Candidates go on the attack, claiming their opponent will do harm to Medicare. After all, people are . These voters are also generally to protect the federal health insurance program for seniors.

It’s no surprise, then, that in an ad released this month, former Vice President Joe Biden’s campaign played the Medicare card.

“Donald Trump is lying about Medicare and Social Security,” an ominous, mature, male voice warns viewers in the . He goes on to say that “Trump’s pushing to slash Medicare benefits.”

Clearly, we’ve heard this dire message before — from candidates of both parties through the years.

We issued a skeptical rating that Trump promised to gut Social Security and Medicare if re-elected, noting that his deferral of payroll taxes did not mention Medicare at all. But Trump has not mentioned cuts to Medicare benefits on the trail, and he’s to the program in the future. So what is Biden’s claim talking about?

As a rationale for the statement, a Biden campaign spokesperson pointed us to the Trump administration’s support of Republicans’ efforts in a court case, , which seeks to overturn the Affordable Care Act. But the ad does not include any reference or explanation of how the case would affect Medicare benefits.

The legal challenge, brought by a group of Republican attorneys general, is pegged to the 2017 tax bill, which zeroed out the tax that functioned as a penalty for not having health coverage — known as the individual mandate. Without this linchpin tax, the Republicans argue, the entire law should be struck down. They based that on the Supreme Court decision in 2012 that the law was constitutional because the penalty was a valid use of Congress’ ability to levy taxes.

In the current case, lower courts have found the law unconstitutional, and a group of Democratic attorneys general appealed to the Supreme Court.

Oral arguments are scheduled for Nov. 10. The Trump administration filed a in support of invalidating the entire law unconstitutional.

Though best known for its vast expansion of health coverage through marketplace plans and Medicaid, the ACA also included a range of consumer protections — such as the ban on discrimination against people with preexisting conditions — and an estimated 165 Medicare-related provisions.

The Biden spokesperson pointed to one, which ended Medicare’s so-called doughnut hole.

We asked experts for their take. Immediately, we found differences in opinion.

That’s a “perfectly fair claim,” said Nicholas Bagley, a professor at the University of Michigan Law School. Closing the doughnut hole matters to many people, he said.

Case Western Reserve University law professor Jonathan Adler took a different view. The argument that Medicare would be affected “is a very aggressive reading of the filing in this case,” he said, referring to the Trump administration’s brief in support of nullifying the ACA.

The next step seemed to be getting a better grasp of what’s at stake.

A Quick Review of the Doughnut Hole, Other Medicare Provisions

The refers to the prescription drug coverage that begins after a beneficiary spends a set amount — usually a few thousand dollars. Before the ACA, beneficiaries who reached that threshold were responsible for 100% of their medication costs until they spent enough for catastrophic coverage to kick in, which could be more than $1,000 in additional spending. Even with this coverage, beneficiaries were responsible for 5% of their drug expenditures. (If beneficiaries were responsible for 100% of costs today, people with high drug costs would obviously pay a lot more without the ACA provision.)

The ACA would have gradually ended that coverage gap. But, in 2018, Congress adopted changes to expedite the process. As of 2019, the doughnut hole was . Adler pointed to that congressional intervention as a step that could keep the doughnut hole closed if the ACA were overturned. Based on this legislative history, the argument could be made that closing the coverage gap was something Congress had an interest in apart from the ACA. Since the doughnut hole is officially closed, some analysts said this provision may not be vulnerable to the upcoming Supreme Court decision on the ACA.

“You can make a lot of claims,” said Gail Wilensky, a former head of the Centers for Medicare & Medicaid Services. “That one is really a stretch.”

Other ACA provisions tied to Medicare benefits seem more at risk, such as the one that mandated annual wellness visits and certain preventive services, such as mammograms, bone mass measurement for those with osteoporosis, and depression and diabetes screening, with no patient cost sharing.

“It’s not clear that the administration actively supports any change to the Medicare benefits with the case before SCOTUS,” said Tricia Neuman, KFF senior vice president and executive director of the KFF’s program on Medicare policy. “But if they didn’t explicitly seek to wall off certain provisions, it is at least conceivable — though maybe not likely — that Medicare benefits in the ACA could be collateral damage.” (KHN is an editorially independent program of KFF.)

According to an filed by the AARP, the Center for Medicare Advocacy and Justice in Aging in 2016, an estimated 40.1 million Medicare beneficiaries received at least one preventive service and 10.3 million had an annual wellness visit with no copay or deductible.

Other experts pointed to a troubling implication for Medicare: the nullification of the ACA provisions related to costs and slowing the growth of the program’s spending. Those efforts had been credited with extending the solvency of the Health Insurance Trust Fund and slowing the growth in Medicare premiums.

It “would impair the financial fitness” of the trust fund, said Paul Van de Water, a senior fellow at the Center on Budget and Policy Priorities.

Trump “may not say it is his intent to slash Medicare benefits,” agreed David Lipschutz, associate director of the Center for Medicare Advocacy, but overturning the ACA entirely would “cause chaos writ large.” And, because of the program’s size, that chaos “would upend the financial markets and the entire health care system,” according to the brief filed by Medicare advocates.

What Comes Next Is Complicated

Enter the concept of severability. Many court watchers are quick to say the high court’s decision could go beyond upholding the entire law or declaring it unconstitutional. Instead, the justices could separate or sever parts of it not directly related to the zeroed-out tax penalty, the so-called individual mandate.

Of course, the Trump administration argued in its brief that the interwoven nature of the ACA’s provisions demanded that the entire law be invalidated.

“If you just go on that basis, they are not arguing for severability,” said Van de Water.

But others point out another layer that warrants consideration.

“Everyone who comments on this focuses on the administration’s argument for inseverability,” Adler said. But he said it was more complicated than that.

The Trump administration’s position is “simultaneously that the entire ACA should be invalidated” and also that relief should be provided only where injury to the plaintiffs is shown. (The administration defines the plaintiffs as the two individuals who signed on to the original challenge.)

Another view is that this point in the administration’s argument is not clear-cut, mostly because it gives no hint as to which programs or provisions would fit into the category of harming the plaintiffs.

Ultimately, the fate of the sweeping health law is in the hands of the Supreme Court.

“Legal analysts didn’t anticipate the case getting as far as it has,” said Lipschutz.

But “the White House threw its weight behind the lawsuit,” said Bagley, at the University of Michigan. “So, they own the consequences. Especially in the context of this presidential campaign.”

Our Ruling

An attack ad by the Biden campaign states that Trump is “pushing to slash Medicare benefits” and ties this charge to the administration’s position on the pending legal challenge to the ACA.

The Biden campaign pointed to an ACA provision that sought to close the Medicare doughnut hole to support this claim. It may not be the best example, though, because some experts suggest it may not be as vulnerable as other parts of the law.

Experts outlined a range of other Medicare provisions that either provided new benefits or shored up the program’s financial fitness. If the whole law were to be nullified, as the administration has advocated, these changes could also be erased — a step that would affect benefits and potentially cause premiums to rise.

Overall, the Biden ad seems plausible, even though the link between Trump’s position on the legal challenge and its impact on Medicare benefits is less straightforward than in similar claims we have checked regarding preexisting conditions.

We rate the claim Half True.

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His campaign’s sweeping set of initiatives, which represent a $775 billion expenditure in a variety of programs, aims to get significant traction among middle-class voters, whose struggles with caregiving issues have been exacerbated during the coronavirus pandemic.

When it came to home health workers, Biden zeroed in on their paychecks. “They’re doing God’s work,” he said. “But home health workers aren’t paid much, they have few benefits. Forty percent are still on SNAP or Medicaid. So my plan is direct. It gives caregivers and early childhood educators a much-needed raise.”

That 40% is a striking number.

After all, there are an estimated 3.3 million home health and personal care aides in the United States, according to the. These workers provide a range of daily living services to millions of older Americans and people with disabilities, chronic illness or cognitive impairment — making them an important part of the health care continuum. As baby boomers age, demand for home health workers is expected to increase rapidly. And, because Biden put a spotlight on the role caregivers could have in boosting the economy, we decided to investigate further.

We contacted the Biden campaign to find out the source for the 40% statistic. A spokesperson pointed us to information from . PHI is a New York-based advocacy organization that studies the direct-care workforce and is frequently cited as a source on this topic.

The group indicated that in 2017 42% of direct care workers, a category composed of personal care aides, home health aides and nursing assistants, received some form of public assistance — defined by PHI as food and nutrition assistance, public health insurance or cash assistance. A further breakdown of this broad job category showed that 53% of home care workers received public assistance, with 30% having received food and nutrition assistance and 33% Medicaid insurance coverage.

Based on these figures, Robert Espinoza, PHI’s vice president of policy, said Biden was certainly in the ballpark.

More Numbers, and Some Context

But there’s more.

The two programs Biden mentioned by name — , or the Supplemental Nutritional Assistance Program, and , the state-federal health insurance program for low-income people — peg eligibility to income limits at or near the federal poverty level, which for an individual is . Those eligibility limits vary by program and state.

Medicaid  for adults depends on where they live, and ranges from 138% of poverty in states that chose to expand the program under the Affordable Care Act to a median of 40% of poverty in those states that didn’t. For SNAP, those limits are set at 130% percent of the poverty level for gross monthly income and 100% for net monthly income. For an individual, that’s $1,354 and $1,041, respectively.

According to the Bureau of Labor Statistics, the median pay for home health workers is about $24,060 per year, and a by PHI concluded that 47% of home health workers have incomes at or below 138% of the poverty level. These numbers further back up Biden’s assertion about the number of home health workers on Medicaid or SNAP. If anything, they suggest his 40% figure may be a lowball estimate.

And one more bit of evidence that Biden was on the right track: noted that many of these workers “supplement their home care work with other jobs to make ends meet.” That PHI report asserted that half of home care workers have only a high school education and often work part time or inconsistent schedules. These jobs are also marked by high turnover rates.

Our Ruling

Biden said home health workers were paid very little, citing a statistic that 40% of these workers relied on public assistance programs like SNAP and Medicaid as evidence.

According to the experts with whom we spoke, and the documents we consulted, Biden accurately described home health workers’ income and their reliance on these programs. His number appears to represent the low end of the spectrum.

We rate this statement True.

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Guess who’s back grabbing headlines? Pharmacy benefit managers — those companies that serve as middlemen in the prescription drug pipeline. Plans to reduce the cost of medicines often target so-called PBMs as primary culprits behind the nation’s out-of-control drug prices.

But consumers often don’t notice or understand PBMs and how they factor into determining costs at the pharmacy counter. This , brought out from our vault, details the emergence of these multimillion-dollar corporations and the impact they have on medication costs and patients’ access to treatments.

For more information on drug pricing issues, check out this chart and these videos:

KHN also offers other videos examining hot topics such as , , and how the health law could be disassembled through the .

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On Tuesday, a federal judge , allowing a lawsuit to proceed that challenges whether the government can legally provide some health plan subsidies. The subsidies are being given to people who meet certain eligibility requirements to help pay for coverage purchased from the new online insurance marketplaces.

According to press reports, the plaintiffs’ argue that these subsidies cannot be used for policies sold on healthcare.gov, the federal health insurance marketplace.  They maintain that the law, as written, stipulates that the subsidies are for use on state exchanges. More than 30 states opted not to create an exchange and instead defer to the federal government.

U.S. District Judge Paul Friedman did not grant a preliminary injunction to prevent the financial assistance from being available while the case, , works its way through the courts. In August, a federal judge in Oklahoma allowed a similar case to go forward.

In a Kaiser Health News column published last November, Stuart Taylor dissected the key issues in play as these lawsuits continue. .

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KHN helps you make sense of the day’s developments on this live blog and with our coverage of the important stories of the day.

5:10 p.m. — FINAL UPDATE:  In a late afternoon press call, Centers for Medicare & Medicaid Services Administrator Marilyn Tavenner offered some thoughts on the launch of the health law’s online insurance marketplaces.

The federal website, , saw seven times more traffic Tuesday than Medicare.gov ever had, she said, adding, “This is certainly a historic day.” And, when asked why several state exchanges did not launch, Tavenner replied, “We are pleased with the progress states are making. They have experienced extraordinary volume to their sites and call centers.”

“This is day one of a six month process,” she said. “We are pleased with the remarkable interest we have seen.”

That’s the end of today’s live blog. Thanks for hanging out with KHN today.

3:56 p.m.: These updated figures were just passed on by KHN’s Phil Galewitz: HHS spokeswoman Joanne Peters said, “Since midnight 2.8 million people visited healthcare.gov.  Additionally, 81,000 have called 1-800-318-2596, and 60,000 have requested live chats.”

3:47 p.m.: In the Golden State, that , the state’s health insurance exchange, reported at 8:46 a.m. that one person was officially “on board.” Later, at a press event, Peter Lee, the marketplace’s executive director, explained that some people may be experiencing delays because the site is getting 10,000 hits every second. Officials don’t expect a wave of applications immediately because the process of comparison shopping and filling out the application is time consuming.

“Washington is talking about shut down. California is talking start up,” Lee said, according to KHN’s Sarah Varney, also reporting from California.

3:44 p.m.: In an interview on , Health and Human Services Secretary Kathleen Sebelius characterized the technical problems that have been experienced on the federal online marketplaces so far as a great problem to have because they’re “based on the fact that the volume has been so high.” She also noted that the health law is not being stopped because of the federal government shutdown.

3:00 p.m.: KHN is also tracking media coverage of President Barack Obama’s Rose Garden remarks in which he said federal officials will overcome the day’s technical glitches. Check out the .

2:58 p.m.: ’s Jeff Cohen reports that Connecticut’s exchange, , so far today has been “glitchy at best, and offline at worst.” The site went live shortly after 9 a.m. ET, and by 9:30, someone had already enrolled. “But throughout the morning, it was nearly impossible to get the Web page to load.”

KHN’s Phil Galewitz reports the latest from Hawaii, which has 100,000 uninsured, or about 10 percent of its population. The state did not launch its online enrollment today, and it could take until Friday for people to be able to shop and purchase plans. On the visitors can fill out a short form, and the Hawaii Health Connector “will contact you in the coming weeks … to inform you of your eligibility and plan options.” reports sources have told them exchange officials hoped to have the software problems resolved by Friday.

2:44 p.m.:Ìý´¡³Ù , Alex Nussbaum offers a look at the big picture, reporting on the range of delays and difficulties websites have experienced so far. “The U.S.-run marketplace meant to serve 36 states was unresponsive early today, with messages saying the site was dealing with ‘a lot of visitors’ or simply ‘down,’” he reported. Meanwhile, “Of the 14 states and Washington D.C. that have their own exchanges, only four — Massachusetts, Rhode Island, Colorado and Washington, D.C. — appeared to be up and ready for business between 9:30 and 10:30 a.m.,” he wrote.

Here’s some state-specific news:

KHN’s Ankita Rao reports on the rollout in Maryland: “A morning website snafu was ‘both expected and unexpected’ for Maryland Health Connection workers on Oct. 1, said Mary Anderson, a public information officer at the Montgomery County Department of Health and Human Services. After months of planning, outreach and training outreach staff, she said the online Maryland exchange attracted a moderate number of visitors and was up and running Tuesday afternoon. Anderson said she advised people looking for health care plans to look carefully at their options and wait until some of the initial glitches in the system were smoothed out before enrolling. Meanwhile, she attended an exchange launch event at Rockville Town Center and said the state had started processing paper applications immediately. ‘Our team is pleased with how things are going; they’re pleased with our readiness,’ Anderson said. ‘But they’re not breathing freely yet because they know this is just the beginning.’”

According to The Seattle Times, a KHN partner, Washington’s site has been effectively down from the start. State officials say they’re making repairs and that it’s not a capacity problem. More details available in the .

reports that the state’s Silver State Health Exchange website, despite launching 17 minutes later than it was scheduled to, was up and running and its call center opened on time.

And reports that Florida’s online marketplace opened Tuesday for browsing at healthcare.gov, with only 34 licensed “navigators” ready to offer advice to the millions who may need it.

2:20 p.m.: It’s a busy day, and a little humor seems to be in order. And for some people, a segment from last night’s Daily Show called “” might help. Stewart attempted to explain the battle lines and rules of engagement in the congressional fight over the health law – which he dubbed “The End of America as We Know It for Reasons No One is Able to Clearly Explain” – and the government shutdown. He even sites sources ranging from the Constitution and Schoolhouse Rock to the NFL.

If you don’t want to watch The Daily Show excerpt, is also highly recommended.

2:00 p.m.: This afternoon, after President Barack Obama met in the Oval Office with a group of people who are benefiting from the health law, he headed outside to the Rose Garden, where he again urged Republicans to reopen the government and abandon their efforts to stop implementation of the Affordable Care Act.

“This shutdown is not about deficits. It’s not about budgets. This shutdown is about rolling back our efforts to provide health insurance to folks who don’t have it,” Obama said.  “This more than anything else seems to be what the Republican Party stands for these days. I know it’s strange that one party would make keeping people uninsured the centerpiece of their agenda.”

Obama also said that more than a million Americans had visited this morning. “There were five times more users this morning than have ever been on Medicare.gov at one time.  That gives you a sense of how important this is to millions of Americans around the country,” he said. But he also acknowledged that there had been problems. He said the traffic had caused the site to be temporarily unavailable but noted that fixes would be made today to handle the demand.

“We’ll be speeding this up in the next few hours to handle all  this demand that exceeds anything we expected,” he said.

1:50 p.m.: An update from Eric Whitney, reporting for Colorado Public Radio, on how things are going for , the state’s online insurance marketplace: It’s open, he says, “but not 100% functional on this, its first day.” He reports that people using the website have been able “to shop for plans, get prices and find out whether they qualify for new tax subsidies to help them afford coverage. But they’re not able to create accounts and actually buy health policies today.” Wait times for callers using the toll-free phone number that supports the portal are reportedly running at least 10 minutes today.

1:25 p.m.: KHN’s Phil Galewitz reports that, as of 1 p.m. ET, three state exchanges were not up and running. Minnesota’s online marketplace, , was scheduled to go live Tuesday afternoon after “several last-minute test and security checks,” according to. Officials in Hawaii are ready to flip the switch for the at 8 a.m. local time, which is 2 p.m. ET.

At last check, Washington Health Plan Finder was still experiencing difficulties.

1:12 p.m.: Celebrities who tweeted their support for the Affordable Care Act today include singer John Legend, actress Mia Farrow, celebrity chef Tom Colicchio, talk show host Conan O’Brien and sports star Magic Johnson, according to . Katie Perry tweeted “YO what a day!” Even the boy band ‘N Sync joined the Twitter chorus, offereing encouragement: “Love, hate, or just confused by it -learn all you can about the Affordable Care Act…”

Meanwhile, Jimmy Kimmel decided to seek the opinions not of celebrities, but of about Obamacare vs. The Affordable Care Act.

1:03 p.m.: Here are two dispatches from NPR member station reporters in Texas, offering vignettes from an application counselor as well as uninsured patients who were signing up for coverage.

Reporter Carrie Feibel of KUHF interviewed Stephanie Pollock, a certified application counselor working at Gateway to Care, a nonprofit health network that serves the uninsured in Houston. Pollock was working the phone bank on Monday when she took a call from a woman who said  her husband has a heart condition and she is diabetic and insulin-dependent. The woman told Pollock that they cope with not being insured by alternating who gets to take medicine each day.

Fiebel recounts the conversation with Pollock: “‘One day I take my insulin, and then the next day he takes his heart meds. Because we can’t afford a whole month’s.’ And she started crying and saying, ‘Do you know you’re saving our lives? We’re gonna live, we’re gonna live!’ And I almost started crying because I thought this is the face of America that we’re talking about, that we’re changing lives.”

In Dallas, KERA’s Lauren Silverman went to Parkland Hospital, the city’s large public hospital where many of the city’s uninsured are treated.  Silverman met with three people signing up for Obamacare on Tuesday morning, one in Spanish and two in English.  They all had to complete paper applications because the website was down, so they had no access to details about the health insurance plans — including what the plans would cost them.

12:55 p.m.: As tensions run high in on Capitol Hill over effort to derail the health law, even if it means keeping the federal government shuttered, The Onion raises an important question: ?

12:25 p.m.: Just hours into a process that will last six months, some state exchanges are reporting traffic to their websites while others are noting difficulties. Here’s a sampling of what we’re hearing:

Kentucky: , the state’s online marketplace, had more than 1,000 applications for coverage by 9:30 a.m. ET. The site went live at midnight, and more than 24,000 people have browsed the site so far today.

New York: New York’s marketplace, the , reports 2 million visits in the first 2 hours of the site launch. Because of this volume, some visitors are seeing a message letting them know the site is currently having log in issues and encouraging users who are unable to log in to come back to the site later.

Connecticut: reports that it has logged 10,000 visitors in the last 3 hours, with 22 enrollments so far.

Maryland: Maryland’s online portal, the , has experienced connectivity issues since it went live at 8 a.m. ET but expects to be operating by midday, according to .

Washington: The state’s Washington Health Plan Finder exchange website experienced difficulties and “went down for maintenance” as it launched, according to Shortly after the site’s launch at 7:30 a.m. PT, officials released the following statement: “We became aware that some users were experiencing slow loading times or difficulty completing their application. While this is not affecting all users, we want to investigate the root cause for why this is happening and will be placing the site in maintenance mode in order to identify and correct these issues. We expect to have an update at 9:30 a.m. [PT]”

11:58 a.m.:  HHS spokeswoman Joanne Peters reports that healthcare.gov had over 1 million visits in the last day. She says this is five times more users than have ever visited Medicare.gov at once. It might be part of why the twittersphere is full of talk of long waits and other frustrations.

KHN’s Phil Galewitz decided instead to take a different route: to call the consumer hotline to search for prices for individual coverage in Florida. Here’s what he reports happened: When he pressed zero to ask for a hotline representative, he was informed the wait would be at least 20 minutes. Luckily, he says, it was only 10 minutes. But it wasn’t entirely smooth sailing from there. “I gave the representative my name and address and then was disconnected,” he says. He then called back and waited a full 20 minutes before reaching a hotline rep. This time she took his name, address and phone number, but she then told him if he wanted any information on the health plans, including premiums and benefits, he had to go to .  She apologized again and again for they delays and stressed he had until Dec. 15 to sign up for coverage to get enrolled this year and how open enrollment runs through March. When he asked the representative where she was, she refused to answer only saying “Southeast.”  She said she was not allowed to say where she was.

11:22 a.m.: In addition to being launch day for the health law’s online marketplaces, it’s also day one of the federal government shutdown – the first one in 17 years. President Barack Obama is with a group of people who will benefit from the health law. Afterwards, at approximately 12:25 p.m., he will speak in the Rose Garden.

11:12 a.m.: In Connecticut, it’s official. Someone got health coverage from Obamacare. By 10:50 a.m. today the state’s health exchange, , reported that they have completed their first enrollment: a family of three. They are believed to be the first state to announce this milestone. Here’s their tweet:

We just confirmed our first enrollment! A family of 3 just got access to affordable health care coverage thanks to

— Access Health CT (@AccessHealthCT)

But the Connecticut marketplace has its own growing pains. Here’s a message from its website:

WARNING: The information shown is not a legal contract. Access Health CT (AHCT) acknowledges that there are some inaccuracies on the shopping screens. For example, cost sharing for out of network benefits should apply only after the deductible is met; the skilled nursing benefit should show a 90 day visit limit; and the standard silver plan’s specialty drug tier should show a 40% co-insurance after the prescription deductible is met. The insurance carriers have provided the exchange with complete and accurate information about each plan. You can view this information by clicking on the “Detailed Plan Documents” (PDF) link, found above the Apply button for each plan. We strongly advise you to review this information before selecting a plan. The inaccuracies are created by the AHCT system. Until these inaccuracies on the plan summary and plan comparison screens are corrected, an AHCT representative will contact you to review and confirm benefits, rates and the health plan selected before your enrollment is finalized.

11:05 a.m.: Eric Whitney reports from Colorado that the state’s online site – — is open and allowing people to browse plans and prices. However, its subsidy determination is not working. Consumers receive the following message when they enter their information to check on eligibility for subsidies: “”Thank you for your patience while we work to fix a technical issue. Please contact us at 1-855-PLANS-4-YOU (1-855 752-6749) if you need assistance.”

10:47 a.m.:  KHN’s Jay Hancock and Ankita Rao report on the , but many consumers are being greeted by delays, hiccups and crashes.

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: For ‘Party Of Business,’ Allegiances Are Shifting Big business is so fearful of economic peril if Congress does not allow the government to keep borrowing — to pay creditors, contractors, program beneficiaries and many others — that it is nearly united in skepticism of, or outright opposition to, House Republicans’ demand that Mr. Obama first agree to equal spending cuts in benefit programs like Medicare and Medicaid (Calmes, 1/15).

: AARP’s Barry Rand: Mend, Don’t End Entitlements The head of the AARP on Tuesday acknowledged changes must be made to programs like Medicare and Social Security, but said cuts to those entitlements aren’t a solution to the nation’s fiscal woes (Glueck, 1/15).

For more headlines …

: New Website Part Of Push For Uninsured To Get Coverage The federal government Wednesday kicks off an effort to raise awareness about the most controversial part of the health care law — the requirement that the uninsured buy health care insurance. Wednesday morning, the Department of Health and Human Services plans to relaunch its website to try to draw in the millions of uninsured people needed to make the health care law work when open enrollment in state and federal health care exchanges begins in October (Kennedy, 1/16).

: US Appeals Judge’s Ruling Allowing Religious Publisher To Reject Contraceptive Coverage The Obama administration is appealing a judge’s order that is temporarily preventing the government from forcing a Christian publishing company to provide its employees with certain contraceptives under the new health care law (1/15).

: Biomedical Science At Stake With Sequestration From his perch at the National Institutes of Health’s sprawling campus in Bethesda, Md., Director Francis Collins is eyeing the impending sequestration cuts warily. If lawmakers don’t find a way to blunt the across-the-board cuts, the government’s premier medical research center will lose 6.4 percent of its budget — a cut Collins calls a “profound and devastating blow” for medical research at a time of unprecedented scientific discovery (Cunningham, 1/16).

: Pension Funding Gap Widens For Big Cities Major U.S. cities emerged from the financial crisis with increasingly underfunded pension and retiree health-care plans, according to a study released Tuesday. Cities employing nearly half of U.S. municipal workers saw their pension and retiree health-care funding levels fall from 79% in fiscal year 2007 to 74% in fiscal year 2009, using the latest available data, according to the Pew Center on the States (Ackerman, 1/15).

: Obama To Announce Most Expansive Gun-Control Agenda In Generations In addition to background checks and restrictions on military-style guns and ammunition magazines, Obama is expected to propose mental health and school safety initiatives such as more federal funding for police officers in schools, according to lawmakers and interest group leaders whom White House officials briefed on the plans (Rucker, 1/15).

: New York State Adopts Toughest Gun Laws In U.S. The Secure Ammunition and Firearms Enforcement Act, or SAFE Act, gives New York the toughest gun laws in the nation and touches on the mental health issues that both pro-gun and anti-gun activists say should be part of any new legislation. Among its key provisions is one requiring the revocation or suspension of gun licenses held by people who are deemed a danger to society by mental health workers. The bill would require mental health workers to report such patients to authorities (Susman, 1/15).

: Experts Say Proposed NY Gun Law Could Hinder Mental Health Treatment Of Dangerous People Mental health experts say a new tougher New York state gun control law might interfere with treatment of potentially dangerous people and even discourage them from seeking help (1/15).

: Law’s Mental-Health Provision Draws Ire The measure requires physicians, psychologists, nurses or clinical social workers to alert local health officials if a patient “is likely to engage in conduct that would result in serious harm to self or others.” After an evaluation, the health officials would pass on the person’s information to law-enforcement agencies that would be authorized to seize any firearm owned by the patient. If a person is found not to own any firearms, the patient would be added to a statewide criminal background check database, marking a significant expansion of who would be made ineligible to legally buy a firearm (El-Ghobashy, 1/15).

: Warning Signs Of Violent Acts Often Unclear That hard fact drives the public longing for a mental health system that produces clear warning signals and can somehow stop the violence. And it is now fueling a surge in legislative activity, in Washington and New York. But these proposed changes and others like them may backfire and only reveal how broken the system is, experts said (Carey and Hartocollis, 1/15).

: NYPD To Try GPS In ‘Bait Bottles’ To Track Drug Thieves New York police plan to distribute “bait bottles” of fake pain-killers equipped with invisible GPS devices in a drive to combat the scourge of pharmacy robberies by addicts and sellers looking for oxycodone tablets, which can fetch more than $80 per pill on the street. New York Police Commissioner Raymond Kelly announced the novel approach at the 2013 Clinton Health Matters Conference in La Quinta on Tuesday, saying his city’s cases of oxycodone-related crime have included a retired police officer who resorted to robbing pharmacies to satisfy his craving for the highly addictive narcotic (Susman, 1/15).

: Delays In Medicaid Pay Vex Hospitals Hospitals in Maine, concerned that further deficit-reduction agreements in Washington could erode funding for Medicaid, are demanding hundreds of millions of dollars in back payments from the state for treatment of patients in the program. States across the nation have long been slow to reimburse hospitals for treating needy Americans in the Medicaid program, but hospitals usually haven’t quibbled, knowing they would be paid eventually. But now, a coalition of 39 Maine hospitals is demanding $484 million in Medicaid payments owed for bills dating to 2009 (Levitz and Radnofsky, 1/15).

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: Obama Escalates Debt Fight Mr. Obama said he was willing to work with the GOP on an agreement to cut spending—including “modest adjustments to programs like Medicare”—but not in the context of the debt ceiling. He said agreeing to link the two would be like a “negotiation with a gun at the head of the American people” in which Republicans would threaten to cut safety-net programs under a threat “to wreck the entire economy.” House Speaker John Boehner (R., Ohio) has acknowledged that delaying an increase in the debt limit could cause economic harm, but he said not reining in government spending also carried consequences (Lee and Hook, 1/14).

: Americans Like Spending Cuts In Theory, Not In Detail, Complicating Deficit Talks In Capital Meanwhile, the clock is ticking toward the March 1 start of major, across-the-board spending cuts that both parties call unwise. These are the postponed cuts — or “sequester,” in Congress-speak — lingering from the partial resolution of the “fiscal cliff” on Jan. 1. These cuts would hit military and domestic programs hard. But they would spare “entitlements,” the popular but costly programs that include Medicare and Social Security. Leaders in both parties say lawmakers soon must confront entitlements if they are to stem the nation’s long-term deficit-spending problem (1/15).

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: States Will Be Given Extra Time To Set Up Exchanges The White House says it will give states more time to comply with the new health care law after finding that many states lag in setting up markets where millions of Americans are expected to buy subsidized private health insurance (Pear, 1/14).

: Arizona: Governor Relents On Medicaid Gov. Jan Brewer says she will expand the state’s Medicaid program to cover citizens who earn up to 138 percent of the poverty line. Ms. Brewer, a Republican, said Monday in her annual State of the State speech that she has fought against the federal health care law known as the Affordable Care Act. But she cited President Obama’s re-election and last summer’s Supreme Court ruling in saying that the law is here to stay (1/14).

: Ariz. Governor Opts To Expand Medicaid The Republican governor’s decision, long awaited by lawmakers and health-care professionals and opposed by many in the GOP, would bring the state an additional $7.9 billion in federal funds over four years to restore and expand the state’s health-care insurance program to an estimated 300,000 low-income residents, according to the Arizona Hospital and Healthcare Association (Sanders and Sanchez/1/14).

: Focus On Obamacare Delays Mental Health Law Mental health advocates say a landmark 2008 law meant to expand access to millions of Americans has gotten back-burner treatment by the Obama administration because of its relentless focus on the Affordable Care Act. As a result, key details are missing from the Mental Health Parity and Addiction Equity Act, awaiting a final rule from the administration that supporters say is “imminent” (Cheney, 1/15).

: Researchers Mine Data From Clinic, Big Insurer The new effort, dubbed Optum Labs, will be part of UnitedHealth’s Optum health-services arm. UnitedHealth Group Chief Executive Stephen J. Hemsley said the company viewed it as a “dedicated research unit…not a profit-driven undertaking,” and the goal was to create “a neutral place to conduct research” with partners from around the health industry, with the findings to be made public. He compared it to the historic Bell Labs, where a number of important technology discoveries were made over decades (Mathews, 1/15).

: Ilyse Hogue Announced As New NARAL President NARAL Pro-Choice America announced Monday that its new president will be Ilyse Hogue, a longtime advocate for liberal causes who the organization hopes will help pass the torch to a younger generation of abortion-rights leaders (Smith, 1/14).

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: Public-Private Fund Aims At Health Care, Housing Gap Hoping to bridge the gap between low-income residents and health-care services, a $100 million fund will be unveiled this week to build community centers near affordable housing as demand for primary-care services is expected to rise. Supporters say it is a new kind of public-private partnership boosted by the philanthropic sector that was inspired by the 2010 Affordable Care Act, which could expand Medicaid coverage by up to 16 million additional people. The act includes about $10 billion for the creation of new, federally qualified health centers. The fund’s backers say the financial need is greater still (Dolan, 1/13).

: Health Care Firms Attract Interest From Financial Backers Two Washington area firms working to engage patients in their health care decisions and treatment have secured financial backing from investors looking to find companies that will play a leading role in the future of medicine (Overly, 1/13).

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: Many Mentally Ill Missing From Gun Background Check System Swept along by the tide of outrage and sorrow after the 2007 Virginia Tech massacre, Congress passed a law to try to prevent future tragedies by keeping guns out of the hands of the mentally ill. The measure, signed by President George W. Bush, promised to strengthen the 14-year-old National Instant Criminal Background Check System by establishing incentives and penalties to prod states to submit records of people legally barred under federal law from buying guns — including those who had been committed to mental institutions. But today, that promise remains unfulfilled. More than half the states haven’t provided mental health records to the federal database that gun dealers use to check on buyers. And the gap in dealing with the mentally ill is just one of myriad problems that have hampered background checks (Tanfani, 1/12).

: Colleagues Say Sen. Rockefeller Will Be Missed On Healthcare Issues With the retirement of Sen. Jay Rockefeller (D-W. Va.), the left — not to mention the Senate — is losing one of its biggest voices on healthcare. Rockefeller announced Friday that he won’t run for reelection in 2014, when his current term ends. Colleagues and allies praised his long record of pushing for universal healthcare coverage, as well as his aggressive defense of Medicaid (Baker, 1/11).

: Roe At 40: ‘It’s Never Been This Frightening Before.’ It’s been almost 40 years since the Supreme Court legalized abortion on Jan. 22, 1973, galvanizing people on both sides. Abortion clinics sprang up across the country. The National Right to Life Committee was founded. Opponents and proponents girded for an epic conflict. But today, the battle is a slog of legislative fights and piecemeal regulations. Here, in a city where the battle over abortion was frequently and sometimes violently joined, combatants on both sides agree: They are dead-tired of the struggle over this clinic’s existence (Kliff, 1/13).

: 21 States Take Aim At Mass. Hospitals’ Medicare Windfall Nestled on an island 30 miles out to sea, Nantucket Cottage Hospital is the only rural hospital in Massachusetts, as defined by the federal government. Its weathered cedar shingles and widow’s walk evoke the bygone era of its founding a century ago, when the hospital consisted of just three tiny cottages. But the 19-bed hospital on the tony island, where the number of residents balloons from 10,000 to 50,000 each summer and the median home price hovers north of $1 million, has become a national symbol of inequity and political machinations in the way the federal government reimburses hospitals for treating Medicare patients (Jan, 1/13).

: Md. Audit Says Commission Inadequately Investigated Impact Of Overbilling At Hospitals A Maryland commission did not adequately investigate the impact of hospital overbilling identified through annual reviews, a state audit released Friday found, noting overcharges of at least $13.2 million at four hospitals (1/11).

: California’s Debt Still A Heavy Cloud Over State’s Future Gov. Jerry Brown proclaimed last week that California, which now has enough cash to pay its day-to-day bills, can no longer be described by naysayers as a “failed state.” But even though it appears to be free of the deficit that dogged the Capitol in recent years, the state is no model of financial health. … Sacramento is legally obligated to pay many billions of dollars withheld from schools, local governments and healthcare providers as lawmakers struggled repeatedly to balance the books. … And it has accumulated a crushing load of debt for retiree pensions and healthcare, now totaling more than taxpayers spend each year on all state programs combined (Halper and Megerian, 1/13).

: Department Of Behavioral Health Will Combine Mental Health, Substance Abuse Functions A new Department of Behavioral Health will become one of the District government’s largest agencies after Mayor Vincent C. Gray (D) announced Friday that he was combining the city’s mental health and substance abuse functions for the first time. The new department, to begin operations Oct. 1, will combine the Department of Mental Health, with its $190 million budget and 1,200 employees, with the Department of Health’s Addiction Prevention and Recovery Administration, which has a $32 million budget and about 90 employees. Those agencies currently manage services for about 35,000 District residents (DeBonis, 1/11).

: Oregon, California Tell Insurance Companies To Stop Denying Transgender Health Care Regulators in Oregon and California have quietly directed some health insurance companies to stop denying coverage for transgender patients because of their gender identity. The states aren’t requiring coverage of specific medical treatments (1/11).

: 2013 Flu Epidemic? Too Soon To Tell, Experts Say This flu season struck hard about a month earlier than usual. But despite all those news reports about overcrowded emergency rooms, it’s too soon to say whether it will be worse than normal. In fact, federal health officials said last week it may already have peaked (Norman, 1/14).

: Hospitals Crack Down On Workers Refusing Flu Shots Patients can refuse a flu shot. Should doctors and nurses have that right, too? That is the thorny question surfacing as U.S. hospitals increasingly crack down on employees who won’t get flu shots, with some workers losing their jobs over their refusal (1/12).

: Cuomo Declares Public Health Emergency Over Flu Outbreak With the nation in the grip of a severe influenza outbreak that has seen deaths reach epidemic levels, New York State declared a public health emergency on Saturday, making access to vaccines more easily available. There have been nearly 20,000 cases of flu reported across the state so far this season, officials said. Last season, 4,400 positive laboratory tests were reported (Santora, 1/12).

: Pharmacies Pressed To Meet High Demand For Flu Vaccine Pharmacies around the city struggled to meet the demand for flu vaccinations on Sunday, a day after Gov. Andrew M. Cuomo declared a public health state of emergency in response to a drastic increase in the number of flu cases this year (Secret, 1/13).

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: Insurers’ 2014 Hikes Already Taking Toll If you work for a small business, your next health insurance premium may give you sticker shock. Many of the small-business and individual insurance policies are working the health reform law’s 2014 fees into their 2013 bills, contributing to double-digit premium increases for some people (Haberkorn, 1/11).

: Big Health Insurers Aim Cautiously – For New Exchanges Some of the biggest health insurers confirmed goals this week to offer plans over state-based exchanges set to launch late this year, but they’re moving cautiously while waiting to learn more about these new markets (Kamp, 1/10).

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: Feds, Ohio Clash Over High-Risk Pool Eligibility The Obama administration and Ohio’s insurance regulator are locked in a fight over whether to dump people from the health insurance pool for some of the state’s sickest residents — and they’re not taking the sides you’d expect. In fact, it’s the overseers of Obamacare who want to cut off health insurance for 14 people — and it’s the state of Ohio that wants to keep them covered (Millman, 1/11).

: In 2nd Look, Few Savings From Digital Health Records The conversion to electronic health records has failed so far to produce the hoped-for savings in health care costs and has had mixed results, at best, in improving efficiency and patient care, according to a new analysis by the influential RAND Corporation (Abelson and Creswell, 1/10).

: Children’s Flu Medicine In Short Supply As influenza cases surge around the country, health officials say they are trying to stem a shortage of treatments for children (O’Connor, 1/10).

: Hobby Lobby Attorney Says Okla. Firm Can Delay Birth-Control Requirement Of Health Care Law An attorney for Oklahoma City-based Hobby Lobby says the company has found a way to delay providing insurance coverage for emergency contraceptives as required under the federal health care law. Peter Dobelbower said in a statement Thursday that the company will shift the plan year for employee health insurance that will delay by several months the Jan. 1 effective date of the requirement (1/10).

: Ken Cuccinelli: ‘Go To Jail’ To Fight Contraception Mandate A devout Catholic, Cuccinelli told Deace that opponents of the mandate should put the controversial measure on trial by making the government enforce it in as heavy-handed a way as possible (Burns, 1/10).

: On Iowa Radio, Cuccinelli Says Jail May Be A Fitting Protest To Feds’ Contraception Mandate Virginia Attorney General Ken Cuccinelli said on a syndicated radio program that going to jail may be an effective way to protest a federal mandate that employers cover contraceptives in insurance plans. On Iowa conservative radio host Steve Deace’s Wednesday night show, the Republican gubernatorial candidate and tea party favorite said civil disobedience is one way to attack the Affordable Care Act requirement now being challenged in a federal lawsuit by the Hobby Lobby stores (1/10).

: New York City To Restrict Prescription Painkillers In Public Hospitals’ Emergency Rooms Some of the most common and most powerful prescription painkillers on the market will be restricted sharply in the emergency rooms at New York City’s 11 public hospitals, Mayor Michael R. Bloomberg said Thursday in an effort to crack down on what he called a citywide and national epidemic of prescription drug abuse (Hartocollis, 1/10).

: Gov. Jerry Brown Commits To Major Medi-Cal Expansion Brown earmarked $350 million in his spending plan to help enroll more Californians in Medi-Cal, the state’s health insurance program for the poor. Under the proposal, enrollment rules would be simplified to cover residents who are currently eligible but not enrolled. Those costs would be split evenly between state and federal governments. The governor’s plan also calls for a separate, larger expansion of Medi-Cal that would cover a group of low-income Californians not currently eligible for the program: adults without children, earning up to 138% of the federal poverty level — or $15,415 a year. The federal government would subsidize costs for the first three years, with the state shouldering a portion of the bill after that (Mishak, 1/10).

: Brown’s Budget Proposal Has Good News For Some California would significantly expand public health insurance under Brown’s proposed budget as part of a plan to implement President Obama’s healthcare overhaul…. Brown earmarked $350 million to help enroll more Californians in Medi-Cal, the state’s health insurance program for the poor. The cost would be split between the state and federal governments (1/10).

: Restored Funding For Prescription Drug-Program Monitoring Program Urged California Atty. Gen. Kamala D. Harris on Thursday called on Gov. Jerry Brown to restore funding to a prescription drug-monitoring program that health experts say is key to combating drug abuse and overdose deaths in the state (Girion and Glover, 1/11).

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: Obama Aide Is Treasury Pick In 2011, as political leaders were designing the spending reductions that would begin this year if a larger deficit-reduction deal wasn’t reached, some Republicans wanted to cut Medicaid, the health-care program for the poor. Mr. Lew bluntly interrupted to say Medicaid was off the table, prompting a GOP aide to hang up the phone, according to a person familiar with the exchange. Several months earlier, during a debate over government funding, the usually-even-tempered Mr. Lew stormed out over a dispute with Republicans about what numbers both sides should use as their “base line” for negotiations (Paletta and Hook, 1/10).

: Obama Selects White House Chief Of Staff Jack Lew To Head Treasury Ideologically, Lew is a deficit hawk, and he thinks Obama should be pursuing an aggressive effort to slow the growth of the federal debt. But he has deep roots in Democratic politics, and in previous negotiations he has passionately resisted efforts to slice the social safety net, particularly Medicaid, the health insurance program for the poor (Goldfarb, Tankersley and Cillizza, 1/9).

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: Obama’s Pick For Treasury Is Said To Be His Chief Of Staff If Mr. Lew is confirmed in time, his first test as Treasury secretary could come as soon as next month, when the administration and Congressional Republicans are expected to face off over increasing the nation’s debt ceiling, which is the legal limit on the amount that the government can borrow. Mr. Obama has said he will not negotiate over raising that limit, which was often lifted routinely in the past, but Republican leaders have said they will refuse to support an increase unless he agrees to an equal amount of spending cuts, particularly to entitlement programs like Medicare and Social Security (Calmes, 1/9).

: Nancy Pelosi’s Claim That The GOP Would Raid Medicare For Tax Cuts We are reluctant to re-litigate the rhetoric of the 2012 presidential campaign, but this comment by Rep. Nancy Pelosi about the House GOP budget jumped out at us. We had frequently written during the campaign about the misleading claim by Mitt Romney that President Obama had gutted more than $700 billion from Medicare to fund Obamacare. And yet here was Pelosi claiming Republicans had used the “same money” to fund a tax cut, compared to Democrats, who she said had used the $700 billion to “increase benefits to seniors.” To alter a common expression, what’s good for the gander is good for the goose. Is Pelosi playing the same kind of rhetorical games? (Kessler, 1/10).

: Leading HHS: Saying Focused On The Goal Requires Teamwork, Innovation And Inspiration As deputy secretary of the Department of Health and Human Services (HHS), Bill Corr is responsible for the operations of the government’s largest civilian department. He most recently served as executive director of the Campaign for Tobacco-Free Kids and previously served for 12 years as counsel to the U.S. House of Representatives’ Subcommittee on Health and the Environment. Corr spoke with Tom Fox, who is a guest writer of the Washington Post’s Federal Coach blog and vice president for leadership and innovation at the Partnership for Public Service. Fox also heads up the Partnership’s Center for Government Leadership (Fox, 1/9).

: States Struggle With How To Sell Their Exchanges From Pandora radio to those paper coffee cup sleeves to the neighborhood laundromat, states are searching for creative ways to advertise their new health insurance exchanges to people who may not know much about how to get covered next year under the health care law — and who may not like what they’ve heard (Cunningham, 1/10).

: Appeals Court Rejects Challenge To Abortion Clinic ‘Buffer Zone’ A federal appeals court upheld a Massachusetts law that creates a buffer zone around abortion clinics, rejecting an interesting First Amendment challenge that took inspiration from the Supreme Court’s 2010 campaign-finance ruling in Citizens United v. Federal Election Commission. Wednesday’s ruling marked the second time in recent years the Boston-based U.S. Court of Appeals for the First Circuit backed the 2007 law, which makes it a crime to linger within a 35-foot radius around the entrances, exits and driveways of abortion clinics (Palazzolo, 1/9).

: Flu Widespread, Leading A Range Of Winter’s Ills The country is in the grip of three emerging flu or flulike epidemics: an early start to the annual flu season with an unusually aggressive virus, a surge in a new type of norovirus, and the worst whooping cough outbreak in 60 years. And these are all developing amid the normal winter highs for the many viruses that cause symptoms on the “colds and flu” spectrum (McNeil and Seelye, 1/9).

: 700 Cases Of Flu Prompt Boston To Declare Emergency Boston health officials have confirmed 700 cases of flu — 10 times the number for the entire flu season last year. … The Boston declaration is meant to drive home the message about the danger of flu and the necessity of getting vaccinated, said Nick Martin, communications director at the city Public Health Commission. … The hospitals in Boston have been overwhelmed, said Jim Heffernan, chief of primary care at Boston’s Beth Israel Deaconess Medical Center. His hospital is full, he said, the emergency room “overflowing because there aren’t enough places to put people. It just snowballs” (Weise and Eversley, 1/10).

: U.S. Ranks Below 16 Other Rich Countries In Health Report It’s no news that the U.S. has lower life expectancy and higher infant mortality than most high-income countries. But a magisterial new report says Americans are actually less healthy across their entire life spans than citizens of 16 other wealthy nations (Knox, 1/9).

: Americans Die Younger Than Peers The study by the federally sponsored National Research Council and Institute of Medicine found the U.S. near the bottom of 17 affluent countries for life expectancy, with high rates of obesity and diabetes, heart disease, chronic lung disease and arthritis, as well as infant mortality, injuries, homicides, teen pregnancy, drug deaths and sexually transmitted diseases (Radnofsky, 1/9).

: Through New Budget, Brown Maps Out Sweeping Change In California Brown’s proposed budget will outline his plans for expanding health coverage under the new federal healthcare law, which is set to require increased coverage beginning in January 2014. The law will put hundreds of thousands of new enrollees into California’s public insurance program, but the governor has raised concerns about what that will cost. In addition, Brown has said the state may reduce the roughly $2 billion it gives to counties to care for the uninsured, amid objections from advocates and county officials (York and Megerian, 1/9).

: NJ Gov. Christie Says He’s Willing To Discuss Tougher Gun Laws Along With Mental Health Issues New Jersey Gov. Chris Christie said Wednesday that he’s willing to have a conversation about stricter gun laws, but says policymakers also must address the mental health system, improve access to drug treatment and look at the impact of violent video games (1/9).

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