They are just three little words — “health savings accounts” — but they are generating a lot of buzz as Republicans contemplate plans to repeal and replace the Affordable Care Act.

Expanding the use of these accounts, based on a long-held conservative view that consumers should be more responsible for their health care spending, is a part of almost every GOP replacement plan under consideration on Capitol Hill.

Here’s the theory behind HSAs: Making consumers bear a bigger upfront share of medical care – while making it easier to save money tax-free for that purpose – will result in more judicious use of the health system that could ultimately slow rising costs.

While the details of the current proposals differ, they all generally seek to allow larger tax-free contributions to the accounts and greater flexibility on the types of medical services for which those funds can be used. Some include tax credit subsidies to help fund the accounts.

Supporters say premiums for the insurance linked to an HSA are lower, and they like HSAs’ trifecta of tax savings: no taxes on contributions, the growth of the funds in the account or on their withdrawal if spent on medical care. But skeptics note the tax break benefits wealthy people more than those who earn less.

Still, expect to hear a lot more about HSAs in the coming months. Here’s a rundown of some of the basics:

How do HSAs work?

HSAs currently must be paired with qualifying health insurance plans that have annual deductibles of at least $1,300 for individuals or $2,600 for a family, although surveys show average deductibles are generally higher than those minimums. Unlike some other types of insurance, the consumer pays the full cost of most doctor visits, drugs or hospital stays until the deductible is met. There are some exceptions for services deemed preventive, such as certain vaccines, prescription medications or cancer screenings.

To pay for those deductibles and other medical costs, consumers can make tax-free contributions to the HSA account. This year, that allowable amount maxes out at $3,400 for individuals or $6,750 for families, and unused portions can roll over to the following year. The amounts in the HSA grow tax-free, similar to retirement accounts. Some employers who offer HSA-coupled insurance contribute to the accounts on behalf of their employees.

Money in the funds moves with the policyholders, even if they change jobs or insurers, similar to how workers can take their 401(k) retirement fund to a new employer. Still, polls have shown that most Americans already have little or no money saved for an emergency, so skeptics say they are not likely to embrace medical accounts.

“Americans who are struggling to afford health insurance right now don’t have the money to set aside,” said Maura Calsyn, managing director, health policy, at the Center for American Progress. “Raising the limits is essentially just providing high-income individuals with a greater tax benefit and doesn’t do anything to increase coverage.”

Critics also point out that older or sicker people could blow through their entire fund every year and never accumulate any savings.

How would they change under GOP proposals?

Several proposals – including the Better Way white paper authored by House Speaker Paul Ryan, R-Wis., would increase HSA contribution limits. Ryan’s plan would allow the tax-free contributions to total as much as the insurance plan’s annual deductible and out-of-pocket maximum. For families, that could be more than $14,000 a year.

Kentucky Republican Sen. Rand Paul’s Obamacare Replacement Act would get rid of the upper limit on contributions entirely. It would also allow the accounts to be coupled with any type of insurance, not just high-deductible plans.

What services can HSA funds cover?

Currently, money in the accounts can be used only for certain health costs, such as deductibles, copayments for doctor visits, hospital care and other out-of-pocket costs. The funds cannot be used to pay premiums on health insurance plans. Both the Ryan proposal and one from Rep. Tom Price, R-Ga., the physician nominated to head the Department of Health and Human Services, would allow the funds to be used to pay fees directly to doctors, for “concierge care,” which refers to arrangements in which consumers pay annual or monthly fees for special coverage that provides quicker access, longer visits or, in some cases, all primary care services.

Christopher Condeluci, an attorney and former counsel to the Senate Finance Committee, said Republicans might seek to loosen the rules around what services are exempt from the deductible, potentially to incorporate medical care important to people with chronic illnesses, such as annual eye exams for people with diabetes. “That would recognize that there are individuals who are high medical utilizers and high-deductible plans just are not appealing to them … unless you can change the definition to make them more appealing,” he said.

How common are HSAs?

An estimated 26 million Americans — policyholders and their dependents — are covered by some type of HSA-eligible plan. That’s a small share of the overall 178 million who have coverage through their jobs or purchased on their own, but it has steadily grown since HSAs first became available in 2003. Among employers who offered insurance last year, about 24 percent had HSA-eligible plans, with average annual deductibles of $2,295 for single policies and $4,364 for families, according a survey by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Paul Fronstin, with the Employee Benefit Research Institute, noted that the slow ramp-up is similar to most trends in health benefits. Now, he said, with the GOP focus on changing the health system, “we could see an acceleration of that trend.”

How much do they cost and what are the advantages?

Eligible health plans may have lower premiums than other types of insurance because of their higher deductibles. Policy experts and economists say the accounts might make people better consumers of health care because they have more “skin in the game” and are more likely to shop for the best prices on drugs, medical care or hospitalizations — and avoid running to the doctor with the sniffles. “It makes people more conscious that the health care they are getting is being paid for with real dollars and not coming out of the ether,” said Joe Antos with the American Enterprise Institute.

What are the disadvantages?

For one thing, it isn’t easy for people to comparison shop on the prices for medical care. And, consumers don’t always make good choices. Among those with HSAs, overall spending on medical care does indeed go down, Fronstin and other researchers have reported. But they also uncovered a disturbing trend: at least in the first year or two, policyholders cut back on everything, including high-value services they should really seek. ER visits go up. And many even forgo screening exams – such as mammograms or other cancer tests – even though they are specifically excluded from the deductible and are therefore “free” to the consumer. Bypassing preventive or other care could lead to higher costs in the future.

Follow Kaiser Health News’ Julie Appleby on Twitter: @Julie_appleby.

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As Congress weighs repeal of the Affordable Care Act, the home state of Vice President Mike Pence Tuesday sought to keep its conservative-style Medicaid expansion under the federal health the health law.

Indiana applied to the Trump administration to extend a regulatory waiver and funding until Jan. 31, 2021, for its package of incentives and penalties that are intended to encourage low-income Hoosiers on Medicaid to adopt healthful behaviors. Beneficiaries pay premiums, get health savings accounts and can lose their benefits if they miss payments.

Though Pence now supports the health law’s repeal, the Healthy Indiana Plan that he established in 2015 as the state’s governor has brought Medicaid coverage to more than 350,000 people. The architect of the plan was health care consultant Seema Verma, who has been nominated to head the Centers for Medicare & Medicaid Services.

Without Trump administration approval, federal money for Indiana’s expansion will run out Jan. 31, 2018. Indiana officials said the Medicaid expansion would continue even if Washington follows through on a Republican proposal to distribute federal Medicaid funds through a block grant program that would give states more flexibility in setting benefits and eligibility levels.

State officials refused to say whether the expansion would continue if Congress repealed Obamacare and eliminated funds for Medicaid expansions. If that happened, it’s unlikely states would have the money to make up for the lost federal aid.

Indiana’s effort to continue its Medicaid expansion demonstrates how states that expanded Medicaid under the Affordable Care Act — even Republican-controlled ones — are counting on additional federal dollars to pay for those expansions. It also reflects deadline pressure: They can’t wait for Congress to finish its debate over the future of the health law because they need to set budgets and programs now for next year.

According to Indiana’s request, continuing the Medicaid expansion will cost Indiana $1.5 billion but bring $8.6 billion in federal funding from 2018 to 2020.

“Indiana has built a program that is delivering real results in a responsible, efficient, and effective way,” Gov. Eric Holcomb, a Republican, said in a statement. “I look forward to maintaining the flexibility to grow this remarkably successful tool and to preserve our ability to respond to the unique needs of Hoosiers.”

Several other states including Kentucky and Ohio are considering adopting features of Indiana’s Medicaid plan.

Tuesday’s filing continues most core elements of the Healthy Indiana Plan, but also expands beneficiaries access to substance abuse treatment and adds incentives for members to quit smoking, use chronic disease management programs and take part in voluntary job referral and training programs.

“Certainly I think the new administration would give the waiver a friendly reception,” said Joan Alker, executive director of the Center for Children and Families at Georgetown University. “But again that doesn’t answer the question about whether the money is going away,” if Congress repeals the health law and the Medicaid expansion.

Rep. Susan Brooks, R-Ind., broke the news of the waiver submission plans at a House committee hearing on Medicaid on Tuesday.

“It’s an outstanding program that I hope folks on both sides of the aisle see it is a way to save and help people who truly need it, and it can be replicated,” Brooks said.

Some Republican plans to scrap and replace the Affordable Care Act don’t include a Medicaid expansion. Republicans have argued for years that the Medicaid program is broken and non-disabled adults who gained coverage under the expansion should not be covered.

Under expansion, states received additional federal funding to expand eligibility to everyone with annual incomes at or below 138 percent of the federal poverty level, or about $16,000.

Holcomb isn’t the only Republican governor counting on Medicaid expansion and the additional federal funding continuing at least through 2018.

Ohio Gov. John Kasich proposed a budget Monday that maintains expansion coverage for 700,000 individuals.

But Kasich plans to switch from a traditional Medicaid expansion to a more conservative version that will require beneficiaries to pay more out of pocket.

This story was produced through a collaboration between NPR and Kaiser Health News, an editorially independent program of the Henry J. Kaiser Family Foundation, a nonpartisan health care policy research organization. You can follow Phil Galewitz on Twitter: @philgalewitz.

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Tuesday is the last day of open enrollment for health coverage for 2017 under the Affordable Care Act. And while Republicans in Congress are working to repeal the law, it’s not at all clear what might replace it.

During the campaign, President Trump suggested a nationwide insurance market that would allow insurance plans to be sold across state lines.

The idea has been kicking around for years, and some states have tried it, including Rhode Island, where it didn’t work too well.

All Things Considered‘s Audie Cornish talked to Christopher Koller who was the Rhode Island’s insurance commissioner when this option was offered.

On the roadblocks of allowing out-of-state health insurance options

It’s very hard to have interstate insurance. It means that a state has to accept the rules of another regulator. That means if a Rhode Island insurer was licensed in Massachusetts, we have to say that whatever they do in Massachusetts is good for us here in Rhode Island. It also requires significant work to coordinate rules and regulations. Insurance regulators are reluctant to take on this task.

Let’s say Rhode Island didn’t allow limited benefit health plans. … If we were to allow insurance to come in from a state that allowed those plans, and they sold them in Rhode Island, you’d have insurers offering policies that were against the laws and policies set forth by Rhode Island legislature. … And if insurers are going to sell across state lines, you’ll see more variation among states which makes it harder to coordinate and for insurers to operate across state lines.

On how health insurance compares to other lines of insurance

It’s not [comparable]. There’s a big difference between a hospital and an auto body guy repairing your car. We have a lot more auto body guys than we have hospitals. We don’t compel auto body makers to take care of our car if we can’t pay for it, but we compel hospitals to treat people if they can’t afford to pay for it. We look at health care very differently from auto insurance.

On why out-of-state health insurance can’t compete with local

In Rhode Island we have one hospital system that has 80 percent of births in the state. [Insurers] need that in [their] network to be competitive. And I can tell you that if a national insurer walked into that hospital, and said, ‘Will you contract with us?’ the hospital would have no reason to give the insurer any discount compared to local established health plans have already. That national insurer can’t offer a competitive product.

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Humans have had to face death and mortality since since the beginning of time, but our experience of the dying process has changed dramatically in recent history.

Haider Warraich, a fellow in cardiology at Duke University Medical Center, tells Fresh Air‘s Terry Gross that death used to be sudden, unexpected and relatively swift — the result of a violent cause, or perhaps an infection. But, he says, modern medicines and medical technologies have lead to a “dramatic extension” of life — and a more prolonged dying processes.

“We’ve now … introduced a phase of our life, which can be considered as ‘dying,’ in which patients have terminal diseases in which they are in and out of the hospital, they are dependent in nursing homes,” Warraich says. “That is something that is a very, very recent development in our history as a species.”

Prolonging life might sound like a good thing, but Warraich notes that medical technologies often force patients, their loved ones and their doctors to make difficult, painful decisions. In his new book, Modern Death, he writes about a patient with end-stage dementia who screamed “kill me” as a feeding tube was inserted into his nose.

“This is probably one of the encounters that I had in residency that I have been unable to shake from my memory,” Warraich says. “I think if you ask any physician, any nurse, any paramedic, they’ll have many such stories to tell you.”

Interview Highlights

On the importance of having a healthcare proxy, living will and advanced directive

One of the biggest problems that we face in not only modern society, but in societies of olden times as well, is that people have always been very afraid to talk about death. In many cultures it is considered bad luck to talk about death and it is thought to be a bad omen. I think to some extent that extends to this very day. But … I think having a living will, having an advanced directive, or perhaps most importantly, having a designated healthcare proxy, someone who can help transmit your decisions to the team when you’re not able to do so, is perhaps the most important thing that we can do for ourselves as patients and as human beings.

On giving CPR and knowing when to stop giving CPR

One of the things about CPR, Terry, is that almost everyone in medicine knows how to start CPR, when to start CPR, really what to do in CPR under even complex situations, but the one thing that almost no one really teaches us, and there are no guidelines for, is when to stop CPR. I think in some ways that is one of the biggest challenges that we in medicine face all the time. …

I was actually working in the hospital last night and it was about 3 in the morning and I was called by one of my other colleagues who was another cardiology fellow, he asked me, “Haider, I need your help. I have a patient that we are doing CPR on,” and he wanted some help from me. So I walked over to the intensive care unit, and the patient was in her 60s. … There was an entire team in the room doing chest compressions on this woman, and they had been doing it for an hour and a half at that point, much, much, much longer than most CPRs last. …

At the same time while this CPR was ongoing, the patient’s family member, her daughter, was outside the room, and she was crying. … Even though we could give her all the information … that wasn’t perhaps what she was looking for, because what we were asking her to think about or to do was one of the hardest things anyone has to ever bear, which was, “Do you want us to stop CPR?” And that’s the type of thing that I don’t think any of us can ever prepare for, especially when it’s our parent that’s involved.

On why he wrote a book about dying

I really wanted to find answers to some very, very basic questions, like what are the implications of the sort of life extension that we have achieved? What is the role of religion, not only a patient’s religion but a physician’s religion when it comes to dealing with the end of life? How is social media affecting how people experience the end of life? …

So many times I’ve found myself in the room where there are people who were so much more experienced in life than I was, yet knew so little about death and dying. And so I wanted to write a book so that people could go into those really, really difficult places and feel like they’re armed with information, that this isn’t a completely foreign territory for them and that in some way could help them navigate and deal with the sort of difficult situations that lay ahead for them.

On the possible repeal of the Affordable Care Act

It is very unfortunate that health is so politicized in this country, because it doesn’t have to be. Health and wellness aren’t red or blue, and they shouldn’t be, but unfortunately that is where we are. I hope that when policies are being enacted in DC, patient’s voices, those who have benefited from the ACA, those who have gained insurance, those voices are not lost in the midst of all of this political activity.

On immigrating to the U.S. from Pakistan

I came to the United States in 2010 and [until now] have only lived in an America in which Barack Obama was the president. I think in some ways Trump’s victory has really shaken me, because of how invested I was in the idea that America is a special place, it’s a truly multicultural society. And I’m still trying to understand, I think like so many others, just exactly what happened. Especially as a writer and as a physician I’ve tried to separate myself from my identity as a Muslim. I’d rather be known as a physician/scientist/writer who happens to be Pakistani, rather than a young Pakistani Muslim immigrant who happens to be a doctor and a writer, but I don’t know. Given how things are changing, I’m not even sure if I’ll be able to set that narrative for myself. That’s a scary thought — to live an identity that is so politicized even when you wish for it to not be.

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Republican lawmakers meeting in Philadelphia this week say they want their replacement of Obamacare to be done by spring. There is no consensus on a plan yet, but several Republicans in Congress have already circulated proposals that could reduce or eliminate features of the federal health law that have benefited older Americans.

Here are some examples:

Prescription drugs

The Affordable Care Act expanded Medicare’s prescription drug benefit. Before the ACA, people on Medicare had to deal with a gap in that insurance coverage that came to be known as the doughnut hole. That’s the point at which Medicare would stop paying part of the cost of drugs, and beneficiaries would have to buy them at full price. Then, when the patient’s out-of-pocket costs reached a level deemed to be “catastrophic,” Medicare would start paying most of the cost of the drugs again.

A 2011 study from the Kaiser Family Foundation showed that when patients had to pay full price, they’d skip some of their prescribed medications — and that could, potentially, result in sicker patients and higher costs for Medicare.

Gradually, the ACA has been closing the doughnut hole coverage gap. According to the Center for Medicare and Medicaid Services, beneficiaries have saved more than $23.5 billion in prescription drug costs. It’s unknown if this program would be maintained in a Republican plan that replaces the ACA.

Medicaid

Medicaid is commonly thought of as the program that provides health care for the poor. But it also pays for long-term care for a lot of older people, including the majority of nursing home residents.

One idea in some of the Republican proposals for replacing the Affordable Care Act is to turn Medicaid from a guaranteed benefit into a block grant to states. States would get a fixed amount of money from the federal government, and could make their own decisions on how to spend it.

That’s an idea that’s been popular for some time among conservatives such as House Speaker Paul Ryan. They argue that states know their needs better than Washington does, and the block grant would give states flexibility in meeting those needs.

Critics fear this could do away with many protections that federal law currently provides for vulnerable older people. They also worry about what might happen in an economic downturn, when the demand for Medicaid goes up, but the amount of federal money allocated for it stays the same. For example, would states have to choose between cutting services for poor children versus cutting programs for the frail elderly?

Limiting the cost of insurance premiums for older adults

Before the Affordable Care Act, insurance companies could charge people in their 50s and 60s many times more than they’d charge a younger person for the same policy. The affordable care act put a limit on that. Now Insurance companies can only charge older people three times as much as they charge people a few decades younger. But the various GOP replacement proposals either set higher limits — five or six times higher — or they don’t have any limits at all.

A study sponsored by the Rand Corporation and the Commonwealth Fund found that if older Americans were charged five times more for insurance than younger people, about 400,000 would no longer be able to afford to buy health insurance.

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With open enrollment season for buying health coverage under the Affordable Care Act ending Tuesday, it seemed like an apt time to talk with folks in charge of some of the state insurance marketplaces created by the federal health law.

It’s the third year these marketplaces, also called exchanges, have been running. The marketplaces are the go-to option for people under 65 who don’t get health insurance through work or qualify for Medicaid.

This time around, there’s a last-minute wrinkle: The Trump administration has halted advertising and outreach for HealthCare.gov, the federally run exchange, in the last week of enrollment, when sign-ups typically surge.

But the states that control their own exchanges also control their own promotion and, for now, their destiny.

All told, 11 states and the District of Columbia run their own marketplaces. Under the ACA, the marketplaces were supposed to become self-sustaining businesses within a few years, supported by fees insurers pay to offer plans on the sites.

But the election of Donald Trump as president and Republican majorities in both houses of Congress mean that proposition, like the rest of the health law, is now in doubt.

Here’s what five exchange chiefs are looking at now and for the future.

California Has Ingredients To ‘Make The Individual Market Work’

Peter Lee, executive director, Covered California

More than 5 million Californians — about a quarter of all Americans now covered under Obamacare — gained insurance either through Medicaid expansion or on the state’s exchange, called Covered California.

With the Affordable Care Act now on the political chopping block, California has a lot to lose.

But Covered California’s executive director, Peter Lee, says he is planning for a different scenario. He hopes to position California as a leader in a new model for health coverage nationwide.

“I do think that we have a number of the ingredients of what can make the individual market work,” Lee says. “And we want to take those lessons to members of Congress and to policy leaders.”

In particular, Lee believes California’s market-based approach is one that would be “in sync, philosophically, with many of the things I hear from Republican and Democratic members of Congress and the Trump administration.”

“We have about 1.4 million Californians shopping in our marketplace picking private plans with the leg up of federal tax credits that make health care affordable to 90 percent of them,” Lee says.

California’s marketplace has had its share of problems. A reliance on inaccurate provider directories left some consumers exposed to higher-than-expected medical bills. Consumers also complained about narrow networks that left them unable to choose the doctors they wanted.

But overall, the state is considered an ACA success story, thanks in part to innovative approaches, including state discretion to choose which insurers could operate in its market and then to negotiate premiums and benefits with those insurers.

“It’s a consumer-centric market solution,” Lee says. “Whether you’re a Republican or Democrat or independent, it’s a market-based solution that has a lesson for the country.”

Still, Lee’s hopefulness is tempered by the knowledge that California faces a loss of $20 billion in federal funds if the promised Obamacare repeal happens without a replacement that preserves Medicaid expansion and premium subsidies.

Under that scenario, Lee says, “people would have their health insurance pulled out from under them in droves.”

“The whole issue of repeal without replace is cataclysmic not just for California or Californians but for any of the 20 million Americans that have coverage because of the Affordable Care Act,” he says.

Even in the face of a “very fuzzy” future, Lee says he is focusing on the present, which includes shepherding more than 300,000 Californians newly enrolled in health care into 2017 coverage. He also wants to get the word out on parts of California’s plan that can be adopted elsewhere.

“There have been some things that have not worked great with the Affordable Care Act; there are some things that have worked pretty darn well,” Lee says. “Let’s make sure the laboratory of the states is a laboratory that’s sharing the lessons of success and failure with one another.”

Stephanie O’Neill, freelance reporter based in Ojai, Calif.

New York Fears A Return To ‘$1,000 A Month For An Individual Policy’

Donna Frescatore, executive director, NY State of Health

The New York state health exchange is fielding its busiest enrollment period yet, even with the uncertainty about the health law’s future.

A repeal of the Affordable Care Act, without significant replacement, could cost 2.7 million New Yorkers their health insurance and the state $3.7 billion, according to Democratic Gov. Andrew Cuomo’s office.

“We believe that the stakes here in New York are dramatic — for consumers, for our health care delivery system and for our state budget as well,” says Donna Frescatore, executive director of NY State of Health, New York’s marketplace.

Losing “momentum” is one of Frescatore’s main concerns. Between 2013 and 2015, the uninsured rate in New York was cut in half, falling from 10 percent to 5 percent, according to the state’s health department.

“We talk to moms who are concerned because their children have pre-existing conditions and they’re afraid coverage might no longer be available. We talk to self-employed New Yorkers who fear that the premiums could increase to the 2013 levels — over $1,000 a month for an individual policy,” Frescatore says.

Without financial support from the federal government, premiums may increase.

Options may revert to health insurance plans as they were in New York before the ACA.

“New York had a number of very strong consumer protections in place before the Affordable Care Act, including guaranteed issue,” says Frescatore. “People could get insurance regardless of whether or not they had a medical condition or illness, as well as other consumer protections. We’ll maintain those protections.”

But without an individual mandate bringing enough people into the insurance pool and no financial assistance, she adds, the price of plans is “just out of reach” financially for many consumers.

For now, the New York exchange continues outreach to enroll consumers and reassure them that policies won’t be disrupted throughout 2017.

“At this point, without knowing more details about repeal or replacement, what we’re really focused on is getting people coverage that they deserve,” Frescatore says.

Karen Shakerdge, WXXI and Side Effects Public Media

Connecticut To Insurers: ‘We’re Making Changes In The Positive Direction’

Jim Wadleigh, CEO, Access Health CT

Connecticut was an early adopter of the ACA. After the law was enacted, the state expanded Medicaid ahead of schedule to cover roughly 200,000 more people a year. For this year, more than 100,000 people enrolled in coverage they found on the state-based exchange, with nearly 80 percent getting subsidies.

But while the exchange may have been attractive to many consumers, it was less appealing to insurers. Two of the four original insurance companies in the marketplace are no longer in it. Now, with an uncertain future ahead, Access Health CT CEO Jim Wadleigh says he has one hard goal in mind as he thinks beyond 2017: “What can we do to help make the business environment that our carriers are in easier for them to be more successful?”

Insurers have told Wadleigh that they lose money on customers who miss open enrollment periods and go through special enrollment — the process reserved for people with big life events or job changes that merit new insurance.

“What the carriers are telling us is, these customers are coming in … finding a reason that they have a life event because they’re sick, get services, and then drop out,” he says.

That’s an expensive pattern. This week, Wadleigh is asking his board to approve a plan to ramp up enforcement.

“If we can do a better job enforcing the special enrollment, we think we can reduce the premiums by potentially 6 percent to 10 percent,” he says.

Another way to reduce costs? Shrink provider networks. So, let’s say you live in Hartford. Do you really need to pay for a plan that covers a doctor’s visit in Danbury?

“Customers are telling us they would go with a network choice option, or a narrow network, if it was cheaper and/or had a lower deductible,” he says.

That chance, he says, could save another few percentage points in premiums.

Third, Wadleigh says he is considering changes that would push more of the cost of emergency room visits to consumers, hoping to deter frequent ER fliers.

The question is whether all of this will work. Wadleigh says he thinks it will. He already has had discussions with existing carriers that are curious whether other insurers are looking to get into the marketplace.

“So what that is telling me is that the carriers think that we’re making changes in the positive direction,” he says. “And we expect that other carriers would be interested in joining our exchange with that.”

Whether they do — and whether the exchange will even be around for them to join — is still very much unclear.

Jeff Cohen, WNPR

Massachusetts Chief Says, ‘Every Day Is a Good Day of Coverage’

Louis Gutierrez, executive director, Massachusetts Health Connector

A near record number of Massachusetts residents are signing up for coverage through the state’s online insurance market, the Health Connector. Enrollment is running 32 percent ahead of last year as the Jan. 31 deadline approaches. Around 47,000 people who didn’t have insurance through the exchange last year have purchased insurance for 2017.

So many members, physicians and others in the health care world were stunned when Louis Gutierrez, who runs the exchange, said he couldn’t guarantee coverage through the end of 2017 for the nearly 240,000 enrollees so far.

“I don’t want to be in the business of speculating or making commitments about things I can’t personally control,” Gutierrez says. “I don’t think any of us really know” what’s going to happen with the repeal of the ACA.

Gutierrez says he is not predicting precipitous changes but adds that he “can’t speak to the future. Every day is a good day of coverage.”

Health insurers, which are threatening to pull out of exchanges in some states, aren’t the main concern in Massachusetts. Gutierrez says he is hearing very little from the state’s “mature and stable market.” Most plans that sell insurance through the Health Connector are nonprofits based in the state. And they may have less reason to worry that healthy members will flee, leaving insurers to cover the high costs of ill members. Massachusetts residents would still be required to buy insurance, by state law, even if the ACA mandate is repealed.

But if federal funds shrink or disappear, it’s likely coverage would become very expensive for the 178,000 men and women who expect to receive subsidies or tax credits for insurance purchased through the exchange.

“We’re interested in maintaining broad and affordable access to coverage,” Gutierrez said, but “that will depend on the shape of any subsidies that change or happen in the new scheme.”

Many Massachusetts residents are wondering whether the state could revert to the law passed in 2006, which became a model for Obamacare. The individual mandate is still on the books, but the employer mandate and other elements were replaced with provisions in the federal law.

Martha Bebinger, WBUR

Colorado Looks Toward ‘Working Together As Western States’

Kevin Patterson, CEO, Connect for Health Colorado

The view from Kevin Patterson, the CEO of Connect for Health Colorado, might be summarized as sunny with storm clouds on the horizon. “I think we’re feeling like things are going really well,” he says.

Patterson says enrollment numbers for 2017 are running 15 percent ahead of last year. But two things are clouding the future. First, the new Trump administration and congressional Republicans are vowing to undo Obamacare.

Second, the Colorado exchange is under fire from state lawmakers. As soon as the legislative session got underway in January, Republicans unveiled a bill to repeal the exchange altogether. They are expected to zero in on a recent federal audit that found the exchange improperly spent millions in federal funds and called for refunds.

Patterson says the exchange has made many changes and disagrees with the recommendation to refund the money.

The exchange is expected to survive the legislative turmoil, but it still faces the possibility of federal subsidies disappearing under a repeal of the Affordable Care Act.

But Patterson believes the exchange could carry on. “I do think there are things that we’ve learned that could be applied in a new era or whatever post-ACA is,” he says.

Still, he worries an Obamacare repeal without a timely, adequate replacement could cause some insurers to pull out of the exchange or charge higher rates. Already consumers saw premiums go up and choice go down this year. And this is pressing — insurers have to file rate requests in Colorado in May. “So the clock is ticking,” Patterson says. “Somebody has to give us a little more guidance I think to the industry around what the new world is going to look like. And I think the sooner we do that the better it is for every consumer.”

But, beyond 2017, he says, the exchange could look to expand its other lines of business beyond the individual marketplace. That could include helping small employers and public sector employers not in the marketplace figure out insurance packages and benefits. “I think that’s somewhere where we can show some more value,” he says.

Colorado’s exchange is also flirting with the possibility of working with neighboring states, particularly those in the Mountain time zone. “We’re kind of used to working together as Western states on problems that are really unique to us,” Patterson says. “That’s where I would start.”

John Daley, Colorado Public Radio

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

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Hundreds of people around the country are still suffering from complications linked to injections of tainted medicine produced at a Massachusetts pharmacy in 2012.

A nationwide outbreak of fungal infections was tied to the shipment of nearly 18,000 contaminated vials of preservative-free methylprednisolone, a steroid, made by the New England Compounding Center in Framingham, Mass.

Barry Cadden, an owner of the pharmacy, is now on trial in U.S. District Court in Boston. He faces federal charges that include racketeering and second-degree murder. He pleaded not guilty.

The trial, which began Jan. 9, is expected to last two or three months.

Federal prosecutors say the steroids were mixed in unsanitary conditions with expired ingredients.

Bruce Singal, Cadden’s attorney, declined to comment. In court, he has said that Cadden oversaw the company’s operations, but didn’t work in the facility’s “clean rooms” or mix the drugs that harmed people. “He is not a murderer and he is not responsible for their deaths,” Singal said, according to the Associated Press.

The outbreak of fungal infections tied to injections with contaminated medicines killed at least 64 people and sickened about 700 more. A report about the public health investigation and response published in The New England Journal of Medicine in 2013, said the outlook for “patients remains uncertain. Although many case patients have completed antifungal therapy and their conditions are currently stable or improved, relapses of infection are possible.”

Many people who got sick after the injections are still waiting for compensation checks from a legal settlement with the compounding pharmacy.

Several people who became sick after injections talked about their lives since then. None has testified in the case but some have plans to attend the trial. Here are excerpts from conversations with them.

Bill Thomas, 62, of Lowell, Mich.

The last injection — the steroid injection that I got in my spine — was for pain in my legs, pain and numbness, due to spinal cord injuries. During the course of the next few days, I felt like I was coming down with the flu … I had trouble remembering things. I came down with an incredible headache that didn’t go away. I had terrible neck pain, and my eyes were very sensitive to light.

I’ve gone from being a person who walked two or three miles a few times a day. … I used to go out a lot in wilderness areas and did backpacking. And now I only leave the house a couple times a week. I’m always tired and always in pain, I can’t think. I get confused easily. … I can’t read like I used to.

Justice needs to be done here. Tremendous harm was done to a great many people, and that should not be forgotten.

Angela Farthing, 46, of Maryland

I had fungal meningitis and was admitted to the hospital. When I was released, I ended up having a stroke and developed a brain aneurysm. I was readmitted, and I was there for almost another two months. … I got very sick. I was vomiting all the time, had horrible headaches every day. I lost a good 30 pounds; I went down to 100 pounds. … I missed about a year of work. And it was discovered later that I’d developed an abscess in my spinal cord. I had to have that surgically removed. But they could not get all of the abscess out, because they said if they would have sliced any deeper, they could have paralyzed me or I could have lost bowel or bladder function.

[My husband] really suffered quite a bit when I was diagnosed. He had to take care of me, he had to bathe me, he had to change me, he had to do my IV. … He had to take over cleaning the house and cooking and taking care of our dogs. … He was a recovering alcoholic, and unfortunately, he stopped going to AA meetings and he succumbed to his addiction.

Kathy Pugh, daughter and caregiver for her mother, Evelyn March, 85, of Pinckney, Mich.

[My mother had] an abscess in her back on her spine at the site of the injection of the tainted medicine. Now she’s not doing well at all. It’s pretty much 24/7 pain. She went from being a very vital woman with just sporadic problems with her back, to where she’s bedridden in a hospital bed on oxygen, looking up at the ceiling. That’s her life — occasionally trying to watch TV, but she finds it hard to concentrate for a very long length of time. That’s one of the side effects of the antifungal medication, which it was ‘take or die.’ “

Evelyn March

My life’s upside-down compared to what it was. I don’t understand why things can be allowed to happen like that. Getting old is bad enough, but then to put something else on to it. … I hope [Barry Cadden] gets his butt burned. I mean he, he, … well, I’d better shut up, because I’d probably say more than I should say.

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A doctor handed Melissa Morris her first opioid prescription when she was 20 years old. She’d had a cesarean section to deliver her daughter and was sent home with Percocet to relieve post-surgical pain. On an empty stomach, she took one pill and lay down on her bed.

“I remember thinking to myself, ‘Oh, my God. Is this legal? How can this feel so good?’ ” Morris recalls.

Soon, she started taking the pills recreationally. She shopped around for doctors who would write new prescriptions, frequenting urgent care clinics where doctors didn’t ask a lot of questions and were loose with their prescription pad.

Morris’s path started with Percocet and Vicodin, commonly prescribed pain medications for acute injuries and illnesses. When those drugs no longer got her high, she switched to Oxycontin pills. Then she started injecting Oxycontin. After that, she got her hands on Fentanyl patches, a highly addictive and potent opioid. She’d chew on them instead of applying them to skin as the package directed.

When doctors got wise to Morris’ shopping tactics, her supplies of the pills diminished, and she turned to heroin, instead.

She started stealing to fund her addiction. Morris then got into the drug trade herself, dealing methamphetamine and other illicit substances, to raise money to buy more heroin.

“You can buy a gram of heroin for 50 bucks,” she says. It’s relatively cheap. “That’s why so many people here have turned to heroin.”

Morris lives in Sterling, Colo., a city of 14,000 that’s a two-hour drive northeast of Denver. The biggest employer is a state prison. Since 2002, the death rate from opioid overdoses in Logan County, which includes Sterling, has nearly doubled, according to data analyzed by the Colorado Health Institute. Morris says she has known at least 10 people in her community who have overdosed on a mix of drugs in the last few years.

Sterling is far from unique. Rural areas and small cities across the country have seen an influx not only in the prevalence of prescription opioids, but in illicit ones like heroin. According to the U.S. Centers for Disease Control and Prevention, opioids were involved in more than 33,000 deaths in 2015 — four times as many opioid-involved deaths as in 2000. A recent University of Michigan study found the rates of babies born with symptoms of withdrawal from opioids rising much faster in rural areas than urban ones.

Like Morris, many new heroin users find themselves using the drug after getting addicted to prescription drugs first. The CDC reports three out of four new heroin users report abusing prescription opioids prior to trying heroin. In the U.S., heroin-related deaths more than tripled between 2010 and 2015, with 12,989 heroin deaths in 2015.

As the drug use reaches into more communities across the country, researchers are scrambling to both diagnose what causes some people and some regions to be more susceptible to opioid abuse, and to devise solutions. Dr. Jack Westfall, a family physician and researcher at the University of Colorado and with the High Plains Research Network, works with a network of rural clinics and hospitals in the state. He says many doctors on the Plains are feeling frantic.

“We don’t know what to do with this wave of people who are using opioids,” he says. “They’re in the clinic, they’re in the ER, they’re in the hospital. They’re in the morgue, because they overdosed.”

For more than a decade, opioids have been a key part of a rural doctor’s pain management for patients, Westfall says. Treatment options are often fewer in a rural area; alternatives like physical therapy may not be available or convenient, so drugs are a prime option.

Some researchers think larger economic, environmental and social factors leave rural Americans at particular risk, says University of California, Davis, epidemiologist Magdalena Cerdá. After the 2008 recession, rural areas consistently lagged behind urban areas in the recovery, losing jobs and population.

“You have a situation where people might be particularly vulnerable to perhaps using prescription opioids to self-medicate a lot of symptoms of distress related to sources of chronic stress — chronic economic stress,” Cerdá says.

Plus, the specific types of jobs more prevalent in rural areas — like manufacturing, farming and mining — tend to have higher injury rates. That can lead to more pain, and possibly, to more painkillers.

In some ways, the social structures of rural regions contribute to the spread of illicit drugs, says Kirk Dombrowski, a sociologist at the University of Nebraska-Lincoln.

“One of the things that is counterintuitive to most of what we think of as [being part of life in] a small town is that rural people have much larger social networks than urban people,” Dombrowski says.

In some cases, his research suggests, rural residents know and interact with roughly double the number of people an average urban resident does — giving rural people more opportunities to know where to access drugs.

“So some of those social factors of being in a small town can definitely contribute,” he says.

“It’s not a fundamentally rural problem,” says, Tom Vilsack, Barack Obama’s secretary for the U.S. Department of Agriculture, who led the Obama administration’s interagency push to curb opioid abuse. “But it’s a unique problem in rural America because of the lack of treatment capacity and facilities.”

That lack of treatment is definitely a problem in Sterling, where patients often have to drive a long way to get care.

Melissa Morris relies on Suboxone, a prescription combination of buprenorphine and naloxone that’s used to help wean people off heroin or other opioids. Morris says she doesn’t get high when taking it, but does avoid the vomiting, diarrhea and sweating that comes with opioid withdrawal. She puts it under her tongue to let it dissolve and take effect.

Morris, who has been off heroin since 2012, makes a two-hour drive to a clinic to pick up her supply of Suboxone. It’s in short supply in many rural communities, in part because few rural doctors have gone through the required training to prescribe it.

There’s there’s a six-week waiting list to get an appointment with the only doctor in Sterling who is certified to prescribe the drug, Morris says. Other areas of Colorado’s eastern Plains have no doctors at all who are legally able to dispense Suboxone.

A new effort from University of Colorado researchers could help there, with plans to train 40 primary care doctors, their clinical care teams, and nurses in Colorado’s Plains and southern San Luis Valley.

Morris acknowledges that close social ties in her town may have contributed to the spread of opioids there; opioid users, she says, tend to “stick up for each other.” Those bonds can spread drug use quickly, but they also cut other ways, she says. Just recently she recruited two opioid-dependent friends to the clinic she goes to weekly for treatment.

“I used to sell them pill and heroin,” says Morris, who is now helping these friends get clean. “And so I do have hope. I’ve seen those success stories.”

This story comes to us from Harvest Public Media, a collaborative public media project reporting on important stories in rural America.

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