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3:43

Recording and mixing music are Vernon Thomas’ passions, but being CEO and producer of Mantree Records isn’t his day job.

He’s an HIV outreach worker for a county health department outside Newark, N.J. He took what was to be a full-time job in May because the gig came with health insurance — and he has HIV himself.

But then the county made it a part-time job, and Thomas lost health coverage before it even started. “Benefits are more important than the money you’re making,” he says.

The Affordable Care Act’s third open enrollment season started Nov. 1, and federal officials are hoping to reach about a million uninsured people nationwide before it closes on Jan. 31.

Newark has an estimated 112,000 uninsured people, including Thomas, around one-third of the city’s population. Newark is one of five areas – along with Houston, Dallas, Chicago and Miami – where the federal government is focusing enrollment efforts.

Altogether, Washington will spend more than $100 million dollars on marketing and enrollment nationwide.

Why has Thomas stayed on the sidelines for Obamacare’s first two years? He values insurance and regular health care, but he says he didn’t fully understand what the law had to offer him. He’s still trying to make up his mind about signing up for coverage this time around.

He has been getting HIV medications, care of the federal government’s AIDS Drug Assistance Program. It doesn’t cover anything else, though, and Thomas says he’d like more medical care, particularly a regular doctor who could keep an eye on issues that worry him.

“Prostate cancer runs in my family on both sides,” Thomas says. “My mother and her mother and her brother all had diabetes. My mother had hypertension also. Fortunately, I have low blood pressure. But now they’re saying I have high cholesterol.”

Thomas’ part-time job doesn’t pay a lot, yet he makes too much to get free health care from Medicaid. He’s eligible to buy a plan on the exchange, but he says it’s too expensive because the cost of living in Newark is high for him.

So he has gone without coverage and kept his fingers crossed. “I try not to think about it — getting sick,” he says.

Thomas didn’t know the health law’s benefits for people in his income bracket. He qualifies for subsidies that would bring his premium down to $100 or less and also cost-sharing support that would pick up much of the deductible and other out-of-pocket expenses.

Brian McGovern, head of the North Jersey Community Research Initiative, says overcoming misconceptions about Obamacare has been one of his staff’s biggest jobs. “It’s always been about trust with some of our patients,” he says.

Susan Nash, a partner at the McDermott Will & Emery law firm in Chicago, says that health insurance is still too expensive for millions of people living paycheck-to-paycheck.

“These individuals are having difficulty affording food and housing, and so it’s a calculus: ‘Do I need health insurance? Do I think I’m going to have a catastrophic event or have some large health care expenditures this year?’ ” Nash says.

The government says about 8 in 10 of these eligible but uninsured people qualify for subsidies. But some of them will get only a little help from the government — and others will get none at all.

Middle-income people can spend hundreds of dollars a month on a high deductible, if they need significant care. And they wouldn’t qualify for the same help with out-of-pocket expenses that Vernon Thomas would. That means they often spend additional hundreds of dollars before coverage actually kicks in.

Still, under the law, most people have to get insurance – or face a tax penalty next year of either 2.5 percent of income or $695 per adult and $347.50 per child under 18, with a maximum of $2,085. Even if people have a sense of these fines, they still might not worry about it. The fines don’t actually hit until Tax Day, 2017. And for many of people, that’s just too far away – and just too abstract.

This story is part of a reporting partnership that includes WNYC, NPR and Kaiser Health News.

7:09

The latest front in the debate over religious freedom is all about an 8 1/2-by-11-inch piece of paper.

This particular piece of paper is a notice — one the state of California will soon require to be posted in places known as crisis pregnancy centers. These resource centers, often linked to religious organizations, provide low-cost or free services to pregnant women, while encouraging these women to not have abortions.

The new notice is mandated by the Reproductive FACT Act, and would make it clear that abortion is legally available in California.

But several pregnancy centers are suing the state, asking for the law to be struck down.

One of the clinics engaged in the lawsuit is the East County Pregnancy Care Clinic in El Cajon, Calif., just outside San Diego. The center describes itself as “a religious, nonprofit, pro-life, free medical clinic licensed by the State of California.” It sits on the corner of a busy intersection, surrounded by strip malls.

A big sign out front says “free pregnancy tests.” That’s one way they get women in the door, according to executive director Josh McClure.

McClure is not a physician, though the clinic does have medical advisors who are doctors, he says. When we recently visited, he didn’t permit NPR to talk to the staff at the clinic, who are all either registered nurses or volunteers. But he did offer to show us around, and walk us through the process of what happens to clients who come to the clinic thinking they may be pregnant.

Most of these women make appointments, he says, but the clinic also receives one or two walk-ins a day. The staff sees about 800 women a year, and that number is on the rise.

First, clients fill out paperwork in the lobby, he explains, then are assigned to a volunteer that he describes as an “advocate.”

These volunteer advocates, who are not medical professionals, take the client into a small room called the library. There the volunteer leads the client through a conversation about her situation.

McClure says his volunteer will ask the client a series of questions to get at these issues: “Why do they think they’re pregnant? [Are] they living with somebody? Is it a husband, boyfriend? What are the circumstances going on in their life? And if the pregnancy does happen to be positive, what are they thinking about right then?”

The library has two shelves with books like What To Expect When You’re Expecting; anatomy models that show the size of the fetus at 4 weeks gestation, 8 weeks, and so on; and VHS tapes about abortion and abortion providers. McClure says the tapes are from the 1970s and hardly ever used.

After a client speaks with the advocate and reviews the pamphlets, she is taken to an exam room to take a pregnancy test.

The exam room looks like any medical examining room, with clean linoleum floors, health pamphlets, and a box of rubber gloves on the counter. In the center of the room is an exam table with a sheet of white tissue paper laid out over it.

That’s where a registered nurse would hand the patient a specimen cup to get a urine sample and do a pregnancy test, McClure says. It’s the same test you might buy at a drug store, he says, but here it’s free, funded by donations. The R.N. signs off on the results.

If the pregnancy test is positive, the nurse tells the client there are three options: parenting, adoption, or abortion.

“We’re going to talk about the benefits, responsibilities, and side effects of all three,” McClure says. “We would say, if it’s an unplanned pregnancy, there really aren’t any good solutions. They’re all hard.”

In the discussion of parenting, the nurse talks about the responsibility of an 18-year commitment to another human life, and the resources in the client’s life that may be helpful. The nurse asks whether the boyfriend or husband would be involved.

In discussing adoption, the clinic goes over several different options: familial adoption to a family member, local or national adoptions and open or closed adoption. McClure says the clinic works with several different adoption agencies and will refer clients to the one that best suits her preferences.

“We do let them know, that if there’s drug abuse, the reality is if you’re not going to straighten your life out by the time the baby is here, that [Child Protective Services] would be coming to take that child,” he says.

When it comes to abortion, the nurses do not tell clients where they can get an abortion or refer them to abortion providers, McClure told us. But they will talk about the clinic’s view of the risks of an abortion and the cost.

“Generally,” McClure says, “the further along you go, the more expensive and more invasive and more risks there are. Risk of sterility is one. Perforated uterus is another. And then, of course, emotional side effects as well. All the information we’re giving about the side effects is backed by research and referenced.”

McClure didn’t mention during our tour that at least some claims in that pamphlet used to train the clinic’s nurses and volunteers are disputed by leading research organizations. For example, the suggestion that there might be a link between abortion and an increased risk of breast cancer has been studied and eventually dismissed by the National Cancer Institute and other medical groups.

The clinic’s pamphlet also states that abortion “significantly increases the risk” for conditions such as “clinical depression and anxiety” and “suicidal thoughts and behavior.” But an American Psychological Association task force on mental health and abortion had a different take in its recent review, recognizing that “abortion encompasses a diversity of experiences.”

According to the APA’s task force report in 2008, “the best scientific evidence published indicates that, among adult women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single, elective first-trimester abortion than if they deliver that pregnancy. The evidence regarding the relative mental health risks associated with multiple abortions is more equivocal.”

Once a pregnant woman at McClure’s clinic has been briefed by the staff on how their organization views the risks of abortion, she is brought to a room where she can get an ultrasound scan, free of cost.

There, McClure tells us, the ultrasound image is enlarged and projected onto a big flat-screen TV. Women often decide against abortion, he says, after they see the ultrasound.

“When you have an image on a screen, all the cloudiness of what we’re talking about kind of goes away,” McClure says. “They’re able to see for themselves: OK, arms, legs, eyes, head. Bingo — that’s a baby.”

The last stop is a closet full of diapers, wipes, baby clothes, blankets and maternity clothes — all available for free to clients who have trouble affording those things.

That’s the end of the tour.

None of these things — no step in that process — would have to change under the Reproductive FACT Act.

Instead, the law requires centers like the East County Pregnancy Care Clinic to post a sign in the lobby that says, in 22-point type:

California has public programs that provide immediate free or low-cost access to comprehensive family planning services (including all FDA-approved methods of contraception), prenatal care, and abortion for eligible women. To determine whether you qualify, contact the county social services office at [insert the telephone number].

If the center is not a licensed medical clinic, the sign would state:

This facility is not licensed as a medical facility by the State of California and has no licensed medical provider who provides or directly supervises the provision of services.

McClure says a sign in the lobby is not how or when he wants his clients at the clinic to hear about abortion. It goes against everything his center stands for, he tells NPR.

One of the people responsible for the law requiring this new sign is Autumn Burke, who represents Inglewood in the California Assembly.

Burke tells NPR that her interest in the issue started the day she went to get her phone fixed at a shop near a clinic that performs abortions. Protesters outside the clinic gave her pamphlets, she says, making claims that she knew weren’t true.

“It [said] that abortion causes breast cancer,” Burke recalls, “that if you are on birth control boys will not like you, or they will take advantage of you.”

A few days later, one of Burke’s colleagues in the California Assembly asked her to co-sponsor the Reproductive FACT Act.

“And I thought, ‘you know what? This is timely,’ ” Burke says. “Making sure women have the correct information.”

A number of health and medical groups, including the regional district of the American Congress of Obstetricians and Gynecologists, the California Nurses Association and the Primary Care Association also supported the legislation.

Burke acknowledges that some crisis pregnancy centers do give good help to women who want to have babies. But she says that others give false information to women, or pose as clinics, even though they don’t have a medical license.

Burke says the law is for those bad actors, and that putting up this sign in these centers wouldn’t be much different than a notice from the health department or the building inspector.

“It’s like a ‘Wash Your Hands’ sign on the wall,” says Burke.

Brad Dacus of the Pacific Justice Institute, one of the groups suing the state of California over the new law, could not disagree more.

“It’s like telling the Alcoholics Anonymous group that they have to have a large sign saying where people can get alcohol and booze for free,” Dacus says. “It’s like telling a Jewish synagogue that they can have their service, and do their thing, but they have to have a large sign where people can go to pray to receive Jesus.”

Dacus’s organization has filed a challenge to the law in federal court.

Some U.S. cities, including Austin, Tex., Baltimore and San Francisco, have passed similar legislation and have faced similar legal challenges — with mixed results.

The state of California so far is the largest jurisdiction in the country to pass a law requiring these centers to inform women about the availability of abortion services. If the law holds up, it could make way for measures like it in other cities and states.

Brad Dacus says that if the case has to go all the way to the Supreme Court to stop the law, so be it. To him, the legal battle is all about upholding the right to religious freedom.

“If people are not allowed to carry out their faith, and act and actually exercise their faith — not just have their private beliefs, but actually exercise their faith — then we really don’t have religious freedom,” Dacus says.

The lawsuits against the Reproductive FACT Act are now making their way through the courts.

Kristin Ford, representing the office of California Attorney General Kamala Harris, says, “We will vigorously defend the state law in court.”

7:09

The latest front in the debate over religious freedom is all about an 8 1/2-by-11-inch piece of paper.

This particular piece of paper is a notice — one the state of California will soon require to be posted in places known as crisis pregnancy centers. These resource centers, often linked to religious organizations, provide low-cost or free services to pregnant women, while encouraging these women to not have abortions.

The new notice is mandated by the Reproductive FACT Act, and would make it clear that abortion is legally available in California.

But several pregnancy centers are suing the state, asking for the law to be struck down.

One of the clinics engaged in the lawsuit is the East County Pregnancy Care Clinic in El Cajon, Calif., just outside San Diego. The center describes itself as “a religious, nonprofit, pro-life, free medical clinic licensed by the State of California.” It sits on the corner of a busy intersection, surrounded by strip malls.

A big sign out front says “free pregnancy tests.” That’s one way they get women in the door, according to executive director Josh McClure.

McClure is not a physician, though the clinic does have medical advisors who are doctors, he says. When we recently visited, he didn’t permit NPR to talk to the staff at the clinic, who are all either registered nurses or volunteers. But he did offer to show us around, and walk us through the process of what happens to clients who come to the clinic thinking they may be pregnant.

Most of these women make appointments, he says, but the clinic also receives one or two walk-ins a day. The staff sees about 800 women a year, and that number is on the rise.

First, clients fill out paperwork in the lobby, he explains, then are assigned to a volunteer that he describes as an “advocate.”

These volunteer advocates, who are not medical professionals, take the client into a small room called the library. There the volunteer leads the client through a conversation about her situation.

McClure says his volunteer will ask the client a series of questions to get at these issues: “Why do they think they’re pregnant? [Are] they living with somebody? Is it a husband, boyfriend? What are the circumstances going on in their life? And if the pregnancy does happen to be positive, what are they thinking about right then?”

The library has two shelves with books like What To Expect When You’re Expecting; anatomy models that show the size of the fetus at 4 weeks gestation, 8 weeks, and so on; and VHS tapes about abortion and abortion providers. McClure says the tapes are from the 1970s and hardly ever used.

After a client speaks with the advocate and reviews the pamphlets, she is taken to an exam room to take a pregnancy test.

The exam room looks like any medical examining room, with clean linoleum floors, health pamphlets, and a box of rubber gloves on the counter. In the center of the room is an exam table with a sheet of white tissue paper laid out over it.

That’s where a registered nurse would hand the patient a specimen cup to get a urine sample and do a pregnancy test, McClure says. It’s the same test you might buy at a drug store, he says, but here it’s free, funded by donations. The R.N. signs off on the results.

If the pregnancy test is positive, the nurse tells the client there are three options: parenting, adoption, or abortion.

“We’re going to talk about the benefits, responsibilities, and side effects of all three,” McClure says. “We would say, if it’s an unplanned pregnancy, there really aren’t any good solutions. They’re all hard.”

In the discussion of parenting, the nurse talks about the responsibility of an 18-year commitment to another human life, and the resources in the client’s life that may be helpful. The nurse asks whether the boyfriend or husband would be involved.

In discussing adoption, the clinic goes over several different options: familial adoption to a family member, local or national adoptions and open or closed adoption. McClure says the clinic works with several different adoption agencies and will refer clients to the one that best suits her preferences.

“We do let them know, that if there’s drug abuse, the reality is if you’re not going to straighten your life out by the time the baby is here, that [Child Protective Services] would be coming to take that child,” he says.

When it comes to abortion, the nurses do not tell clients where they can get an abortion or refer them to abortion providers, McClure told us. But they will talk about the clinic’s view of the risks of an abortion and the cost.

“Generally,” McClure says, “the further along you go, the more expensive and more invasive and more risks there are. Risk of sterility is one. Perforated uterus is another. And then, of course, emotional side effects as well. All the information we’re giving about the side effects is backed by research and referenced.”

McClure didn’t mention during our tour that at least some claims in that pamphlet used to train the clinic’s nurses and volunteers are disputed by leading research organizations. For example, the suggestion that there might be a link between abortion and an increased risk of breast cancer has been studied and eventually dismissed by the National Cancer Institute and other medical groups.

The clinic’s pamphlet also states that abortion “significantly increases the risk” for conditions such as “clinical depression and anxiety” and “suicidal thoughts and behavior.” But an American Psychological Association task force on mental health and abortion had a different take in its recent review, recognizing that “abortion encompasses a diversity of experiences.”

According to the APA’s task force report in 2008, “the best scientific evidence published indicates that, among adult women who have an unplanned pregnancy, the relative risk of mental health problems is no greater if they have a single, elective first-trimester abortion than if they deliver that pregnancy. The evidence regarding the relative mental health risks associated with multiple abortions is more equivocal.”

Once a pregnant woman at McClure’s clinic has been briefed by the staff on how their organization views the risks of abortion, she is brought to a room where she can get an ultrasound scan, free of cost.

There, McClure tells us, the ultrasound image is enlarged and projected onto a big flat-screen TV. Women often decide against abortion, he says, after they see the ultrasound.

“When you have an image on a screen, all the cloudiness of what we’re talking about kind of goes away,” McClure says. “They’re able to see for themselves: OK, arms, legs, eyes, head. Bingo — that’s a baby.”

The last stop is a closet full of diapers, wipes, baby clothes, blankets and maternity clothes — all available for free to clients who have trouble affording those things.

That’s the end of the tour.

None of these things — no step in that process — would have to change under the Reproductive FACT Act.

Instead, the law requires centers like the East County Pregnancy Care Clinic to post a sign in the lobby that says, in 22-point type:

California has public programs that provide immediate free or low-cost access to comprehensive family planning services (including all FDA-approved methods of contraception), prenatal care, and abortion for eligible women. To determine whether you qualify, contact the county social services office at [insert the telephone number].

If the center is not a licensed medical clinic, the sign would state:

This facility is not licensed as a medical facility by the State of California and has no licensed medical provider who provides or directly supervises the provision of services.

McClure says a sign in the lobby is not how or when he wants his clients at the clinic to hear about abortion. It goes against everything his center stands for, he tells NPR.

One of the people responsible for the law requiring this new sign is Autumn Burke, who represents Inglewood in the California Assembly.

Burke tells NPR that her interest in the issue started the day she went to get her phone fixed at a shop near a clinic that performs abortions. Protesters outside the clinic gave her pamphlets, she says, making claims that she knew weren’t true.

“It [said] that abortion causes breast cancer,” Burke recalls, “that if you are on birth control boys will not like you, or they will take advantage of you.”

A few days later, one of Burke’s colleagues in the California Assembly asked her to co-sponsor the Reproductive FACT Act.

“And I thought, ‘you know what? This is timely,’ ” Burke says. “Making sure women have the correct information.”

A number of health and medical groups, including the regional district of the American Congress of Obstetricians and Gynecologists, the California Nurses Association and the Primary Care Association also supported the legislation.

Burke acknowledges that some crisis pregnancy centers do give good help to women who want to have babies. But she says that others give false information to women, or pose as clinics, even though they don’t have a medical license.

Burke says the law is for those bad actors, and that putting up this sign in these centers wouldn’t be much different than a notice from the health department or the building inspector.

“It’s like a ‘Wash Your Hands’ sign on the wall,” says Burke.

Brad Dacus of the Pacific Justice Institute, one of the groups suing the state of California over the new law, could not disagree more.

“It’s like telling the Alcoholics Anonymous group that they have to have a large sign saying where people can get alcohol and booze for free,” Dacus says. “It’s like telling a Jewish synagogue that they can have their service, and do their thing, but they have to have a large sign where people can go to pray to receive Jesus.”

Dacus’s organization has filed a challenge to the law in federal court.

Some U.S. cities, including Austin, Tex., Baltimore and San Francisco, have passed similar legislation and have faced similar legal challenges — with mixed results.

The state of California so far is the largest jurisdiction in the country to pass a law requiring these centers to inform women about the availability of abortion services. If the law holds up, it could make way for measures like it in other cities and states.

Brad Dacus says that if the case has to go all the way to the Supreme Court to stop the law, so be it. To him, the legal battle is all about upholding the right to religious freedom.

“If people are not allowed to carry out their faith, and act and actually exercise their faith — not just have their private beliefs, but actually exercise their faith — then we really don’t have religious freedom,” Dacus says.

The lawsuits against the Reproductive FACT Act are now making their way through the courts.

Kristin Ford, representing the office of California Attorney General Kamala Harris, says, “We will vigorously defend the state law in court.”

5:10

Sheena Calliham is all too aware of statistics showing that millennials have less job security and more student debt than their parents.

“Student loan debt is a primary financial stressor and concern for my generation,” she says, “and we’ve also faced a challenging job market.”

Calliham is 32, manages healthcare centers in Columbia, S.C, and has a 2-year-old daughter. A few weeks ago, she signed up for a financial wellness program offered by her employer. She says the stress of the debt and the cost of raising a child were affecting many aspects of her life.

“It can be a stressor that I can take home with me,” she says, “and that may cause me to take things out on people that I love.”

About half of all U.S. employers now offer financial wellness programs, although how they define them varies. Many companies have long offered lectures on topics like retirement. But increasingly, say analysts tracking the trend, employers are tailoring their programs to the worker — more like a personal trainer who works on your budget rather than your waistline.

Most large companies are expanding their financial wellness programs this year, says Rob Austin, director of retirement research at consulting firm Aon Hewitt. And employers realize one-on-one counseling is a far more effective way to reach people and address their particular concerns.

“It really goes much deeper and much broader,” he says.

According to Evren Esen, who directs survey programs at the Society for Human Resource Management, more than two-thirds of professionals in human resources say personal finances are having an effect on their employees at work, and that can affect health.

Money problems cause stress, which can lead to bigger health insurance bills for an employer. And if an employee’s car breaks down and they can’t afford to fix it, that causes unexpected absences. Studies show that a firm’s health costs and absenteeism are both likely to decrease when the company starts a financial wellness program — though how big a difference it makes can vary and be hard to quantify.

There are still challenges, Esen says. The benefit isn’t cheap, and often participation is low. It can also be hard to get employees to open up about their finances at the workplace – even though their privacy is, and must be, protected.

However, she says, for those workers who do participate, employers see real benefits.

“They tend to be more loyal and they’re more likely to stick with the company,” Esen says. “And they’re more likely to give back to the company.“

These programs, which started out with counseling regarding retirement benefits, expanded during and after the lean years of the Great Recession, says Liz Davidson, founder of Financial Finesse, a firm that manages financial wellness programs for employers.

“Financial wellness becomes more attractive when economic times are hard,” she says, “because if you’re going to cut someone’s pay or suspend their raise or cut their match into their retirement plan, that puts pressure on them to figure out, ‘How do I navigate this?’ “

If the social safety net weakens, financial wellness is likely to become all the more important, Davidson says. “We’re not necessarily going to have the corporate or government support we used to have, and financial self-sufficiency is going to become more of a necessity.”

That sort of support from an employer can be especially important for workers in lower income brackets, who are less likely to be able to afford financial planning.

“The people that need it the most don’t get it through traditional channels,” Davidson says. “So, with the model where it goes through the employer, they have access, free of charge, to sit down with a certified financial planner and work through whatever their issue is.”

Calliham, the healthcare manager, says she now strongly encourages her colleagues to use the service. Just having a plan to manage her finances, she says, has made a huge difference in her attitude.

“I definitely — day to day as a mother, as a manager, as an employee, as a wife — I definitely feel like I have my head on straighter,” says Calliham. “I feel like I’m more in control, and they have definitely helped me get there.”

3:46

A decades-long decline in the death rate of middle-aged white Americans has reversed in recent years, according to a surprising new analysis released Monday.

The cause of the reversal remains unclear. Researchers speculate it might be the result of the bad economy fueling a rise in suicides, plus overdoses from prescription painkillers and illegal drugs like heroin, and alcohol abuse.

“That could be just a volatile mix that could set off something like this,” says Angus Deaton, a professor of economics at Princeton University who conducted the research with his wife, Anne Case, another Princeton economist.

Deaton was awarded the 2015 Nobel Prize in Economics for his work on poverty.

Overall, the U.S. mortality rate has been falling by about 2 percent a year since the 1970s.

But the upsurge in suicides and drug overdoses among middle-age whites, among other trends, prompted Deaton and Case to look more closely at this group. They analyzed data from CDC and other sources, including other countries.

“Pretty quickly we started falling off our chairs because of what we found,” says Deaton, whose findings were published by the Proceedings of the National Academy of Sciences.

The mortality rate among whites ages 45 to 54 had increased by a half-percent a year from 381.5 per 100,000 in 1999 to 415.4 in 2013, the most recent year for which data are available, the researchers found.

Even so, the mortality rate for middle-aged African-Americans was higher: 581.9 per 100,000 in 2013. Hispanics fared better with a mortality rate of 269.6 per 100,000 in the same year.

“There was this extraordinary turnaround” among whites, Deaton says, likening the reversal to a large ship suddenly changing directions.

Based on the findings, Deaton and Case calculated that 488,500 Americans had died during that period who would have been alive if the trend hadn’t reversed.

“We’ve been talking about this at various academic meetings and you look around the room and peoples’ mouths are just hanging open,” Deaton says.

“This is a deeply concerning trend,” says Dr. Thomas Frieden, who heads the Centers for Disease Control and Prevention but wasn’t involved in this research. “We shouldn’t see death rates going up in any group in society.”

The Princeton researchers analyzed data from other Western countries and didn’t see the same trend.

“It’s particularly important that they don’t see it in other countries,” says John Haaga, the acting director of behavioral and social research at the National Institute on Aging, which funded the research. “So something’s clearly going wrong with this age group in America.”

The trend appears to be being driven by increased mortality among those with the least amount of education.

“Those are the people who have really been hammered by the long-term economic malaise,” Deaton says. “Their wages in real terms have been going down. So they get into middle age having their expectations just not met at all.”

It remains unclear why the mortality rate only increased among whites and not African-Americans or Hispanics.

Deaton and others have a theory about the difference for whites.

“One possible explanation is that for whites their parents had done better economically and they had been doing pretty well. Then all of a sudden the financial floor dropped out from underneath them,” says Jon Skinner, a professor of economic and medicine at Dartmouth College who co-authored a commentary accompanying the article. “For African-American and Hispanic households things had never been that optimistic and so perhaps the shock wasn’t quite as great.”

3:53

Gunnar Ebbesson is used to paying a lot for health insurance, but the small business owner from Fairbanks got a shock recently when his quote came in for next year’s coverage.

“I don’t understand who can afford this,” he says. “I mean, who really can afford this? I can pay it, but I can’t afford it.”

The premium for his family of five came to more than $40,000 a year. That’s for a bare-bones plan with a $10,000 deductible — the plan that’s through the marketplace set up by the Affordable Care Act.

Customers can begin buying plans on HealthCare.gov starting on Nov. 1, and do so through Jan. 31, 2016. Rates for individual health plans went up an average of 7.5 percent nationally, but Alaska is a special case. It has the highest premiums in the country and it has seen some of the highest percentage increases over the past two years.

Why that’s true is still murky. There are a tangle of suggested reasons that likely play a role — among them that the state has relatively few doctors in certain specialties, only two insurers offering plans on the individual market, and relatively few people seeking insurance that way. What’s clear is that a lot of people who have to buy that insurance are feeling the pinch.

Ebbesson makes a good living and he doesn’t qualify for a subsidy to help pay for insurance because his family income is more than $142,000 a year. But, he says, his insurance costs more than his mortgage.

“I’m not able to put money in retirement, savings for my kid for college — my 10-year-old. Believe me,” he says, “I could find lots of stuff to do for my future with $40,000.”

Ebbesson supports the Affordable Care Act. He calls the Alaska rates a wrinkle in the law that needs to be fixed.

The average 2016 premium for a 40-year-old in Anchorage is $719 a month — more than double the national average. Most Alaskans, and most Americans, qualify for a subsidy that rises with premium increases — insulating consumers from the big jump. But about 5,000 Alaskans pay the full sticker price.

“We want people to have access to affordable coverage and that’s not happening right now in the marketplace in Alaska,” says Eric Earling, spokesman for the insurance company Premera Alaska, one of only two companies selling on Alaska’s exchange.

Earling says even with the high prices, the company is losing millions of dollars on Alaska’s tiny individual market. He says in the first six months of this year, 37 Premera customers filed over $11 million in claims.

“The important thing is they deserve access to coverage, and we’re glad they have it,” he says. “The trick is creating a sustainable environment where those costs can be absorbed in a way that doesn’t adversely impact all consumers.”

Premera is proposing legislation that would use Alaska’s high risk pool to allow the biggest claims to be paid from a special fund.

The state’s Division of Insurance hasn’t taken a position on the idea.

Victoria Cronquist is a dental hygienist in Anchorage. She doesn’t care what the solution is, as long as it helps her find more affordable insurance.

“It’s just getting too expensive,” she says. “I’m up against the wall. I can’t do it all.”

This year, she pays $1,600 a month for herself, her husband and two kids, ages 16 and 20. She gets a stipend from her work to help pay that premium, but her rate is going up to $2,600 a month next year. And her stipend isn’t going up. Cronquist says she may cancel her insurance.

“To be quite frank, to have a $2,600 monthly premium payment and all this is stressful to me,” she says. “Extremely. And that increases my odds of getting ill! That’s the other way I look at it.”

Cronquist doesn’t take the decision lightly. Her family has dropped health coverage in the past. They had to pay a steep price when her daughter ended up in the ICU a few months later.

Gunnar Ebbesson, from Fairbanks, also has a difficult decision ahead. He’s thinking about dropping his policy and putting money toward savings instead. Ebbesson says his family could fly to Thailand for any big, necessary medical procedures. If something catastrophic happened, though, it would put his family in a tough position.

“It’s a scary proposition,” he says. “There’s always bankruptcy but, my goodness, why should I be having to even think about things like that related to my health insurance?”

The high rates will push more Alaskans into a category that allows them to avoid paying the penalty for going uninsured. The law includes an “unaffordability” exemption if the lowest cost insurance amounts to more than 8 percent of your income.

This story is part of NPR’s reporting partnership with Alaska Public Media and Kaiser Health News.