He, like many Republicans these days, walks a perilous line when talking health care.

Ben Jacobs, a reporter for The Guardian, approached the candidate armed with an audio recorder and persistent, pesky questions about a Congressional Budget Office (CBO) report, which found that the GOP’s American Health Care Act would leave 23 million more Americans uninsured over 10 years and would effectively price out from coverage millions with preexisting conditions.

Though the AHCA passed muster in the House of Representatives, disapproval of the Republican plan has been high among voters — by ratios of more than 2-to-1 among men and more than 3-to-1 among women, according to a . Over 50 percent of Republicans opposed cutting federal funding for Medicaid, a component of the bill.

Torn between conflicting impulses, the GOP candidate for Montana’s only seat in the House of Representatives had already stepped into the health care muck twice — on opposite sides of the issue. He told reporters for the Obamacare repeal bill passed by the House earlier this month, but a tape surfaced of during a fundraising call with D.C. lobbyists. No wonder he wasn’t eager to respond to Jacobs’ question.

On the other side of the political divide, Democratic challenger Rob Quist tried to seize the moment, making opposition to the AHCA a campaign issue. On the final weekend before Thursday’s vote, Quist made a major buy of political ads that pinned the erosion of preexisting condition protections on his opponent. He confided his own preexisting condition — related to “a botched gall bladder surgery” — and noted that about half of all Montanans have a preexisting condition. Approximately 52 million Americans have a health history that could make them uninsurable in the future, if laws don’t guard against the practice.

According to the CBO report, “people who are less healthy (including those with preexisting or newly acquired medical conditions) would ultimately be unable to purchase comprehensive nongroup health insurance at premiums comparable to those under current law, if they could purchase it at all.”

Quist’s health narrative also dissolved one of Gianforte’s most potent attacks on him: financial problems that led to bankruptcy. Medical bills caused that bankruptcy, Quist said, and indeed, as a folk singer for most of his life, Quist was someone who had to buy health insurance on the unstable and discriminatory individual market. At 69, he can now rely on Medicare.

Gianforte, at 56, is in the age range of those who can be charged five times more than younger people for insurance under the House-passed bill. But, like President Donald Trump, Gianforte is a wealthy businessman, who likely has not had to focus deeply on the high costs of health coverage.

The altercation may not have affected the election. The seat has been occupied by a Republican for more than two decades, and nearly two-thirds of the expected turnout had already cast a ballot by mail. Montana also has same-day voter registration. Reporters from Montana Public Radio heard from brand-new voters Thursday — some who were appalled and compelled by Gianforte’s behavior and others who thought Jacobs was in the wrong.

It’s hard to say how much health care influenced Gianforte’s 6 percentage point win over Quist. The use of public lands had been the central issue in the election, and both candidates had avoided the topic of health care for much of the race, which replaces the seat vacated by Interior Secretary Ryan Zinke.

But Gianforte’s election eve scuffle may signal how tense and explosive health care will be politically for the 2018 election cycle.

Eric Whitney of Montana Public Radio contributed to this report.

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In a to the state senate, Brown advised legislators to consider the issue during the budget process. Brown wrote: “Allowing more estate protection for the next generation may be a worthy policy goal. The cost of this change, however, needs to be considered alongside other worthwhile policy changes in the budget process next year.”

The issue is important to people like Anne-Louise Vernon, who recently signed up for Medi-Cal under the Affordable Care Act’s expansion of the program. Vernon of Capitol Public Radio that she fears using her new coverage.  “I feel so unsettled about this whole estate recovery thing that I’m afraid to go to the doctor,” she said.

The law has been on California’s books for two decades, but with the expansion of Medi-Cal it now has the potential to affect many more people.

More from Pauline Bartolone’s story for Kaiser Health News and Capitol Public Radio:

Elizabeth Landsberg of the  said it turns what was intended to be a safety net program into a long-term loan program and undermines the security that families might pass on to the next generation.

“So in most cases it’s modest family homes that we’re talking about, and so the state will most often come back and put a lien on that home, and unfortunately it does force the kids to sell the homes sometimes,” said Landsberg.

Landsberg said the law is unfair under the Affordable Care Act, because other people buying insurance and getting premium subsidies through Covered California aren’t subject to the same rules.

“For the first time people have to have health coverage. So it’s created an inequity where the lowest income people could lose their assets, and other higher income people who are also getting publicly-subsidized health coverage have no worries,” said Landsberg.

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Department of Health and Human Services Secretary Sylvia Burwell tapped Counihan to lead the site as part of a that aims to have the second year of Obamacare run more smoothly than the first.

Access Health CT, under Counihan’s leadership, is one of the more successful state-run exchanges. About 257,000 people got coverage, according to the state, including  for private insurance. Surveys show that about in the state were previously uninsured.

“One of the most important things we did is we showed that government can work,” Counihan said at a press conference in Hartford Tuesday. “It can take on a highly complex social program and succeed.”

But taking the reins of healthcare.gov will be a much tougher job. Connecticut has a Democratic governor and legislature, and it embraced the law early, including the expansion of Medicaid. Healthcare.gov serves states that are actively hostile to the law in the Deep South, states that are embracing the law to some minimal degree and states that are active partners in running the exchange.

At the press conference, Connecticut Gov. Dannel Malloy said Burwell had called him to discuss Counihan. The governor joked that Counihan should have his head examined for agreeing to go to Washington.

Burwell, in a press release, said that Counihan “will be a clear, single point of contact for streamlined decision-making.” The announced several other hires as well.

Obamacare year 2 starts with enrollment opening on Nov. 15, and the challenges are many. In addition to making sure the technical glitches stay in the rearview mirror, Counihan will be responsible for keeping people who are already signed up satisfied, as well as reaching out to the millions of Americans who are eligible for coverage but not yet insured.

Counihan said he’s optimistic that it can be done. “People understand intuitively that having people uninsured is not right for them or right for the country,” he said. “Now, how we go about doing it — people can debate and there can be solid policy differences.  But I’m fundamentally very optimistic that, even though there are some big ideological schisms, that those can be bridged.”

Counihan’s exchange excelled at marketing Obamacare insurance — taking the pitch to , jazz festivals and a storefront on a city street. And he credits some of that success to the pool of executive talent he was able to draw on in Hartford, an insurance capital.

Counihan has several decades of experience in health care, including launching complex new coverage programs. After a career in the private insurance industry (Tufts Health Plan, Cigna), he helped launch Massachusetts’ successful health exchange starting in 2006. He also helped launch a private insurance exchange in California.

Counihan is the second high-profile addition to the healthcare.gov second year team. Earlier this summer HHS brought on Andy Slavitt, who helped fix the site’s initial problems as an executive with contractor Optum.

Counihan may have caught the president’s attention a year or so ago during a conference call with the leaders of the state-based exchanges. Counihan recalls talking to the president about the marketing event at the Lil Wayne concert: “And he said, ‘Lil Wayne.  I’ve never been to a Lil Wayne concert.’  And I said, ‘Well, Mr. President, neither [had] I, and I don’t think I’m exactly in the target demographic.'”

Later in the meeting, another exchange official from a different state talked about advertising their state’s exchange on coasters at bars. “My counterpart in that state had said that she felt too old or embarrassed to actually go into bars to see if it’s working,” Counihan said. “At which point the president said, ‘Well, if Kevin can go to a Lil Wayne concert, you certainly should be able to go to a bar.'”

Julie Rovner contributed.

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Brawley, who has been an , answers many important questions that Jolie’s decision raises.

Should all women have the genetic test? No, says Brawley, but they should all have a conversation with their doctors.

This does not mean every woman needs a blood test to determine their genetic risk for breast and/or ovarian cancer. What it does mean is women should know their cancer family history and discuss it with their regular provider. If appropriate, they should be referred to and have the opportunity to discuss their risk and their options with a genetic specialist.

Are insurers required cover the genetic tests? What about the preventive surgery? Brawley says:

Insurance plans created before the passage of the Affordable Care Act are not required to cover the costs of genetic counseling, testing, and any surgery to reduce the risk of breast cancer. Under the Affordable Care Act, new plans are required to cover the costs of counseling and testing for breast cancer risk. There is no such mandate for the coverage of surgery.

Brawley points out that only a small number of breast cancers are linked to genetic risk factors, but women, like Jolie, who are at high risk should know it. He warns women to proceed cautiously and get a second opinion before deciding to have a preventive surgery. “Nonetheless, after careful consideration, this might be the right choice for some women,” Brawley writes.

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“One in 32, think about that,” said singer-songwriter Alicia Keys, citing the Centers for Disease Control and Prevention statistic. “Thirty years after we first heard of AIDS, it is really a tragedy that anybody is being infected.”

But people are being infected with the virus in the U.S. and, as Keys said, black women are affected disproportionately. Keys stammered a little as she read the word “disproportionately” from her notes, and then recovered and repeated it with force saying, “It’s a big word and it’s a bad thing. That’s not acceptable.”

Keys’ comments came at the kickoff of the campaign, an effort to increase awareness of HIV and AIDS among women, a new part of the Greater Than AIDS public information push by the Kaiser Family Foundation. (Kaiser Health News is an editorially independent part of the foundation.)

The and black women in particular are sobering.

• There are more than 1.1 million people living with HIV in the U.S., and one-in-four of them are women.
• The rate of infection for black women was 20 times higher in 2010 than it was for white women (38.1 per 100,000, compared to 1.9 per 100,000).
• In 2010, 60 percent of women with HIV were African American, 19 percent were Latino, and 18 percent were white, according to the CDC.
• Newly infected black and Latina women are more likely to be younger, with 23 percent of black women and 21 percent of Latina women in the 13-24 year old age range.
• In 2009, black women accounted for the greatest share of deaths among women with HIV at 65 percent, followed by white women at 17 percent and Latinas at 14 percent.

One of the main themes of the campaign – which includes videos, public service ads, and social media efforts — is to make the issue personal for women. A living with HIV. “They are just like you and just like me,” Keys says in the video of the women, who all sat in the front row of the foundation’s conference center during Monday’s kickoff.

Valerie Jarrett, senior advisor to President Barack Obama, and chairwoman of the White House Council on Women & Girls, also spoke at the event, making the point that the issue of women and AIDS has long been a personal one for her.

“Every day I carry around the heartbreak of losing my sister-in-law, who died nearly 20 years ago,” Jarrett said. “She went months without being diagnosed because nobody thought to test a married woman at the time.”

Jarrett pointed out that, under the Affordable Care Act, HIV testing is now covered as a preventive service without cost sharing, and beginning in 2014, people with HIV cannot be denied insurance because of a pre-existing condition.

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“Expanding access to Medicaid services for three years is a compassionate, common sense step forward. It is not the end of our work to improve health care,” Scott said. “And, it is not a white flag of surrender to government-run health care.”

The move makes Scott the seventh Republican governor to back Medicaid expansion.

Florida has the nation’s third highest rate of residents without coverage, and more than 1.5 million people can expect to gain coverage with the Medicaid expansion. The governor’s support is significant, but the measure will still have to win approval in the legislature.

Tia Mitchell of the Tallahassee bureau of the The Tampa Bay Times and Miami Herald Scott’s decision:

Hours after the federal government agreed to grant Florida a conditional waiver to privatize Medicaid statewide, Gov. Rick Scott appears ready to endorse a plan to conditionally expand the health care program to about 1 million Floridians or more. …

Scott previously has said that Florida cannot expand Medicaid unless the federal government approves the state’s plan to privatize the system.

Today, he got the waiver he sought.

Earlier Wednesday, the federal Centers for Medicare and Medicaid Services  that will allow the state to enroll almost all of its Medicaid patients into private managed care plans. From :

“This is a great win for Florida, and it would not have been possible without the support of legislators who began the fight for this Medicaid flexibility many months ago,” Scott said in a release.

He said it will give patients with chronic illnesses better coordination of care and help taxpayers by lowering costs.

Here’s video of Scott’s press conference, via :

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This week, a  of Medicare data showed that 2,211 hospitals will face penalties in October for having too many patients readmitted for care within 30 days of discharge.

Hospital executives around the country have had something to say about those penalties and the new policy. Here’s a round-up of how the story played as it was picked up and localized by some of our reporting partners at NPR member stations around the country.

Pennsylvania & Delaware

Taunya English, covering the at WHYY in Philadelphia, reported on resistance to the policy coming from the regional hospital association.

“[Medicare] needs to remember that people are not cars,” Curt Schroder, head of the Delaware Valley Healthcare Council, told English. “They seem to be treating hospitals like auto repair shops. In other words, ‘You should be able to change the tire, send them on their way and not see them for another 5,000 miles.'”

English also interviewed Coy Smith, vice president for patient-care services and chief nursing officer at St. Francis Hospital in Wilmington, Del. St. Francis is facing a partial penalty— 0.66 percent of their Medicare reimbursements out of a possible 1 percent hit.

“We are looking at better handoffs to home care, skilled nursing facilities, better discharge preparation of patient families and using home care as an avenue to really track them. Because it’s the right thing to do, truly,” Smith told English. “But having these penalties over our head does kind of make a difference.”

Smith made the point that St. Francis has lowered readmission rates for all three categories in the past 18 months, but the new ranking uses historical three-year data from 2008 to early 2011, English reported.

New York

In New York, WNYC’s Fred Mogul  that the “ includes some of the region’s biggest players: city hospitals, like Bellevue, Jacobi, Coney Island and Elmhurst; academic medical centers such as Beth Israel, St. Luke’s-Roosevelt and Mt. Sinai; and suburban ones like North Shore and Hackensack medical centers.”

Jim Mandler, a spokesman for Continuum Health Partners, which owns Beth Israel and St. Luke’s-Roosevelt, told Mogul that the company is addressing the problem, but New York City may be a special case. “The complex issues that urban healthcare providers face, particularly here in New York City, clearly affect readmission rates and contribute to rates that are above national averages,” said Mandler.

Georgia

At Atlanta’s WABE, Jim Burress Ìý³Ù³ó²¹³ÙÌý will pay a penalty.

Vi Naylor, executive vice president of the Georgia Hospital Association, told Burress that it’s ok for hospitals to be held accountable for quality, but the organization would like to see other metrics used. And Dr. Ashish Jha, health policy professor at Harvard, told Burress: “Not all readmissions are bad.”

Hospitals with high readmission rates often have low mortality rates, Jha said, and those mortality rates are a better assessment of quality than readmissions.

One surprise in Atlanta: the beleaguered safety net hospital Grady Memorial got a penalty of one tenth of 1 percent, among the lowest in all of Georgia.

Minnesota

Minnesota had relatively good news in the analysis, as Minnesota Public Radio’s Elizabeth Stawicki : No hospital in the state got the maximum penalty. From Stawicki’s story:

Mayo Clinic’s Health System in Fairmont was the highest at 0.81 percent. Sanford Medical Center in Worthington and Fairview Ridges Hospital in Burnsville both face penalties of 0.43 percent.

Mayo is concerned about any unnecessary readmission, said Kevin Burns, regional director of public affairs for Mayo.

“Every patient deserves the best possible care, the very best comprensive treatment regardless of our cost to provide that treatment,” he said. …

Dan Anderson, president of Fairview’s community hospitals, said the penalty will amount to about $100,000. He says the penalty is perplexing because the government recognized Fairview for its ability to improve care and reduce cost. But he says Fairview supports what Medicare is doing.

“No patient wants to be readmitted if they don’t have to be and we don’t want to have them there if we can figure out a way to help them avoid it,” Anderson said.

Wisconsin

Wisconsin is another good-news state, where Wisconsin Public Radio’s Shamane Mills,  that about 70 percent of the hospitals won’t be penalized, and no hospital will get the full penalty. Kelly Court, chief quality officer at the Wisconsin Hospital Association told Mills that the success on readmissions is due to coordination.

Court said discharged patients have to get good care from community doctors, home care agencies and nursing homes when they leave. “Hospitals can only do so much to prevent the readmission, like [making] sure patients understand their discharge instructions, understand their medications, make a good transition to a physician after the patient leaves the hospital,” Court said. “But once the patient leaves, the hospital has very little control.”

Related post:

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From the speech:

With this decision, states now have the option to expand Medicaid to cover people below poverty. Mr. President, the states had that option before the Affordable Care Act was passed.  So what does this decision mean in real terms?

It will be up to the states to determine if they will cover the poorest of the poor.  The federal government cannot guarantee coverage. So now people with jobs will have to purchase insurance under the tax mandate.  People without an income, people who are below poverty are dependent upon the state in which they reside.

…

Now I know some people will believe that the choice is perfunctory, that Medicaid expansion will move forward because the federal government has offered to pay for more than 90 percent of the expansion.

But if you were a state, would you really trust a promise from a federal government that is $15 trillion in debt?

Read the whole statement .

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Two Democratic governors — of Connecticut and of Maryland — tried to tamp down the controversy over contraception coverage at Catholic institutions this week by quoting the same number:  28 states already require insurance coverage of contraception.

That’s true and it’s mentioned in a by the reproductive health think tank, the Guttmacher Institute. But it’s not the whole story.

The same report shows that 20 of those 28 states have exemptions from the coverage policy for religious employers and insurers. Guttmacher categorizes eight of those exemptions as “expansive” – and both Connecticut and Maryland are in that category.

For Maryland, that means that most Catholic schools, universities and hospitals are not required to cover contraception for their employees. In Connecticut, religious insurers are required to offer contraceptive coverage through a subcontract, according to the report.

Eight states have no exemption – so Catholic employers in Colorado, Georgia, Iowa, Montana, New Hampshire, Texas, Vermont, Virginia and Wisconsin must provide contraception coverage under state laws.

Four more states have a limited exemption that cleaves closely to the new federal rule. That rule applies narrowly to churches that employ mainly members of their own faith. The four states with narrow exemptions from the contraception coverage mandate are Arizona, California, New York and Rhode Island.

Massachusetts is on the roster of states with an exemption to the coverage mandate that Guttmacher labels as “broader” — meaning that most churches and  schools don’t have to provide birth control coverage but universities and hospitals do.

Elizabeth Nash is the state issues manager for Guttmacher; she put together the policy brief. Nash says there’s wide variation state to state, and that the coverage laws have evolved over time. “The first law was adopted in 1998 in Maryland, and it had a very broad exemption, ‘Religious organizations may opt out.’ There was no definition of what a religious organization is,” Nash said.

It is unclear how many Catholic institutions would be affected if the new federal rule goes into effect, which is as political pressure from within Democratic circles heats up. A spokeswoman for the Association of Catholic Colleges and Universities said her organization doesn’t track which of its member institutions are required to offer contraception coverage under state laws.

Calls to the Catholic Health Association, representing Catholic hospitals, and the United States Conference of Catholic Bishops were not returned by press time.

Jeff Cohen of in Connecticut contributed to this report. This is part of a reporting partnership that includes NPR, member stations and Kaiser Health News.

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Keep watching this second clip at least until you get to the pantomime moment: That’s the biggest laugh line of the interview.

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