Robert and Tiffany Cano of San Tan Valley, Ariz., have a new marriage, a new house and a 10-month-old son, Brody, who is delighted by his ability to blow raspberries.

They also have a stack of medical bills that threatens to undermine it all.

In the months since their sturdy, brown-eyed boy was born, the Canos have acquired nearly $12,000 in medical debt — so much that they need a spreadsheet to track what they owe to hospitals and doctors.

“I’m on these payment arrangements that are killing us,” said Tiffany Cano, 37, who has spent her lunch hours from her job at a regional bank on the phone negotiating payoff plans that now total $700 a month. “My husband is working four jobs. I work full time. We’re a hardworking family doing our best and not getting anywhere.”

The pair, who earn nearly $100,000 a year, are insured and have had no major illnesses or injuries. Still, the Canos are among the 1 in 4 Americans who report in multiple polls that the high cost of health care is the biggest concern facing their families. And they’re at risk of filing for bankruptcy; 62 percent of people who file do so, in part, because of medical bills.

“Oh, yes, that worry is always in the back of my mind,” Tiffany said.

The family is part of a struggling group: Middle-class folks who have followed the rules and paid for employer-based medical insurance, only to find that soaring health care costs — combined with high deductibles, high copayments and surprise medical bills — leave them vulnerable.

“I thought we’d be covered, and it’s just not enough coverage at all,” she said.

Robert Cano, also 37, had family health insurance for 2018 through his job as a manager at a large chain retail store, for which he pays nearly $500 per month. The plan’s $3,000 annual deductible and 40 percent coinsurance fees have added up faster than the Canos anticipated.

First came the nearly $4,000 bill from the in-network hospital where Brody was born Jan. 2, followed by separate fees from the anesthesiologist and the doctor who performed the routine delivery. Then, at 2 months, Brody was hospitalized with breathing problems that doctors said could be related to allergies or asthma. In May, Tiffany came down with a stomach virus that sent her to the emergency room for drugs to treat nausea and dehydration. Last month, the baby developed a bad case of bacterial conjunctivitis, or pinkeye.

“It’s been, like, $300 here, $700 there,” said Tiffany. “We had a hospital bill for him being sick of, like, $1,800.” Unable initially to find a pediatrician she liked, Tiffany has agonized over whether to use the ER when Brody gets sick. When he had pinkeye, she debated whether to take him in, hoping it would get better on its own.

Then he got worse, she said, pulling up a photo on her phone of her son with half-moons of red, puffy flesh under his dark eyes.

“I let him suffer for a day like that,” she said.

The Canos lost their first child, a girl, midway through her pregnancy in 2016. Tiffany acknowledges that experience has left her more anxious than the average first-time mom.

“It gave me so much fear that something would happen to him,” she said.

As for their own health care needs, the couple put themselves lower on the priority list. Tiffany has used a prosthetic limb since childhood, when her lower left leg was amputated because of a birth defect.

She needs a new prosthesis because her body changed during pregnancy, but she can’t see how to afford it.

A model suitable for the busy life of a working mom would easily cost $10,000 to $15,000, according to Tom Fise, executive director of the American Orthotic & Prosthetic Association.

“I try to push through,” Tiffany said. “I put on that brave face of just walking, but it’s so painful to walk. I have bruises all over my leg. I get blisters all the time.” Lately, she has been wearing an old prosthesis, one she used in high school, because it’s a little bit more comfortable.

The Canos don’t know how exactly they fell into such debt, because they tried hard to make responsible decisions. After meeting three years ago, they knew quickly that they wanted to marry and have a family.

“I waited until I found the right guy,” said Tiffany, who was thrilled when, in 2016, they were able to afford a 2,500-square-foot, two-story home in one of the stucco-and-tile neighborhoods an hour outside Phoenix.

But, taken together, the medical payment plans and premiums are almost as much as their $1,300 monthly mortgage. All told, the Canos spend about 15 percent of their annual income on health care, almost three times the average for non-Medicare households in the U.S.

That leaves too little for day care, car payments, gas, food and dozens of other domestic expenses, Tiffany said.

For 17 years, Robert had comprehensive health insurance through his job as a soldier in the Army Reserve and paid little or nothing for medical care. He left the Army in 2017, however, after he learned he would be deployed for an extended time away from his wife and new son.

“I told them, ‘I have to be at home,’ ” he recalled. The Army insurance ended on Dec. 31, two days before Brody was born.

That meant moving to his employer’s insurance plan. Like more than 40 percent of 152 million Americans who get health insurance through work, the Canos are enrolled in a plan that demands thousands of dollars before any coverage kicks in.

The couple discovered that they earn too much to qualify for financial assistance from medical providers or for subsidies if they shifted their insurance to a plan under the federal health insurance exchange. She is a full-time bank compliance officer. He is a full-time store manager.

Tiffany wrote to Kaiser Health News after seeing stories about sky-high medical bills on TV.

Dr. Merrit Quarum, the chief executive of WellRithms, a health care consulting firm, reviewed the family’s medical bills and the responses from their health care providers.

Though Quarum had questions about some of the fees in the itemized bills — $4 for a 600-milligram ibuprofen tablet? $3,125 to place an epidural? — he found the charges were legitimate under the terms of the contract between the hospital and the Canos’ insurer.

Tiffany’s only recourse was to set up the five payment plans she navigates each month.

“I wish I could say it wasn’t so, but it is,” Quarum said.

Mostly to pay off that health care debt, Robert has taken several part-time gigs this year — as a substitute teacher, a nighttime security guard and a sandwich deliveryman for a fast-food chain in Scottsdale, 40 miles away, where tips are better. He said he sometimes works up to 120 hours in a week.

“I’m not ashamed or embarrassed, even as old as I am, to deliver sandwiches,” he said, pulling on his retail chain polo shirt before rushing to a Saturday morning shift. “I know people, they’d rather get food stamps and feel sorry for themselves. But I’m a fighter. I will not give up … If I can bring in an extra $400 a week or $800 a month, she can get what she needs for the baby.”

Often home after midnight, he keeps shampoo and shaving cream in his car and naps in parking lots between jobs, relying on Red Bull to stay alert.

That means on many nights, when Tiffany picks up Brody from day care after her 90-minute commute, she handles most of the chores at home.

“Sometimes I feel like a single mom because my husband is never around,” she said.

She carefully tracks the family’s medical expenses, trying to juggle them with ordinary outlays that can’t wait — like $500 for the brakes that went out on her car this month.

At the rate they’re going, the bills won’t be paid until Brody is 3, Tiffany said. The Canos are getting older and they would like to have another baby before it’s too late, but, for now, that seems impossible.

For 2019, the couple have decided to switch to a different plan offered through Tiffany’s employer. The premium is higher — $650 a month — but the deductible is $1,500 with just 10 percent coinsurance.

“It is going to be a lot more per paycheck, which is going to hurt us,” Tiffany said. “But after what just happened, I want to make sure we are prepared in case anything does occur.”

How to fix a health care system that burdens middle-class families so heavily is beyond her, she said.

“The only thing we can do is just keep working,” Tiffany said. “I always wonder: How does everybody else do it?”

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

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The partial government shutdown that started Saturday will affect quite a few activities of the Food and Drug Administration.

Although most of the agency’s employees weren’t working over the weekend and on Monday and Tuesday because of federal holidays, FDA will furlough some 40 percent of its staff starting Wednesday.

However, much of the agency’s workforce will continue through the shutdown, with more than 10,000 FDA employees — nearly 60 percent — reporting to work, according to numbers released by the agency Friday.

The majority of those people are doing work funded by user fees paid by pharmaceutical and medical device companies, according to an analysis by the Alliance for a Stronger FDA, an advocacy group representing patient and consumer advocates as well as trade associations.

Here is a quick breakdown of how the shutdown will affect the agency’s work.

Activities that will continue during the shutdown

The FDA will continue work that’s critical to public health and safety. It will be able to respond to emergencies, like the flu and foodborne illnesses. It will continue recalls of any foods, drugs and medical devices that pose a high risk to human health.

As FDA Commissioner Scott Gottlieb tweeted over the weekend, the agency will also continue to screen “food and drug imports” and inspect any facilities that might pose “an imminent threat to health and life.”

Some criminal and civil investigations where there is an immediate risk to public health will also continue through the shutdown, as will all of the agency’s work that is funded by user fees.

For example, the agency will continue to oversee the manufacturing and distribution of all tobacco products. “The tobacco program is 100 percent user-fee funded,” says Steven Grossman, deputy executive director at the Alliance for a Stronger FDA.

Similarly, much of the agency’s work with new products is funded by fees paid by industry, so the FDA will continue reviewing and approving drugs and medical devices where the fees have already been paid. It will also continue to review requests for clinical research and issue any necessary guidance.

Activities that will stop during the shutdown

Broadly speaking, all activities that are less likely to have an immediate impact on health and safety of consumers will come to a halt. For example, routine regulatory and compliance work for medical products, animal drugs and most foods will be paused, according to a contingency staffing plan put forward by the Department of Health and Human Services.

Routine inspections of facilities and all work related to cosmetics and nutrition will also be paused during this period.

And the shutdown may affect some aspects of the drug review process as an estimated 30 percent of that work is funded by appropriations, according to the analysis by the Alliance for a Stronger FDA.

Should consumers be concerned about food and drug safety during the shutdown?

Probably not, at least not for now, says Grossman. “In the short term, consumers should not see much of an impact,” he says. That’s because “anything that could affect human health and safety [in the near term] will be staffed.”

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Rural hospitals close when they don’t have enough paying patients to care for, but they’re also dinged when the same patients show up over and over again. That puts outlying medical facilities in the precarious position of needing to avoid repeat customers.

Charlotte Potts is the type of patient some hospitals try to avoid. She lives in Livingston, Tenn. — a town of 4,000, tucked between rolling hills of the Cumberland Plateau.

“I’ve only had five heart attacks,” Potts says with a laugh. “I’ve had carotid artery surgery. Shall we go on? Just a few minor things.” She jokes that she’s “a walking stent.”

The heart trouble has affected the way Potts deals with her health problems. She spends much of her day in a recliner in her apartment, tethered to a pulsing oxygen machine, and listening to the radio.

Fortunately, her apartment sits within spitting distance of Livingston Regional Hospital — a 114-bed facility large enough to have a dedicated cardiac unit. But the hospital doesn’t want to see her every time her heart flutters.

So last time she landed in the ER, they helped her connect with a few companies that could provide care at home.

“If I’m going to have certain things going on here in my chest, I call for help, and they’re there,” Potts says of the home care team she chose.

A new era in hospital management

There were days when the hospital might have viewed a home health agency as a competitor. Not anymore.

“When I started this almost 40 years ago, the mission was different,” says Tim McGill, CEO of Livingston Regional. “We wanted patients in the hospital. That was the incentive. We were paid for it. Now you’re not.”

Hospitals used to run on a so-called fee-for-service model with virtually no limit to how many times they could see a patient. But, under pressure from private and government insurance programs, that model is transitioning to one in which hospitals are rewarded for safety and efficiency — which often results in a patient spending less time in the hospital.

Under the Affordable Care Act, Medicare began to ding hospitals if too many patients are readmitted to any hospital within 30 days of discharge. The measure is broadly unpopular with the hospital industry, since so much falls outside a hospital’s control. Medicare has even walked back the rules for safety-net facilities, which tend to treat a sicker population.

The penalty is meant to encourage hospitals to get it right the first time. In Livingston, the hospital operates on the thinnest of margins — just 0.2 percent in the most recent figures. And “readmissions” have been a drag on the bottom line.

One in five patients with heart failure was back within the month. The hospital has paid the maximum penalty in some years — nearly $200,000. So leaders started asking a basic, unifying question of other providers in town, McGill says: “What can we do together so they’ll stay out of the hospital and stay healthier in their home setting? That’s where the work is.”

Collaborating instead of competing

The work took the form of quarterly lunch meetings at the local library.

Mary Ann Stockton, a nurse at the hospital, invites all the home health agencies as well as hospice providers and the leaders of nursing homes.

At one meeting, she applauds the other providers for increasingly meeting patients inside the hospital before they’re discharged. She says it helps patients and families accept these home health workers.

“We know in our area, people don’t like to have a total stranger come into their home,” she says.

The group brainstorms how to generate the same kind of acceptance for hospice care, which — as one doctor in the meeting puts it — some families view as assisted suicide.

And on this day, the groups spends much of its time reviewing the value of flu shots, especially for the staff in nursing homes. Stockton says elderly patients with bad lungs become a hospital emergency room’s “frequent fliers.”

“Flu starts off, goes into pneumonia, COPD exacerbation — and they are a revolving door in our hospital,” Stockton says. “They’re hitting that ER a couple of times a week.”

Advance directives are on the agenda for next time — another way to keep people near the end of life from becoming ER regulars.

Livingston’s parent company, LifePoint Health, is launching this community approach in many of its 80-or-so markets, which are primarily in the Southeast and almost all rural. LifePoint vice president Cindy Chamness helps hospitals find willing partners.

“We were very frustrated for many years,” Chamness says, “because we weren’t able to impact readmissions just working on it by ourselves, as a hospital.”

“Are we saving ourselves right out of business?”

The solution looks different from one town to another. In Lake Havasu, Ariz., paramedics now visit discharged patients to make sure they’re following doctors’ orders. The house calls also cut down on government-funded ambulance rides.

It’s not just rural hospitals — all hospitals can be penalized for readmissions now. And threatening the bottom line in that way does seem to be effective. Readmissions have been falling across the board, according to the latest research.

But rural hospitals, which already treat fewer patients than urban hospitals, wonder if they’ll have enough patients to survive, says Michael Topchik of the Chartis Center for Rural Health.

“[A] CEO from Montana said to me, ‘The problem is, when we do the right thing, are we saving ourselves right out of business?’ ” says Michael Topchik of the Chartis Center for Rural Health.

The focus on cutting readmissions — by definition — cuts overall admissions too, he notes.

“So, this is the real inherent tension and challenge: Hospitals get reimbursed for doing ‘sick care,’ ” Topchik says. “But more and more they’re being asked to do population health, and really focus on ‘wellness.’ “

To make up the volume, the Livingston hospital is expanding its maternity ward and general surgery offerings.

There is also some immediate financial upside to reducing readmissions: Livingston Regional has cut readmissions more than any other rural hospital in Tennessee and even the nation, according to data compiled by Chartis.

As a result, the hospital’s Medicare penalty in the coming year will be reduced to 0.3 percent of its reimbursements — down from the maximum of 3 percent, which was roughly $200,000 a year.

That’s all because patients like Charlotte Potts now can safely stay home.

“I got a real bad tightness in the chest,” Potts recalls about a recent episode. She’d questioned whether to call an ambulance. “I was very uncertain about what was going on.”

But she phoned her home health agency, took a nitroglycerin pill as the agency advised, and instead of going to the ER, was able to get back to sleep.

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Sure, they’re less expensive for consumers, but short-term health policies have another side: They’re highly profitable for insurers and offer hefty sales commissions for brokers.

Driven by rising premiums for Affordable Care Act plans, interest in short-term insurance is growing, boosted by Trump administration actions to ease Obama-era restrictions and possibly make federal subsidies available to consumers to purchase them.

Short-term plans can be far less expensive than ACA plans because they set annual or lifetime payment limits. Most of these plans exclude people with pre-existing medical conditions, don’t cover prescription drugs and exclude in fine print some conditions or treatments. Injuries sustained in school sports, for example, often are not covered.

These plans can be purchased at any time throughout the year, which is different than plans sold through the federal marketplaces. The open enrollment period for those ACA plans in most states ended Dec. 15.

The rising demand for short-term plans is a boon for insurance brokers, who often see commissions on such policies hit 20 percent or more.

On a policy costing $200 a month, for example, that would translate to a $40 payment each month. By contrast, ACA plan commissions are often flat dollar amounts rather than a percentage of premium and can range from zero to $20 per enrollee per month.

“Customers are paying less, and I’m making more,” said Cindy Holtzman, a broker in Woodstock, Ga., who said she gets 20 percent on short-term plan sales.

Large online brokers also are eagerly eyeing the market.

Ehealth, one such firm, will “continue to shift our focus to selling short-term plans and non-ACA insurance packages,” CEO Scott Flanders told investors in October. The firm saw an 18 percent annual jump in enrollment in short-term plans this year, he added.

Insurers, too, see strong profits from plans because they generally pay out very little toward medical care when compared with the more comprehensive ACA plans.

Still, some agents like Holtzman have mixed feelings about selling the plans, because they offer skimpier coverage than ACA insurance. One 58-year-old client of Holtzman’s wanted one, but he had health problems. She also learned his income qualified him for an ACA subsidy, which currently cannot be used to purchase short-term coverage.

“There’s no way I would have considered a short-term plan for him,” she said. “I found him an ACA plan for $360 a month with a reduced deductible.” (A federal district court judge in Texas issued a ruling Dec. 14 striking down the ACA, which would among other things affect the requirements of ACA coverage and subsidies. The decision is expected to face appeal.)

Consequently, short-term insurers don’t have to pay as many medical bills, so they have more money left over for profits. In forms filed with state regulators, Independence American Insurance Co. in Ohio shows it expects 60 percent of its premium revenue to be spent on its enrollees’ medical care. The remaining 40 percent can go to profits, executive salaries, marketing and commissions.

A 2016 report from the National Association of Insurance Commissioners showed that, on average, short-term plans paid out about 67 percent of their earnings on medical care.

That compares with ACA plans, which are required under the law to spend at least 80 percent of premium revenue on medical claims.

Short-term plans have long been sold mainly as a stopgap measure for people between jobs or school coverage. While exact figures are not available, brokers say interest dropped when the ACA took effect in 2014 because many people got subsidies to buy ACA plans and having a short-term plan did not exempt consumers from the law’s penalty for not carrying insurance.

But this year it ticked up again after Congress eliminated the penalty for 2019 coverage. At the same time, the premiums for ACA plans rose on average more than 30 percent.

“If I don’t want someone to walk out of the office with nothing at all because of cost, that’s when I will bring up short-term plans,” said Kelly Rector, president of Denny & Associates, an insurance sales brokerage in O’Fallon, a suburb of St. Louis. “But I don’t love the plans because of the risk.”

The Obama administration limited short-term plans to 90-day increments to reduce the number of younger or healthier people who would leave the ACA market. That rule, the Trump administration complained, forced people to reapply every few months and risk rejection by insurers if their health had declined.

This summer, the administration finalized new rules allowing insurers to offer short-term plans for up to 12 months — and gave them the option to allow renewals for up to three years. States can be more restrictive or even bar such plans altogether.

Administration officials estimate short-term plans could be half the cost of the more comprehensive ACA insurance and draw 600,000 people to enroll in 2019, with 100,000 to 200,000 of those dropping ACA coverage to do so.

And recent guidance to states says they could seek permission to allow federal subsidies to be used for short-term plans. Currently, those subsidies apply only to ACA-compliant plans.

Granting subsidies for short-term plans “would mean tax dollars are not only subsidizing commissions, but also executive salaries and marketing budgets,” said Sabrina Corlette of Georgetown University Center on Health Insurance Reforms.

No state has yet applied to do that.

For now, brokers are focusing on getting their clients into some kind of coverage for next year. Commissions on both ACA and short-term plans are getting their attention.

After several years of declining commissions for ACA plans — with some carriers cutting them altogether a couple of years ago — brokers say they are seeing a bit of a rebound.

Among Colorado ACA insurers monthly commissions have ” gone from about $14 to $16 per enrollee to $16 to $18,” said Louise Norris, a health policy writer and co-owner of an insurance brokerage.

Rector, in Missouri, said an insurer that last year paid no commissions has reinstated them for 2019 coverage. For her, that doesn’t really matter, she said, because once carriers started reducing or eliminating commissions, she began charging clients a flat rate to enroll.

Norris noted that some states changed their laws so brokers could do just that.

At least one state, Connecticut, ruled that insurers had to pay a commission, which she thinks is protective for consumers.

“Insurance regulators need to step in and make sure brokers are getting paid,” said Norris, or some brokers, “out of necessity,” might steer people to higher-commission products, such as short-term plans, that might not be the best answer for their clients.

Her agency does not sell short-term or some other types of limited-benefit plans.

“I don’t want to have a client come back and say I’ve had a heart attack and have all these unpaid bills,” she said.

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

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If last Friday’s district court ruling that the Affordable Care Act is unconstitutional were to be upheld, far more than the law’s most high-profile provisions would be at stake.

In fact, canceling the law in full — as Judge Reed O’Connor in Fort Worth, Texas, ordered in his 55-page decision — could thrust the entire health care system into chaos.

“To erase a law that is so interwoven into the health care system blows up every part of it,” says Sara Rosenbaum, a health law professor at the George Washington University School of Public Health. “In law they have names for these — they are called superstatutes,” she says. “And [the ACA] is a superstatute. It has changed everything about how we get health care.” (That concept was developed by Abbe Gluck, a professor at Yale Law School.)

O’Connor’s decision is a long way from implementation. He still must rule on several other aspects of the suit brought by 18 Republican attorneys general and two GOP governors. And a group of state Democratic attorneys general has promised to appeal O’Connor’s decision, which would send it to the 5th Circuit Court of Appeals and, possibly, the U.S. Supreme Court. The high court has rejected two previous efforts, in 2012 and 2015, to find the law unconstitutional.

Meanwhile, here are five ways that eliminating the ACA could upend health care for many, if not most, Americans:

Millions could lose coverage directly

More than 20 million Americans who previously were uninsured gained coverage from 2010 to 2017. Some of that was due to an improving economy, but many also gained the ability to buy their own coverage, thanks to the law’s federal subsidies to defray the cost of insurance. Other provisions of the Affordable Care Act played a significant role, including its ban on restrictions for people with pre-existing medical conditions, expansion of the Medicaid program to more low-income adults and allowing adult children to stay on their parents’ health plans until reaching age 26.

If the law were reversed, federal funding for Medicaid and individual insurance subsidies would stop, and insurers could once again refuse coverage to or charge more for people who have health problems.

Fundamental changes to the health care system could be stymied

The impact of eliminating the ACA could be felt well beyond those people who are the direct beneficiaries of the law.

Gail Wilensky, who ran the Medicare and Medicaid programs under President George H.W. Bush, says such a change “would be very disruptive because so much [of the ACA] has affected the way health care is organized and delivered, and the way insurance is provided.”

For example, says Rosenbaum, the increase in health coverage meant that “suddenly it became possible for health care systems to care for, by and large, an insured population.”

Previously many hospitals, doctors and other health providers spent considerable time and effort figuring out how to treat — without going broke —people who lack insurance.

After the ACA kicked in, these providers began to worry less about whether they would get paid. And the federal government started pushing them to create new initiatives aimed at improving the quality of care.

Those include, for example, measures that base some federal payments on patients’ health outcomes rather than on each individual procedure performed. Under the ACA, the government also encouraged strategies that improve health across the U.S. — like improving the availability of healthful food, bicycle paths and preventive care.

If millions of people lost insurance, Rosenbaum says, those health providers “would have to go back to wondering how they will be able to pay their bills.”

Medicare and Medicaid would be dramatically altered

The popular Medicare program, which covers an estimated 60 million seniors and people with disabilities, was a major focus of the ACA.

Elimination of the federal health law would take away some popular benefits the ACA conferred — everything from free preventive care to the closing of the “doughnut hole” in Medicare’s prescription drug coverage. The doughnut hole refers to a coverage gap that had previously exposed large numbers of beneficiaries to thousands of dollars in drug costs.

The law also changed the way Medicare paid for hospital, home health and outpatient care. Many current payment policies are based on authority provided by the ACA, and if it went away, Medicare would have to rewrite those payment regulations. Millions of beneficiaries belong to accountable care organizations that were created under the health law, and it is unclear how their care would be affected.

The biggest change in the Medicaid program would be the elimination of the expansion of coverage. Loss of the ACA would also roll back a 23-percentage-point boost in Medicaid prescription drug rebates, which has saved states billions of dollars, according to Cindy Mann. She ran Medicaid under President Barack Obama and is now a partner at the health consulting firm Manatt Health.

The ACA required states to calculate Medicaid eligibility differently — changing what counts as income — so all the work states did to alter their information systems would have to be recalculated, she says.

Wide array of health programs at risk

Shorthand descriptions of the health law often stop at its provisions providing consumer protections and expanding Medicaid. But the ACA included sweeping changes to other parts of the health system that rarely get mentioned.

For example, it created the first pathway for Food and Drug Administration approval of generic copies of expensive biologic drugs, by incorporating the Biologics Price Competition and Innovation Act of 2009. Biologic drugs are more difficult to reproduce than other types of medications.

Also hitching a ride on the ACA was a long-delayed bill providing permanent spending authority for programs provided by the Indian Health Service, which serves Native Americans.

And the law included a series of grant programs to help train more health professionals who would be needed to treat the millions of newly insured Americans.

All those programs would be thrust into doubt by invalidating the law.

Loss of the ACA also would impact a popular program that predates Obamacare: the Health Insurance Portability and Accountability Act, or HIPAA.

The ACA’s protections for pre-existing conditions — banning insurers from charging people with health problems higher premiums or refusing to sell to them altogether — built on similar protections for people with employer insurance. Congress included those protections in HIPAA, which was enacted in 1996. And far more people are touched by HIPAA than by the ACA, because far more people get health insurance through their employer than through the individual market.

However, when Congress wrote the ACA, it incorporated HIPAA safeguards into the pre-existing-condition provision. That means if the ACA is struck down, the HIPAA protections might disappear as well.

Even the Trump administration’s health agenda could be compromised

President Trump has railed against the health law, but his Department of Health and Human Services has a priority list that relies in some significant ways on the continued existence of the ACA.

For example, efforts to address the opioid epidemic — one of the administration’s top health challenges — could be seriously set back if the Medicaid expansion were to end. Medicaid is the largest single payer for mental health and substance abuse treatments.

Much of the president’s effort to limit drug prices flows through the Center for Medicare & Medicaid Innovation, which was created by the ACA and would lose its legal authority if the law became invalid.

Similarly, the administration is using this center to pursue “bundling” payments for certain surgical procedures — an effort to try to get more value for dollars spent.

Kaiser Health News, a nonprofit news service, is an editorially independent program of the Kaiser Family Foundation and not affiliated with Kaiser Permanente. KHN senior correspondent Phil Galewitz contributed to this story.

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U.S. District Judge Reed O’Connor has a history of siding with Republicans on ideologically motivated lawsuits. His ruling last week, in which he sided with the GOP on a challenge to the Affordable Care Act, was not a one-off.

In fact, critics say, his history is ultimately why that case was before him in the first place.

By all accounts, O’Connor’s ruling is sweeping. It says the entire health care law became invalid when Congress zeroed out, in 2017, the tax penalty for Americans who don’t have health insurance — a penalty that had been tied to what’s known as the law’s individual mandate that nearly everyone have insurance.

“I think he went too far in rejecting the entire law,” says Josh Blackman, a conservative legal scholar and professor at the South Texas College of Law in Houston. “I think he could have stopped short and simply severed the Obamacare mandate.”

While O’Connor’s decision may seem a bit extreme to some legal scholars, it wasn’t surprising.

Justin Nelson, a law professor at the University of Texas, Austin, says if you know anything about O’Connor’s past rulings, this was predictable.

“In case after case,” Nelson says, “what he has shown is that he has tended to side with the Republican attorneys general who are bringing ideological suits.”

Nelson recently ran an unsuccessful campaign to oust Texas Attorney General Ken Paxton, who led this multistate legal challenge to the health care law. Nelson says Paxton and the other Republican attorneys general have filed lawsuits in the U.S District Court for the Northern District of Texas because they know there’s a good chance they’ll get O’Connor as the judge.

“Judge O’Connor has been the go-to judge for Ken Paxton and Republican attorneys general who want to file ideological suits in any court across the country,” Nelson says. “Reed O’Connor is their best shot to get a ruling that they like.”

O’Connor, who did not respond to NPR’s requests for comment, was a Republican staffer on Capitol Hill before he was nominated to the federal bench by George W. Bush in 2007. So far, he has had to weigh in on at least a couple of contentious issues.

For example, O’Connor is known for striking down an Obama-era rule that protected transgender students. In that case he also sided with Paxton, who filed that legal challenge.

“They’ve done this over and over again on the hope that Judge O’Connor would rule on behalf of an ideological agenda,” Nelson says. “And I don’t think that is proper. I don’t think that is right.”

Paxton has filed lawsuits in other courts, too. He filed challenges to Obama-era immigration laws in a court in South Texas, which also has a reliably conservative judge on the bench.

However, Blackman believes criticism of this practice is “overblown.”

“All lawyers generally file the case where it leads to the best chance of success,” Blackman says. “And to the extent that [there’s a] criticism — that’s criticism of the attorney general and not of the judge. The judge doesn’t control which cases come to him.”

Furthermore, because O’Connor is getting a lot of ideological lawsuits brought to him, it’s making his voting record more controversial, Blackman adds.

“I think by virtue of the attorney generals’ form selection,” he says, “Judge O’Connor’s had a greater share than average of hot-button issues.”

However, Blackman says he is concerned that criticisms of controversial opinions are increasingly shifting toward the judges who issue the opinions — instead of toward the decisions themselves.

“President Trump does this all the time,” Blackman says. “Politicians do it all time. And usually this happens to Supreme Court justices, but here it is being done to a district court judge in Fort Worth — who, 99 percent of his docket no one will even know about.”

No matter how controversial O’Connor’s ruling on the health care law, Blackman says, the decision over the Affordable Care Act will now pass to another judge, as the case moves on to a higher court.

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Sarah Witter couldn’t catch a break even though her leg had gotten several.

As she lay on a ski trail in Vermont last February, Witter, now 63, knew she hadn’t suffered a regular fall because she couldn’t get up. An X-ray showed she had fractured two bones in her lower left leg.

A surgeon at Rutland Regional Medical Center screwed two gleaming metal plates onto the bones to stabilize them. “I was very pleased with how things came together,” the doctor wrote in his operation notes.

But as spring ended, the wound started to hurt more. In June, Witter returned to the doctor. “He X-rayed it and said it broke,” she said. “And I was thinking, what broke? And he said, the plate. He said they do sometimes.”

The doctor performed another operation, removing the cracked plate and replacing it with a larger one.

Witter said she had been dutifully following all the instructions for her recovery, including going to physical therapy and keeping weight off her leg.

“I was, of course, thinking, ‘What did I do?’ ” Witter said. “The doctor said right off the bat it was nothing I did.”

Then the bill came.

Patient: Sarah Witter, a retired teacher and ski buff who had moved from Pennsylvania to Vermont for the outdoorsy lifestyle.

Total bill: $99,159 for emergency services, therapy and hospital care, including $52,587 for the first surgery and $43,208 for the second surgery. Altogether, Witter’s insurer, Aetna, paid $76,783. Witter paid $18,442 — including $7,808 for the second surgery. About half of Witter’s total expenses were copayments; an additional $7,410 was the portion of hospital charges that Aetna considered unreasonably high and refused to pay.

Service provider: Rutland Regional Medical Center, the largest community hospital in Vermont, performed the surgeries. Emergency services, anesthesia and physical therapy were done by other providers.

Medical service: In February, two metal plates called bone fixation devices and manufactured by Johnson & Johnson’s DePuy Synthes division were surgically attached to two lower leg bones Witter had fractured in a skiing accident. These plates are long, narrow pieces of metal with holes drilled in them at regular intervals for screws to attach them to the bones. A crack had developed in one of the plates running from the side of one of those holes to the edge of the plate. A second surgery was required to remove the plate and replace it.

What gives: When devices or treatments fail and need to be replaced or redone, patients and their insurers are typically expected to foot the bill. That may be understandable if a first course of antibiotics doesn’t clear bronchitis, requiring a second drug. But it is more problematic — and far more expensive — when a piece of surgical hardware fails, whether it’s a pacemaker, a hip that dislocates in the days after surgery or a fractured metal plate.

Warranties, standard features at an electronic store or a car dealership, are uncommon for surgeries and medical devices used in them.

Dr. James Rickert, an orthopedic surgeon in Indiana and president of the Society for Patient Centered Orthopedics, said a plate like the one implanted in Witter’s leg can fail if the surgeon doesn’t line it up correctly with the bone, although usually that causes the screws to break or back out. A plate also can fail if the patient puts too much weight on it or doesn’t follow other recovery instructions. There can also be a flaw in the implant.

“When the plate breaks, it’s usually from overworking it, or a defect in the plate itself,” Rickert said. “The vast majority of people follow their instructions and are honest about it. If a person comes in and tells you they’ve been following their instructions and the surgery’s done properly, to me that’s a hardware failure.”

Nancy Foster, vice president for quality and patient safety policy at the American Hospital Association, said sometimes hospitals won’t charge for a second surgery “if they were aware that it was something they did that caused the patient to need follow-up care.”

Rutland Regional, Witter’s hospital, wouldn’t discuss Witter’s care or bills, even though she gave it permission to do so. “The organization is not comfortable in getting into the specifics of an individual patient’s case,” a spokeswoman wrote. The hospital also declined to discuss under what circumstances, if any, it would discount a second surgery’s cost because of the first’s failure.

Hospitals don’t consider it their responsibility if a medical device failure is the problem, Foster said. But manufacturers are reluctant to take the blame for an unsuccessful surgery.

AdvaMed, a trade group for medical device manufacturers, said some companies will provide replacement devices if theirs failed, but others don’t, especially if the failure of a procedure cannot “easily be attributed” to the device, the group said in a written statement.

“There are numerous factors outside of a manufacturer’s control — and unrelated to the safety of the device as designed — that could result in a device not performing as intended,” AdvaMed said.

These devices aren’t cheap: Witter’s hospital billed $9,706 for the first set of plates. It billed $12,860 for the replacement and an extra piece of equipment to attach it.

DePuy Synthes, which manufactured Witter’s plates, said in a written response that “in rare circumstances” metal plates “may fracture under normal weight-bearing or load-bearing in the absence of complete bone healing.” Even then, the company said, that is a chance patients have to take.

AdvaMed said it doesn’t keep statistics on device performance, and DePuy didn’t respond to questions about how often its plates fail.

Resolution: The second surgery delayed Witter’s recovery by four months and prevented her from gardening, golfing, hiking, biking and motorcycling through the summer and fall, as she usually does. “I was pretty much chairbound for 20 weeks,” she said.

In November, she wasn’t able to join her husband and son on a trip to Iceland. Instead of volunteering at a nearby ski resort, as she had done for six years — and which carries the benefit of a free season pass — Witter said she tried selling hand warmers and lip balm out of a small kiosk and watching the skiers through a window. She said she had to quit after six days because of the pain in her feet.

“The biggest annoyance with this whole thing, even though it took eight months out of my life, is I hate to pay for it again, and the doctor clearly said it wasn’t anything I did,” she said.

Aetna said in a statement that while it doesn’t allow providers to charge for indisputably inept medical mistakes such as leaving a surgical sponge in a patient or operating on the wrong limb, a broken plate doesn’t qualify for such protection. (Medicare follows a similar approach.)

After reviewing Witter’s records, Aetna said it concluded the hospital had billed Witter for the portion of charges Aetna had considered excessive — a practice known as “balance billing.” While Aetna cannot reject those charges because the hospital doesn’t have a contract with it, the spokesman said Aetna would try to negotiate with the hospital on Witter’s behalf to reduce the bill.

Rutland Regional, however, indicated in its statement that the only reason it would discount a bill was for people who had inadequate insurance or were suffering financial hardship from the size of the bills. Witter said she doesn’t meet the hospital’s criteria.

The hospital invited her to meet with her surgeon and its chief financial officer.

The takeaway: Witter brought up the seeming unfairness of the double charges to the hospital’s billing department as well as to her doctor, who, she said, was “charming,” but told her “he had no wiggle room to do anything.” Patients are usually out of luck when a second surgery is needed because of the failure of a medical device or a surgeon’s mistake. A few places, most prominently the Geisinger health system in Pennsylvania, offer warranties for hip and knee, spine and coronary artery bypass surgeries, among other procedures.

AdvaMed says that if a company provides a replacement, the hospital or surgeon isn’t supposed to bill Medicare or the patient for the equipment — even if the operation incurs charges.

Patients should scrutinize their bills and question their doctor and hospital or surgical center about charges for replacement devices.

If the doctor or hospital is partially at fault for the failure of the first procedure, request that part or all of the costs of the second surgery be waived. Get it in writing so you can make sure the billing department follows through. Also, in a medical market where insurers want to pay only for value-based care, let your insurer or employer’s human resources department know that you are being charged twice for the same surgery. Let them fight the battle for you.

NPR produced and edited the interview with Kaiser Health News’ Elisabeth Rosenthal for broadcast. Nina Keck, a reporter with member station WVPR in Vermont, provided audio reporting.

Do you have an exorbitant or baffling medical bill that you’d like KHN and NPR to look into? You can tell us about it and submit a copy of the bill here.

KHN is a nonprofit news service covering health issues. It is an editorially independent program of the Kaiser Family Foundation that isn’t affiliated with Kaiser Permanente.

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Sen. Cory Booker, D-N.J., says he will introduce federal legislation this week that would require more transparency surrounding states’ Medicaid drug decisions. The bill comes in response to a recent investigation by the Center for Public Integrity and NPR.

The measure, known as the “Medicaid Drug Decisions Transparency Act,” would require pharmaceutical companies to disclose their payments to pharmacists and others who serve on state Medicaid drug boards. These boards help decide which drugs Medicaid patients will be able to access easily. Currently drugmakers must only disclose perks given to doctors, such as free dinners, speaking fees and consulting gigs. In addition, the bill would increase penalties for companies that fail to comply with reporting requirements.

“These are really nefarious tactics that drug companies use, and they use them to influence state Medicaid programs’ drug coverage decisions,” says Booker. “My bill’s going to address this problem by increasing transparency — shining a light onto these payments.”

The proposed federal legislation was prompted by the recent Medicaid, Under the Influence investigation from the Center for Public Integrity and NPR, which revealed how drugmakers influence states’ choices regarding drugs for Medicaid patients.

The investigation, published in July, found that drug companies swarm state Medicaid board meetings when their drugs are under consideration, and have given payments and perks to three out of five doctors recently serving on those boards. The companies’ efforts to undermine state drug cost controls have helped push up Medicaid expenses nationwide.

The Senate bill would also require states to publish and update the lists of members on their Medicaid drug boards. The Center for Public Integrity had to scour meeting minutes, call agencies and formally request public records to compile a list of board members across the U.S. Even so, reporters still could not obtain information on two committees in Illinois and South Carolina.

Booker’s bill would require the U.S. Secretary of Health and Human Services to provide states with summaries of drug company payments made to members of their Medicaid drug committees.

With only weeks remaining in the current session of Congress, the bill is unlikely to pass. But Booker says he hopes it will help set the upcoming agenda for Democrats; he intends to reintroduce it in 2019.

The Center/NPR investigation previously prompted Arizona Gov. Doug Ducey, a Republican, to issue an executive order tightening his state’s ethics rules and to boot a doctor from the Medicaid committee who had received more than $700,000 in payments and perks from drugmakers. Officials in Colorado, New York and Texas also took action in response to the Medicaid investigation.

The Center for Public Integrity is a nonpartisan, nonprofit investigative news organization in Washington, D.C. You can follow Liz Essley Whyte on Twitter at @l_e_whyte.

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In 2009, Steve Burrows’ mom, Judie, went in for hip replacement surgery. She came out with brain damage and mobility issues after a weeks-long coma that would change her and her family’s life.

In the new HBO documentary Bleed Out — Burrows, a filmmaker and comedian, tracks his 10-year odyssey to find out what happened to his mother and who is to blame. It’s a deep dark dive into the heart of America’s health care system.

What happened to Judie is complicated, but it essentially began with massive blood loss.

“In the end, that’s really how this whole thing started,” Burrows says in an interview with NPR’s Lulu Garcia-Navarro. “She lost over half the blood in her body.”

After her surgery, she was put into recovery and left alone with that’s called an electronic intensive care unit, or eICU.

With a series of monitoring tools that usually include microphones, video cameras and alarms, eICUs are meant to provide the 24-hour monitoring that many patients require after a major medical emergency.

“This [eICU] didn’t notice my mom was in a coma for at least a day and a half and I wanted to talk to the ICU doctor who was there that night,” Burrows says. “We were told there was no doctor there. I said ‘Well that’s insane, what do you mean?’ “

He says there were doctors monitoring the cameras out by the airport in Milwaukee and they were supposed to be the safety net for his mother.

Burrows says that when he asked whether the camera was on, the head of the ICU told him it wasn’t because of patient privacy issues.

As Burrows dug into his mother’s case and the failure of the eICU to recognize her coma, he came across a staggering statistic. According to a study by researchers at Johns Hopkins University, the third leading cause of death in the United States is medical errors.

And those errors, Burrows says, can leave patients one step away from financial ruin.

“That’s the hard lesson we learned,” Burrows says. “My mom, certainly. She was a single mom, she raised my sister and I. She did everything right. She was set. And this happened and two and half years later, she’s broke. She’s on Medicaid … and now we, all the American taxpayers, are paying for her.”

Burrows says that before her surgery, Judie was a vibrant, independent and adventurous woman. These days, her health care has become increasingly more complicated, and in the past two months, she has started long-term hospice care.

“She is very compromised,” Burrows says. “She lost her speech several years ago and that was really the thing that really hurt her the most because she was so articulate and so full of life. I know that the loss of her speech is really the thing that is really killing her the most.”

Throughout the 10 years that Burrows documented his mother’s struggles, he recorded many conversations — both openly and secretly. One of those conversations was with the doctor who conducted his mom’s hip replacement surgery. At the time, the doctor didn’t know he was being recorded.

Steve: If you were in my shoes, right now, what would be …

Doctor: I’d like an accounting, just like you, for why in the hell no doctor was there. Their intensive care unit, where this problem occurred, we still don’t know what happened. We don’t have accountability.

Steve: I mean, do you think they’ll ever tell the truth?

Doctor: No. I don’t.

Up until this point, Burrows had been asking basic questions to the doctors and caregivers involved in his mom’s situation and their stories were always changing, he says. When he finally heard what he thought was the truth by the doctor, Burrows says it was shocking.

He started filming his mother’s pain and suffering after consulting with attorneys about trying to pursue justice for her. She was at her most vulnerable. It was painful and uncomfortable, but he knew he had to do it.

At the time, he didn’t want to make a documentary, but he eventually decided others needed to know what happened.

“When I started to find out about this universal thing, about the third leading cause of death, and then the eICUs, I thought I really have to tell people about what I just found out,” Burrows says. “Because I’m a pretty informed guy and I didn’t know about any of this stuff.”

Although he’s done his best to make sure his mother is comfortable, Burrows says he hasn’t been able to give her what she really wanted, which was to get her life back.

“I had a great mom and I really tried hard to give her everything she wanted and I couldn’t give her any of that,” he says. “She wanted to go home. She wanted to drive. She wanted her life back.”

Burrows says he hopes that as people watch the film, they realize they need to ask thoughtful questions when it comes to their health care, and he stressed the importance of having a patient advocate in case things like this happen.

“You need to shop for doctors and hospitals like you’d shop for a car,” he says. “You know, shop like your life depends on it because we found out that it does.”

NPR’s Sarah Handel and Cindy Johnston produced and edited the audio for the story. Wynne Davis adapted it for Web.

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