please be aware that the authoritative record of NPR’s programming is the audio.