Coinsurance? Premium tax credit? HMO and PPO?

Swimming through the health insurance word soup can be frustrating for anyone. Even though I cover health, I couldn’t define “cost-sharing reduction plan” until I Googled it just now.

And it seems I’m not the only clueless 20-something here. Young adults, who generally have little experience managing their own health care expenses, are finding it especially hard signing up for insurance under the Affordable Care Act, according to a study published Tuesday in the Journal of Adolescent Health.

Researchers at the University of Pennsylvania wanted to see how well young people would fare navigating through HealthCare.gov. So they rounded up about 30 young adults, aged 19 through 30, who were interested in enrolling for insurance. They were all college-educated, and based in Philadelphia.

The researchers sat them in front of computers and observed as they navigated through the online enrollment process. “We asked them to think out loud, so we could really capture their experience,” says Charlene Wong, a pediatrician at the University of Pennsylvania who lead the study.

Wong and her colleagues interviewed the participants right after they completed their enrollment and again a month later.

“Many of them said, ‘You know, I’ve never tried to do this before and it feels a little bit overwhelming because there’s so many different options,’ ” Wong says.

Half of the participants couldn’t define “deductible,” and three quarters couldn’t explain “coinsurance.”

Plus most of them were unaware of subsidies for insurance, and they didn’t have an idea of how much insurance plans generally cost. Most thought that an affordable plan cost less than $100 a month — but the cheapest plan in Philadelphia cost $187 monthly, without tax credits.

The study involved college-educated, tech-savvy young people, Wong points out. “Considering that, we were really surprised at just how much they didn’t know.”

Previous surveys have turned up similar findings. The recent study is small, Wong says. But it takes a more in-depth look at how young people feel about the enrollment process.

The results suggest that the government as well as insurance companies need to do a better job of educating people about the basics, Wong says. Making the process easier for young people is crucial to the success of Obamacare, she points out, since more healthy young Americans need to pay into the insurance system to help cover the costs for older, sicker people.

Of course, getting anyone to retain information about insurance isn’t easy. “It’s dry material,” says Erin Hemlin the health care campaign director at Young Invincibles, an advocacy group that helps educate young people about health policy.

Young Invincibles has tested out some creative ideas to get people interested, like sponsoring concerts. They conduct weekly Twitter chats. And they’ve developed an app that helps guide people through the enrollment process.

If the process is confusing for the young people in this study, Hemlin says, it’s even harder for demographic groups.

“I spent about four months in Texas during the first open enrollment period helping a mostly low-income, Latino population apply for insurance,” she says. “It was so disheartening, because these insurance terms are confusing in English. And they don’t translate well at all.”

Lots of young people she encounters are intimidated by the process so they’re not able to take advantage of the services available to them, Hemlin says. “This lack of health insurance literacy is the biggest barrier right now. I want more young people to realize ‘Oh, wait, I actually can afford this.’ “

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A North Carolina law that would require women who want an abortion to have an ultrasound scan prior to the procedure suffered a final defeat Monday, when the Supreme Court refused to review the case. A federal judge declared the law illegal in early 2014.

The controversial law had been placed under an injunction soon after it took effect back in 2011. It was struck down on the grounds that it reflected ideological, rather than medical, priorities and violated doctors’ right of free speech.

The 4th U.S. Circuit Court of Appeals sustained the earlier ruling last December. Member station WUNC quotes the three-judge panel’s opinion:

“Transforming the physician into the mouthpiece of the state undermines the trust that is necessary for facilitating healthy doctor-patient relationships and, through them, successful treatment outcomes.”

Here’s how we described the North Carolina law last year:

“The state’s law required that the women have a medical professional tell them what the image depicts. It also said the women should ‘listen to the heartbeat of the unborn child.’

“U.S. District Judge Catherine Eagles issued her ruling in Greensboro, N.C., where the News Observer reports the judge ‘called the law “overbroad” and said it didn’t sufficiently protect women who didn’t want to be exposed to that information.’ “

In the Supreme Court’s list of orders including the one that denied North Carolina’s petition, Justice Antonin Scalia was named as the lone dissenting justice.

At SCOTUSblog, Lyle Denniston notes: “Because the Court, as usual, provided no explanation for its vote not to review … North Carolina’s 2011 ultrasound law, its action was not a reliable indicator of how the Justices would have ruled on the issue had they taken it on.”

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Play ball! Fore! Swish!

Americans love sports — watching them and playing them.

But as participants, Americans’ relationship with sports changes as we grow older. About three-quarters of adults say they played sports when they were younger. By the time people are in their late 20s, however, only 26 percent say they’ve played sports in the past year.

Those are just two of the findings from the latest poll by NPR, the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health that takes a look at sports and health in America.

The nationwide poll, conducted from late January through early March, gathered responses from more than 2,500 adults contacted by landline telephone and by cellphone. The margin for error is plus or minus 2.7 percentage points.

When it comes to recent participation, the higher your household income, the more likely it is that you’ll have played sports in the past year. People making at least $75,000 a year were more than twice as likely to have played sports in the last year as those making less than $25,000.

When asked the sport they play most often, adults reported playing more than 50 different sports, ranging from hockey and fishing to martial arts and bowling. Overall, the favorites (in order) were: golf, basketball, baseball/softball, soccer and running/track.

The favorites varied by age and gender.

Men under 50 played basketball and soccer the most. For those 50 and up, golf was No. 1. Volleyball was popular with women younger than 50. Walking was a winner for women 50 and older.

The top reasons adults say they play sports are for personal enjoyment (they’re fun!) and health, such as staying in shape or losing weight. When it comes to exercise, the workout seems like work. Only 17 percent of people said they exercised mainly for enjoyment or personal satisfaction. Nearly three-quarters — 71 percent — said they exercised for health-related reasons.

What do people say they get out of sports and exercise? Less stress and better mental health are high on the list. Improved physical health is another commonly reported benefit.

What about the important reasons cited by people who don’t engage in sports? Half say they refrain for a health-related issue, such as old age or a problem other than an injury. Almost half say they don’t have the time, money or opportunity.

You can find a full report on the poll and its findings here.

Our Sports and Health series continues over the summer, based on the results of our poll with the Robert Wood Johnson Foundation and the Harvard T.H. Chan School of Public Health.

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Almost no one disputes that the implementation of the federal health law has helped Americans who were previously uninsured gain coverage. But exactly how much has the uninsured rate dropped?

A whole lot, says President Obama.

“Nearly 1 in 3 uninsured Americans have already been covered — more than 16 million people -– driving our uninsured rate to its lowest level ever,” he told a cheering crowd at the Catholic Health Association’s annual conference Tuesday. “Ever,” he added for emphasis.

But is the uninsured rate really the lowest ever? Maybe, say experts. But you can’t really tell.

Many pundits and others have been citing periodic polling by the Gallup organization. The 11.9 percent uninsured rate (among adults) it reported in April for this year’s first quarter is the lowest measured since it’s been keeping track. But Gallup has been measuring only since 2008.

A survey with a longer history – the one conducted by the National Center for Health Statistics at the Centers for Disease Control and Prevention – also found an uninsured rate of 11.9 percent for the first three-quarters of 2014. That was down from 16 percent in 2010, the year the Affordable Care Act became law.

But even that survey changed its methodology back in 1997, which was well after employers had begun shedding coverage for workers and families.

“I would say that we have definitive evidence that the uninsured rate for the nonelderly is the lowest it has been since 1997,” said Genevieve Kenney, a policy researcher at the Urban Institute and co-director of its Health Policy Center. (Most surveys only measure the nonelderly because nearly everyone over age 65 has Medicare.) “Before that we are on less solid ground because of data limitations.”

“Some of the surveys being used now to determine the rate weren’t even around or weren’t asking health insurance questions a decade ago,” agreed Paul Fronstin, who’s been studying the uninsured at the Employee Benefit Research Institute since 1993. “The surveys that have been around have changed.”

Indeed, the administration’s own numbers suggest that in the 1970s and 1980s, the uninsured rate might have been almost the same as it is now or even lower. A December report by the President’s Council of Economic Advisers noted that that the uninsured rate at the end of 2014 was “at or near historic lows.”

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If you’re one of the more than 100,000 people in the United States waiting for a kidney transplant, you might not realize that an economist is trying to get that kidney to you faster. And he wants to make sure it’s the best possible kidney for you, so you’ll have many healthy years ahead.

The economist in question, Alvin Roth, won a Nobel Prize in 2012 for his work in matching markets. Those are markets where price isn’t a key factor. You can’t buy a good job or a spot in college. And you can’t buy a kidney, because that’s illegal.

In his new book, Who Gets What — and Why?, Roth explains how he has applied his understanding of matching markets to make practical improvements in New York City’s high school lottery, assignment of medical residencies and finding kidney donors. This conversation has been edited for length and clarity.

Why kidney transplants? It’s not a typical topic for an economist.

Often people expect I have some touching personal story about kidney disease, but it’s actually the mathematics that led me to it.

When I would teach students about game theory in markets, I started using kidneys as an example. You can’t use money because it’s illegal to pay someone for a kidney. I moved to Harvard in 1998, and in 2000 the first kidney exchange in the United States was done at a hospital nearby.

I started to think, gee, there might be a way where I could help organize it, make it easier for people to find kidneys.

You really seem to like finding practical applications for your theories. For instance, you helped come up with a better lottery system for New York City high schools. Why is that?

Practically, I was trained as an engineer. My degrees are all in operations research, not in economics. I gravitated to economics because I’m interested in how people coordinate and collaborate with each other. Economics studies all the ways people get along with each other.

There aren’t many kidney donors, which makes it hard for people to get a good match, or any match at all. And transplant centers tend to run their own databases. How did you overcome that?

There are a couple of challenges as you make a marketplace. You have to make a marketplace thick. So the first thing we had to do was build a database of people who were willing to participate in a kidney exchange. We had to get re-consent forms from everyone in New England; there were 14 transplant centers working with us. Assembling the database and getting the permissions took about a year. Then the hospitals had to get organized so they could do surgeries on the same day. That took about a year to complete.

Once marketplaces get thick, they suffer from congestion. It has to do with all the things you have to do to complete the transaction. When you’re shopping on Amazon, it involves searching. There’s all this stuff, and you have to find what you want. When you’re doing kidney transplants, you have to find out who can exchange kidneys with whom, doing blood tests to make sure it’s true. You can’t just work on the preliminary data. Then you have to organize the logistics. Initially we were doing simple exchanges, with two pairs of people or three pairs. An exchange with two pairs, where the patients got a kidney from the other patient’s incompatible donor, needed four operating rooms because the surgery was done simultaneously. That way if a donor changed her or his mind at the last moment, someone wouldn’t be left without a kidney. And a three-way exchange required six. That’s about as much as we could manage in New England.

How did you break that logjam?

We figured out that if you had a nondirected donor, someone who wasn’t paired with a patient but who was willing to donate a kidney to anyone, you didn’t have to do simultaneous exchanges. If the chain of transplants was broken along the way, no one would be tragically harmed. So nowadays we do quite long chains of exchanges.

Market design is a very outward-facing form of economics. I’m talking with doctors. I’m talking with school administrators. I’m doing a lot these days on school choice. I’m constantly talking with people who aren’t economists. A big deal in market design is finding the inside champions who the economists can help. I kind of think of economists as being helpers here. We have some ideas, but we don’t do any of the surgeries.

What next?

There’s a terrible shortage of organs around the world. Right now in the United States, there are 100,000 people waiting for a kidney. I’ve become interested in the fact that it’s against the law to pay for a kidney anywhere in the world. But it’s not against the law to remove financial disincentives. You might have to fly to California and be in a hotel room and miss a few days of work. Right now we don’t make it easy to recoup those expenses, but the current law doesn’t forbid it.

I would like to see steps taken making it easy for hospitals to reimburse donors’ costs and then get reimbursed by Medicare or private insurance. This would pay for itself, because every transplant saves a quarter of a million dollar in the first five years. It costs $90,000 a year to do dialysis, $100,000 for the transplant and $20,000 a year for anti-rejection drugs. Plus you go back to work, you start feeling good again, you’re not tied to a dialysis machine.

Medicine is a big part of the economy. Kidney disease is a big part of the medical economy. If we could do some of these better, it would be good. At some point in the future we won’t have to do transplants anymore, but all of the people who need kidneys now will be dead by then. So we need better ways to organize our resources.

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Judy Naillon called her insurer several months ago to find out why she was being charged $35 every month for birth control pills. Her friends said they were getting their pills free under the federal health law.

Why wasn’t she getting the same deal?

The insurance representative explained that was because the plan Naillon and her husband had through his job was “grandfathered” under the health law. In other words, unlike other health plans, Naillon’s insurance policy, which existed before the health law was enacted, doesn’t have to cover many preventive services, including contraception.

Naillon would have to continue to pay a share of the cost of her pills, the insurer told her. The plan also wouldn’t pay if she wanted to switch to an intrauterine device, and there’s no coverage for an annual physical.

“I’m just really frustrated,” says the Wichita, Kan., music teacher. When her husband took a new marketing job last fall, she says, “I thought that surely all these insurers must now be covering these benefits.”

About a quarter of insured workers today are enrolled in grandfathered plans, according to the Kaiser Family Foundation, and these plans haven’t significantly changed their benefits or costs to consumers since 2010.

Old Plans Not Subject To New Rules

These older plans differ in other ways, too. They don’t have to guarantee a member’s right to appeal a decision by the insurer, for example, and may charge consumers higher copays or higher co-insurance for out-of-network emergency services. The plans also aren’t required to comply with the law’s limits on a policy-holder’s annual out-of-pocket spending (currently $6,600 for someone in an individual plan and $13,200 for families). So, consumers who have these health plans may be on the hook financially for more of their medical care than people with Obamacare policies.

When the health law passed, President Barack Obama sought to reassure anxious consumers by promising that “if you like your health care plan, you can keep it.” Since then, the number of grandfathered plans has steadily declined.

In 2011, about 72 percent of companies that offered health insurance included at least one grandfathered plan; by 2014 that number had declined to 37 percent, according to the Kaiser Family Foundation’s annual survey of employer health benefits.

Smaller employers are more likely than large ones to offer the older policies, says Steve Wojcik, vice president of public policy at the National Business Group on Health, which represents the interests of large employers. Small firms typically buy a plan from an insurer that pays their claims. Larger companies, in contrast, often design their own plans and are self-insured — they pay their employees’ claims directly.

Individual plans can also be grandfathered.

Some people who study the insurance market have two words for the demise of grandfathered plans: Good riddance. These policies lack many consumer protections and are generally subject to weaker regulation, so aren’t necessarily good options for people who have health problems.

“Grandfathered plans are more likely to hang onto people who are low risk,” says Sarah Lueck, a senior policy analyst at the Center on Budget and Policy Priorities.

Some Upsides

On the other hand, the grandfathered policies may come with lower monthly premiums, and in some ways can be a good deal for people who are young and generally healthy.

In order to retain their grandfathered status, the older plans are limited in how much they can increase a policyholder’s copayments and deductibles. So, if someone covered by such a plan had a $20 copayment in 2010, for example, the copayment today could be no more than $26 next year, says Joe Kra, a partner and actuary at Mercer, a human resources consulting firm. Likewise, a $500 annual deductible for such a health policy could rise to no more than $652.

“If an employee is in a grandfathered plan, they’re one of the fortunate minorities,” Kra says.

But Naillon probably wouldn’t agree with that statement.

“Even though my doctor would like to do a physical and run labs,” she says, “I can’t afford to have those services.”

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Lots of people say they have trouble sleeping. And 1 in 10 Americans has chronic insomnia.

Most often, sleep disorders are treated with medication. Between 6 and 10 percent of adults in the U.S. use sleeping pills.

But a review of the medical evidence has found that therapy might help people with chronic sleep troubles just as much — or even more — than pills.

Evidence that cognitive behavioral therapy — a form of talk therapy that focuses on changing how a person reacts to specific situations — can help people with chronically bad sleep has been growing over the past decade, says Dr. David Cunnington, director of the Melbourne Sleep Disorders Centre in Australia, and the senior author of the recent study.

“We wanted pull together all the smaller studies that have been done on cognitive behavioral therapy for insomnia,” Cunnington says. “to really get a bigger pool of data and a better idea of how effective this is.”

The results were published Monday in the Annals of Internal Medicine.

A typical treatment plan for insomnia includes four to six sessions with a sleep psychologist. Therapists help train patients to wake up at the same time every day and develop good sleep habits , such as avoiding alcohol or caffeine near bedtime and reserving their bed for sleep (rather than watching TV, for example). They also teach relaxation techniques and challenge people’s negative attitudes toward sleep.

After completing therapy, on average, patients fell asleep almost 20 minutes faster and were awake in the middle of the night almost half an hour less, the study found. And the time they spent sleeping soundly increased by nearly 10 percent.

“Based on other studies, we know that these results from therapy are very similar to what you’d see with patients who take medication,” Cunnington says.

In many cases, therapy is a better treatment option, since it treats the underlying anxieties that cause insomnia. “A medication just puts a blanket over that anxiety and helps people get rest,” Cunnington says. “But cognitive behavioral therapy addresses the core problems, challenging people’s thinking around sleep. It can actually break the cycle of chronic insomnia.”

Plus, medications can come with side effects — like feeling sedated all day. And most sleeping pills lose their effectiveness over time, Cunnington notes.

So why don’t more doctors recommend therapy for sleep problems?

“I think it’s an issue of awareness,” says Kelly Baron, a clinical psychologist at the Northwestern University Feinberg School of Medicine who specializes in sleep disorders.

“This review definitely gives us some hard and fast numbers on the efficacy of therapy,” says Baron, who wasn’t involved in the recent study.

But primary care doctors often don’t know where to refer patients with chronic sleep issues, Baron says. And there’s a shortage of therapists who are trained to treat insomnia, especially outside of big cities.

Proponents of therapy for insomnia are working to develop a better certification program for sleep psychologists, Baron says. “What we really need to focus on at this point is increasing accessibility, so more people with sleep disorders have the option to choose therapy if they want it.”

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