Feds strengthen anti-discrimination health rules

Photo from mdxipe.wordpress.com

By Danielle Ray
Kentucky Health News

The Department of Health and Human Services issued rules Friday in an effort to ensure equality in health care for women, the disabled and people who speak English as a second language.

The new provisions protect women from discrimination not only in the health coverage they obtain but in the health services they seek from providers. They also prohibit denial of health care or health coverage based on a person's sex, including discrimination based on pregnancy, gender identity and sex stereotyping.

The rule also requires providers to take reasonable steps to provide communication access to people with limited English proficiency. In addition, it requires that providers make electronic information and newly constructed or altered facilities accessible to individuals with disabilities, including providing auxiliary aids and services.

HHS Secretary Sylvia Burwell called the rule "a key step toward realizing equity within our health care system." She said in an agency news release that it reinforces the central goal of the Patient Protection and Affordable Health Care Act, to improve access to quality health care.

The rule covers any health program or activity that receives federal funding, such as providers who accept Medicare or Medicaid; any health program that HHS administers; and federal- and state-based health insurance marketplaces and insurers that participate in them.

The new rule implements Section 1557 of the 2010 health-reform law, which is the first federal civil-rights law to prohibit discrimination based on sex in federally-funded health programs. Previously, civil rights laws enforced by the agency's civil rights office barred discrimination based only on race, color, national origin, disability, and age.

The rule does not resolve whether discrimination on the basis of an individual’s sexual orientation status alone is a form of sex discrimination under the reform law. However, the provisions leave room for the agency's civil-rights office to evaluate complaints that allege sex discrimination related to a person’s sexual orientation to determine if they can be considered sex stereotyping, which the rule prohibits. In cases where religious freedom would be violated, health-care providers are not required to follow the regulation.

A summary of the new rule can be accessed here.

House Republicans want to make it harder for schools to get free meals for all students; could affect more than 350 Ky. schools

Photo from npr.org

By Danielle Ray
Kentucky Health News

Kentucky school officials are concerned about a proposal by Republicans in the U.S. House that would make it harder for schools to offer free meals to all students using federal money.

The House is considering changes to the 2010 Hunger-Free Kids Act, now in its second year, which allows schools who serve a high-poverty population to offer free meals to every student.

Instead of collecting individual applications for free or reduced-price meals, the Community Eligibility Provision uses data that illustrates how many students in a given school may be "food-vulnerable": how many students live in households that receive government assistance, live in foster care, are homeless, and other similar criteria.

Under current CEP rules, schools with greater than 40 percent of students who qualify as food-vulnerable are eligible to offer free meals to all students. A bill approved May 18 by the House Education and Workforce Committee would raise the threshold to 60 percent, forcing schools between 40 and 59 percent range off the program.

"Proponents of community eligibility say it spares schools from paperwork and administrative burdens, and that it allows low-income children to eat free meals without the stigma or red tape of particpation in the free meal program, which is often a barrier for participation," Evie Blad reports for Education Week. "But Republicans on the committee said the provision is wasteful, potentially allowing children from higher-income families access to free meals."

The change could affect more than 350 Kentucky schools. Kentucky has 804 schools eligible to offer free meals under current CEP rules, according to the Center on Budget and Policy Priorities. Under the proposed bill, only 441 would qualify, according to the center.

More than 10,000 students at 17 public schools in Lexington alone would be affected, according to the Lexington Herald-Leader reported. More than 190,000 students statewide could be affected, the Herald-Leader said.

Nick Brake, superintendent of Owensboro schools, told Keith Lawrence of The Messenger-Inquirer that he is hopeful that his district will be spared cuts.

"I have been working with Congressman (Brett) Guthrie’s office on this issue," Brake said. "We are still looking at the overall numbers, but our district average is 63 percent, so it looks favorable that we will be able to continue to provide the benefit of this vital program in the future."

Muhlenberg County Supt. Randy McCarty told Lawrence he thought his district would still qualify. "Once a district goes CEP, it stays in place for four years," he said.

Hopkins County, which recently expanded its use of free meals to all public schools, faces uncertainty if the changes are passed.

"I have no idea if school districts will be grandfathered in, or how Congress will write everything, but I am afraid that if we don't jump on this now, we may not get this opportunity again," Michael Dodridge, food services director of Hopkins County schools, told Laura Buchanan of The Messenger in Madisonville. "I would hate to pass this up."

UPDATE, May 26: The Harlan Independent School Board voted to join the program, Joe Asher reports for the Harlan Daily Enterprise.

The proposed CEP changes are part of House Resolution 5003, the child nutrition reauthorization bill introduced by Indiana Republican Rep. Todd Rokita. For more information on the proposed changes, click here.

Effects of new vaping regulations won't be felt immediately; American and British researchers have differing views of e-cigs

By Danielle Ray
Kentucky Health News

A long time coming, the U.S. Food and Drug Administration released new regulations this month for all tobacco products, including electronic cigarettes, vape pens, hookahs, dissolvables, and pipes. But the effects might not be felt for as long as two years.

Photo: excusemyvapes.com

The regulations require health warnings on packages and advertisements and ban sales to minors. Other regulations include reporting ingredients to the FDA, requiring photo identification to buy, banning free samples and banning the labeling of products as moderate, with words such as "light" or "mild,"

The FDA called the regulations a milestone in consumer protection. It believes the new rules will help prevent misleading claims by manufacturers moving forward and allow for review of new products not yet on the market. The agency already regulated traditional cigarettes, smokeless tobacco, and roll-your-own tobacco prior to the decision.

The new rules will take effect in stages. The ban on sales to minors begins Aug. 8, but according to Phil Galewitz of The Washington Post, the ban will primarily affect Michigan and Pennsylvania, as the other 48 states already ban sales of e-cigarettes to minors. Warning labels will take effect May 2018. The labels will read: “WARNING: This product contains nicotine. Nicotine is an addictive chemical.”

Don't expect changes overnight. Manufacturers have two years to submit products for review and another year for the agency to perform evaluations.

Why did the FDA take on vaping? For one thing, because the market has so far been unregulated, the ingredients in vaping liquid are largely a mystery. However, a 2015 Harvard University study found several dangerous chemicals present in these liquids. The chemicals can destroy tiny passageways in lungs, leading to scar tissue buildup and eventually respiratory disease, according to the study.

For another thing, adolescents and teenagers are vaping at unprecedented rates. More than 3 million middle and high school students used e-cigarettes in 2015, up more than 500,000 from the year before, according to the FDA.

E-cigarettes have been the most commonly used tobacco products among youth for two consecutive years. Sixteen percent of high schoolers and about 5 percent of middle schoolers were vapers of e-cigarettes in 2015, according to the FDA. More than 80 percent of them cited appealing flavors, which include "gummy bear" and "cotton candy," as their primary reason for use.

The science is still out on whether the harmful qualities of vaping negate any potential benefits. Some studies have found e-cigarettes to be less harmful than traditional cigarettes. For example, a 2015 Public Health England review concluded that e-cigarettes are about 95 percent less harmful than traditional cigarettes.

"E-cigarettes are not completely risk free but when compared to smoking, evidence shows they carry just a fraction of the harm," said Professor Kevin Fenton, director of health and well-being at PHE, said in a news release. "The problem is people increasingly think they are at least as harmful and this may be keeping millions of smokers from quitting."

As noted in the Harvard study, e-cigarettes are not harmless. The question remains if vaping can be a tool to help current smokers quit, if they lure in kids who otherwise would not become smokers or if it's a little of both.

According to the British study, there is no evidence that vaping attracts non-smokers. Fewer than 1 percent of either adults or young people who have never smoked are becoming regular e-cigarette users, the study noted.

As for fears that vaping leads to traditional smoking, Linda Bauld, a cancer prevention expert at Cancer Research United Kingdom, said in a news release that those claims are unfounded.

"Fears that e-cigarettes have made smoking seem normal again or even led to people taking up tobacco smoking are not so far being realized," Bauld said. "In fact, the overall evidence points to e-cigarettes actually helping people to give up smoking tobacco."

Attitudes toward vaping have been much more favorable overall in the UK. Public health officials there seem more willing to accept e-cigarettes as a safer alternative and even a stop smoking tool than do U.S. officials.

For more background information on the FDA's new regulations, click here.

Health-care consumers get little help resolving complaints, columnist says, citing some horrific examples

By Trudy Lieberman
Rural Health News Service

Who protects consumers of health care?

Two recent emails from readers got me thinking about that question. I don’t mean consumers in their role as patients whose medical well-being is looked after by state medical boards and health departments that police doctors and hospitals. Those organizations don’t always do a perfect job protecting patients from harm, but at least they are in place.

But who protects patients when things go wrong on health care’s financial side? What happens when you receive a bill you didn’t expect and can’t afford to pay? What happens when insurers send unintelligible explanations of benefits you can’t understand? What about questionable loan arrangements to avoid medical bankruptcy? Consumers of health care are pretty much on their own.

From the 1960s though the 1980s when people complained, they got action from consumer organizations, government and even businesses that set up departments to handle complaints. That consumer movement is now but a flicker.

“We don’t have as many public-interest minded regulators, and officials who try to grab these issues by the horns and deal with them,” says Chuck Bell, director of programs for Consumers Union.

The emails I received show that although it’s an uphill battle to get redress, fighting back as an individual can get attention and may ultimately lead to better protections for everyone.

John Rutledge, a retiree, got snared in Medicare’s three-day rule by a hospital near his hometown Wheaton, Ill. At the end of March he took his wife, who was having breathing problems, to the hospital where she was held for three nights of “observation.” Patients must be in a hospital for three days as an in-patient before they are entitled to Medicare benefits for 100 days of skilled nursing home care, as I noted in a recent column.

Thousands of families have been caught when hospitals decide their loved ones are admitted for “observation,” a tactic that allows them to avoid repaying Medicare if government auditors find patients should not have been classified as “in-patients.” Playing the “observational” game is worth millions to hospitals but costs families tens of thousands of dollars when someone doesn’t qualify for Medicare-covered skilled nursing care.

Rutledge knew about the three-day rule. Both his doctor and a pulmonologist at the same medical practice recommended an in-patient stay, and Rutledge refused to sign a hospital document saying his wife was admitted for observation. Still, the hospital prevailed, claiming a consultant made the decision to keep her for “observation.”

Rutledge was stuck with a bill that, so far, totals over $15,000 for the skilled nursing care his wife did need. He said he had been a “significant donor” to the hospital foundation, and “I have told the foundation that what I spend as a result of “observation” will come out of what I planned to give them, starting with the annual gift.”

The second email came from Kathryn Green, a college history professor who lives in Greenwood, Miss. Green is fighting an air-ambulance company, which transported her late husband to a Jackson hospital after he suffered a fatal fall in their home. This “nightmare,” as she calls it, is a bill from the transport company that claims it’s outside her insurance network, and says she owes them $50,950.

“I am 63 and will have a devastated retirement if this is upheld,” Green told me.

Blue Cross & Blue Shield of Mississippi, the administrator for her insurance carrier the State and School Employees’ Health Insurance Plan, paid $7,192 of the $58,142 the transport company billed. Blue Cross has told Green that she should be held harmless and should not be charged for the “balance after payment of the Allowable Charge has been made directly to that provider.”

Green is raising a ruckus and has taken her case to state and national media, members of Congress, the state attorney general, and the Mississippi Health Advocacy Program. The company has told her it will begin collection efforts.

In both cases there’s a legislative solution. The three-day rule can be fixed by counting all the time a patient spends in the hospital whether they’re classified as an “in” or as an “observational” patient. The ambulance problem can be fixed by changing the 1978 airline deregulation law that prevents states from interfering with fares, services, and routes. But money and politics block the federal changes that would help people like Rutledge and Green.

“It’s like playing a game of health-insurance roulette,” Bell says. “Your coverage exposes you to these gaps that have been normalized. It’s become the way of doing business.” A resurgent consumer movement could change all that.

What consumer problems have you had with balance billing? Write to trudy.lieberman@gmail.com.

Kentucky Center for Economic Policy report warns about impact of Bevin's proposed Medicaid changes

By Danielle Ray

Kentucky Health News

A research group with a liberal outlook warned Monday that Republican Gov. Matt Bevin should be careful in changing the state Medicaid program.

The Kentucky Center for Economic Policy said the state’s expansion of Medicaid eligibility under Democratic Gov. Steve Beshear has increased health screenings and job growth in health care.

Tobacco counseling and interventions increased 169 percent from 2013 to 2014, the first year of the expansion, the report noted. Influenza vaccinations went up 143 percent and breast cancer screenings increased 111 percent, it noted.

In addition, Medicaid expansion brought Kentucky health-care providers nearly $3 billion through mid-2015 and resulted in a 4.6 percent job growth in the health-care sector from 2014 to 2016, according to the report.

“No matter how you look at Medicaid expansion in Kentucky, it’s clear it has had a positive effect on access to health care that will improve our state’s economy and quality of life,” Jason Bailey, executive director of KCEP, said in a news release.

However, Bevin says the state can’t afford to have more than a fourth of its population on Medicaid and is seeking a waiver from the federal government to make changes in the program, such as “skin in the game” for beneficiaries: co-payments, deductibles or health savings accounts, as used in a year-old experiment in Indiana, which he has cited as an example.

The KCEP reports says the Medicaid waiver Bevin is seeking could result in additional costs to recipients and benefit changes. Arkansas was the first state to design a Medicaid expansion using such a waiver. So far, five other states have implemented similar waiver-based programs.

Waiver programs differ from standard Medicaid expansion in that they utilize some or all of the following: health savings accounts, a cost-sharing account to be used for health care expenses; lockouts, periods in which recipients who have been dis-enrolled for failure to pay premiums are barred from re-enrolling; and premium assistance, the use of Medicaid funds to buy private insurance plans.

These waivers are designed to grant states the freedom to enact experimental programs within Medicaid, so long as the programs continue to reflect the overall goal of Medicaid, increasing coverage of low-income individuals and improving overall health care, as well as efficiency and stability of health care programs that serve that population.

The Foundation for a Healthy Kentucky, which convened a meeting of Medicaid stakeholders last week, is holding off on making judgments of the proposed waiver program. “We believe that diverse input is essential to sustaining these gains, and to continue improving our health care system and health outcomes in Kentucky,” said Susan Zepeda, president of the foundation.

Zepeda said research the foundation has funded has shown a greater decrease in the number of Kentuckians who lack health insurance than any other state, which she attributes largely to Medicaid expansion adding about 400,000 Kentuckians to the rolls.

More than 1.4 million Kentuckians are enrolled in Medicaid, 39 percent of whom are children. Nearly 32 percent are enrolled under the expansion: childless adults in households that earn less than 138 percent of the federal poverty line, currently $33,000 for a family of four.

The KCEP report also asserts that Kentucky’s Medicaid benefits are on par with those of other states, specifically that 12 out of 13 of Kentucky’s optional benefits are also covered in at least 40 other states and territories. Kentucky Medicaid only covers services that are deemed medically necessary.

KCEP noted that Medicaid is a partnership in which the federal government funds a minimum of half of traditional Medicaid spending in each state, with poorer states receiving a larger federal match. In Kentucky, the federal share is about 70 percent. For people covered by the expansion, the federal government is paying the full cost through this year, but the state will pay 5 percent in 2017, rising in annual steps to the law’s limit of 10 percent in 2020.

The full KCEP report is at http://kypolicy.org.

Rogers says House Republicans want $622 million for Zika; McConnell, Senate plan $1.1 billion; Obama wants $1.9 billion

UPDATE, May 16: The Republican package totals $622 million. May 17: Obama calls that "woefully inadequate," says he would veto it.

House Republicans' funding to fight the Zika virus will be about half the $1.9 billion President Obama requested, but still "adequate," U.S. Rep. Hal Rogers of Kentucky's Fifth District, chair of the House Appropriations Committee, said Friday.

Dierdre Walsh and Ted Barrett report for CNN, "Ever since they sent the request to Capitol Hill, the White House has complained that Republicans are ignoring a public health crisis and need to sign off on more money soon, especially before the potential risks from the mosquito-borne virus increase with the summer months."

Rogers told reporters the bill he plans to introduce Monday will provide "less than a billion" for Zika but will be "adequate funding to face the problem." Also, "the money will be targeted for agencies to spend right away," Walsh and Barrett report. Rogers said the House could vote on the bill as early as Wednesday, May 18.

"Rogers and other congressional Republicans said they hadn't acted before now because the Obama administration wasn't giving Congress the details on how they would spend" the money, CNN reports, "and they were working through their own analysis on how much the various agencies needed to deal with the immediate needs. House conservatives also demanded that any new money for Zika needs to be paid for with cuts to other programs."

His bill is "fully offset" with cuts, Rogers said, but he declined to say where, "saying his committee was still finalizing those details," CNN reports. "But the White House and congressional Democrats argue in these cases Congress doesn't traditionally specify cuts to pay for additional funding. An unnamed Democratic aide on the appropriations staff told the network, "We don't offset emergency funding, period. And this is the definition of a public health emergency."

Meanwhile, Senate Majority Leader Mitch McConnell, R-Ky., and Democrats in that chamber "worked out a bipartisan $1.1 billion Zika proposal that they plan to attach to a separate spending bill" and scheduled it for a vote Tuesday, May 17, CNN reports. "The Senate will also vote on two competing proposals -- one from the two Florida senators, Bill Nelson, a Democrat, and Marco Rubio, a Republican. It would fully fund the President's request. The second is from Sen. John Cornyn, R-Texas, that would provide about $1 billion and be offset with cuts elsewhere. Those last two proposals are not expected to pass."

Air ambulances save lives in rural Kentucky, but are costly; Junction City buys Air Evac memberships for everyone in town

Medical helicopters are especially important to rural Kentucky because they get people to the medical care they need quickly, but this service comes at a cost that many can't afford, Miranda Combs reports for WKYT.

Air Evac Program Director Donald Hare told WKYT that "the average cost of a flight is around $32,000 and insurance pays, on average, $8,000 and $12,000 of that cost," Combs writes.

"About 14 to 16 percent of our flights are people with no insurance whatsoever and don't have the ability to pay for that flight," Hare said, noting that they try to work with people to set up a payment plan in this situation.

Jim Douglas, the mayor of Junction City, told Combs that his city council has decided to buy memberships with Air Evac Lifeteam, which has a hub in the Danville Airport, for everyone in the city to cover them if they need to use the service. He said more than 60 people were flown out of Boyle County on a medical helicopter last year.

"It could be a lifesaving thing," Douglas told Combs, and said it will "cost the city just under $12,000," Combs writes. And while he said he fully expected some people to use the service for non-emergency reasons, he asked,  "But who's to make the call? I wouldn't want to."

Michael Bentley, a paramedic, assured WKYT that most of their transfers are emergencies.

"We generally get called out to the sickest of the sick patients. We're generally not going out to 'Joe that stubbed his toe on the refrigerator at home.' Our patients are major trauma type patients or cardiac events that have happened to these patients," Bentley told WKYT.

Adam Tubbs, an EMT in Nicholas County, told Combs that medical flights were important because it takes "precious time by ground to get to an emergency call" in such a large rural county. He noted that, on average, they call for air ambulances several times a week. The Nicholas County Hospital closed more than one year ago.

The cost of these air transports has become such a problem that Rep. Tom McKee, D-Cynthiana, filed a bill during the last legislative session calling for a study of air-ambulance charges. The bill passed out of the House, but did not make it out of committee in the Senate.

Tips for staying healthy and safe on Kentucky's waters

Brad Molnar on Taylorsville Lake
(Courier-Journal file photo, 2003)

The state Division of Water and Department for Public Health offer tips to help Kentuckians stay safe and healthy as they go boating, fishing, swimming or otherwise recreate in the state's waterways this summer:

• Avoid ingesting or inhaling the water.
• Thoroughly clean hands and other areas that have come in contact with the water.
• Avoid allowing open wounds to have direct contact with the water.
• Avoid areas where swimming or harmful algal bloom advisories have been issued.
• Avoid water with obvious odors or surface scums.
• Avoid getting in water after heavy rainfall, especially in dense residential, urban and agricultural areas.
• Avoid areas below wastewater-treatment outfalls, animal feedlots, straight pipes or other obvious sources of pollution.
• Restrict pets and livestock from drinking the water if a bright green or blue-green surface scum is present.

James Bruggers, environmental reporter for The Courier-Journal, reminds us: "The Clean Water Act of 1972 declared that all waterways in the United States were to be 'fishable and swimmable' by 1985. We've made progress, but we have a long way to go. Be safe out there."

Doctors, medical students and others in Louisville say America needs a system of single-payer health care

A group of physicians, medical students and others in Louisville said May 10 that the U.S. needs a national single-payer system of health coverage because "health care in America costs too much and too many people go without it," Deborah Yetter reports for The Courier-Journal.

"The Affordable Care Act has helped," said Dr. Barbara Casper, a University of Louisville professor of medicine and chief of internal medicine. "But we still have a significant number of people falling through the cracks."

The event, held at U of L by Kentuckians for Single Payer Healthcare, "follows the recent call in the American Journal of Public Health for a single, national health care system similar to that of most industrialized countries. It was signed by more than 2,200 doctors nationwide," Yetter reports.

Physicians and medical students at the event said they see too many patients "who lack coverage or can't afford the costs of their health plans, such as high deductibles and copays," Yetter writes. "Brandi Jones, a U of L medical student and past president of the group, said she supports universal coverage because as a future physician dedicated to healing people and saving lives, she can't 'condone a system that allows people to die'."

Dr. Syed Quadri of Elizabethtown said his free clinic "sees many working people who make too much for Medicaid – the government plan for the poor – but can't afford private plans that often come with high costs."

The speakers "acknowledged it will be a tough political battle to sell a national health plan, possibly by expanding the current Medicare system to all Americans," Yetter reports. "Dr. Morris Weiss, a cardiologist who said America spends far more of its gross domestic product on health care than European nations such as France, Germany and Italy – with far less to show for it. When it comes to health outcomes, 'We're one of the bottom countries of all the industrialized nations,' he said."

Insurance commissioner sues contractor for failed Kentucky Health Cooperative, alleging gross negligence in handling claims

State Insurance Commissioner Brian Maynard, acting as liquidator of the failed Kentucky Health Cooperative, filed suit in Franklin Circuit Court Friday against against the company that the co-op hired to process and pay claims. The suit contends that CGI Technologies and Solutions Inc. was "grossly negligent" in processing and paying claims and thus breached its contract.

The co-op, created by federal health reform to compete with insurance companies and hold down premium costs, had financial problems from the start. This year Republicans accused former Gov. Steve Beshear, a Democrat who embraced health reform, of holding down co-op premiums to make the reforms look good. Beshear denied the charge.

The co-op announced in October 2015 that it would close because Congress did not provide sufficient "risk corridor" payments to insurers with disproportionately sick policyholders and the Obama administration was unwilling or unable to make up the difference. The co-op, which had a deficit of $50 million in 2014, was expecting a risk-corridor payment of $77 million but got only $9.7 million. Most other co-ops also failed.

“We have a duty to investigate the causes of the co-op’s collapse and to hold responsible those individuals who caused the collapse,” Maynard said in a press release. “This includes recovering funds from responsible parties so that the doctors, nurses, and hospitals that treated Kentuckians insured by the co-op are fairly compensated for their services.”

Thousands of patients and thousands of providers will have to wait until Oct. 15 or later to find out how much of their medical bills sent to the co-op will be paid, Kentucky Health News reported in February. The co-op "left thousands of providers waiting for payment," Stephanie Armour reported for The Wall Street Journal. It covered about 51,000 people through the end of 2015. Franklin Circuit Judge Phillip Shepherd will decide how much will be paid to whom.

McDonald's stops sending to schools man who says he lost much weight eating only at McDonald's, including Big Macs and fries

Photo via flickriver.com

McDonald’s has stopped "giving nutrition advice to students in schools, pulling back on a program that critics said was a subtle form of fast-food marketing that could imperil kids’ health and understanding of nutrition," Roberto Ferdman reports for The Washington Post.

The company had been sending to schools "a middle-aged teacher from Iowa who came to fame after claiming to have lost almost 60 pounds eating only McDonald’s," including Big Macs and french fries, Ferdman writes.

"McDonald’s said in a statement this week that Cisna stopped those visits last fall, after a Washington Post article highlighted how McDonald’s used its relationship with local schools and teachers’ associations to get its message in front of students. . . . McDonald’s had long defended the practice, saying that Cisna’s presentation was about choice, not about eating McDonald’s. But critics argued it amounted to little more than a veiled attempt to woo customers at a young and impressionable age."

Health-insurance stocks fall in reaction to federal judge striking down one Obamacare subsidy; ruling is stayed pending appeal

"Shares of Humana, Aetna and other health insurance companies tumbled on Thursday, as a federal judge ruled that Affordable Care Act subsidies could not be dispensed without congressional approval," Boris Ladwig reports for Insider Louisville. "Humana’s shares slid 2.5 percent, and Aetna’s dropped 3.26 percent. Insurers Anthem and UnitedHealth Group also booked declines."

District Judge Rosemary Collyer of the District of Columbia ruled that Congress had never provided money for the subsidies to people who buy health insurance through Kynect and other exchanges. "Without subsidies, fewer people would be able to afford to purchase health insurance, which means insurance companies would lose customers," Ladwig explains.

Collyer, an appointee of George W. Bush, allowed the program to continue while the Obama administration appeals her ruling to the D.C. Circuit Court of Appeals. The Supreme Court appears likely to decide the issue.

The suit by House Republicans involved only cost-sharing subsidies, not the income-tax credits that apply to monthly premium payments. The Obama administration funded the cost-sharing with money from the tax-credit account.

The cost-sharing subsidies are available to people with incomes between 100 and 250 percent of the federal poverty level — between $24,300 and $60,750 for a family of four. "Several million Obamacare customers receive cost-sharing subsidies, but the exact figure is unknown," Jennifer Haberkorn reports for Politico. "As of the middle of the last Obamacare enrollment period, 57 percent of people who signed up for coverage through the federal exchange on HealthCare.gov receive them. . . . If the subsidies are ultimately struck, it would reinforce claims from opponents of the health law that the Obamacare insurance plans are not actually affordable."