In the midst of the uncertainty about the Affordable Care Act, Minnesota has taken three unusual actions.

This article first appeared February 7, 2017 on Kaiser Health News.

By Mark Zdechlik, Minnesota Public Radio

What's going to happen to the federal health law? The quick answer is no one knows. But in the midst of the uncertainty about the Affordable Care Act, states still must govern their insurance markets. Most have been muddling through with the 2017 status quo, but Minnesota is a special case, taking three unusual actions that are worth a closer look.

Last month, Minnesota:

• Passed a one-time bailout for some consumers in the individual insurance market dealing with skyrocketing premiums.
• Rejected an attempt to let insurers offer cheaper, bare-bones coverage.
• Laid the groundwork for a sort of homegrown "public option" insurance plan.

Here's more on each item.

The Bailout
Faced with some of the country's highest hikes on premiums in the individual market — 50 to 67 percent, on average — Minnesota lawmakers passed a bailout for people who earn too much to qualify for the Affordable Care Act's federal tax credit. The $300 million law will cut monthly 2017 premiums by 25 percent for about 125,000 Minnesotans.

Democratic Gov. Mark Dayton backed the measure since October when he called the ACA "no longer affordable to increasing numbers of people." But passage wasn't assured as both houses of Minnesota's legislature are controlled by Republicans.

It is thought to be the second time a state has offered up state tax dollars to stabilize an insurance marketplace created by the ACA. (Alaska came up with a $55 million bailout for insurers in 2016.)

Bare-Bones Coverage
A failed amendment to the Minnesota legislation sought to strip dozens of so-called "essential benefits" from health plans with the expectation that slimmed-down coverage would cost less.

Republican State Rep. Steve Drazkowski, who offered the amendment, said he was trying to eliminate the current, "government-controlled, one-size-fits-all, dictating set of mandates.

"What we're doing is trying to create an environment that, if and when the ACA goes away, that Minnesotans will have the freedoms they need in order to start to bring some free-market competition, some free-market ingenuity and innovation into the health insurance market," he said.

The laundry list of benefits that consumers could choose to have covered or not under Drazkowski's amendment included maternity care, diabetes treatment and mental health care among many others. Some items on the list are very specific: Lyme disease, prostate cancer screenings, outpatient surgery.

Dayton and other Democrats opposed the amendment and it dropped out of the final legislation.

Still, it caught the eye of Minnesota native Andy Slavitt, who is the former administrator of the Centers for Medicare & Medicaid Services, which oversee the health law marketplaces. Slavitt, who tweeted about the amendment, said it is a cautionary tale about high-deductible catastrophic plans that cover little or no basic care.

Americans are scared & don't want to go back to pre-existing conditions or "health plans" that look like the new one proposed in MN. 18 pic.twitter.com/z75hyQLnC7

— Andy Slavitt (@ASlavitt) January 28, 2017

There's no replacement plan for ACA in Congress.

But good news is there is one put forward in a state to look at. https://t.co/bG9D3IWlZd

— Andy Slavitt (@ASlavitt) January 29, 2017

"Telling people, 'Only buy what you need,' implies that people know that they're not going to need the emergency room or that there's not going to be an addiction problem in their family," Slavitt said in an interview. "I don't think we, as a country, want people to not have access to the services they need."

He did not dispute the notion that the individual market needs help, but he says offering extremely limited plans is ill-conceived, "gotcha" insurance.

"This is the most blatant one I've seen," Slavitt said of the failed amendment.

But other amendments did get passed, including a provision that changes longstanding laws requiring HMOs, insurance plans that will cover only services provided by their network of doctors and other health providers, to be not-for-profit. The new law allows out-of-state, for-profit HMOs to sell health plans in Minnesota.

Dayton said these measures were not well thought out. "I think it is unnecessary and unwise to rush the 'reforms' added to this bill, without proper public review or full consideration of their consequences," he said.

A State-Based Public Option?
Minnesota is one of just two states offering a so-called basic health plan that can cover lower and moderate income residents. MinnesotaCare provides subsidized health coverage to about 100,000 state residents, capping eligibility for a family of four at $49,000 in earnings per year. Dayton wants to open the plan to all Minnesotans, with higher income residents paying full price for their coverage.

"This public option could offer better benefits than any policies presently on commercial markets, more options for people to keep their doctors and clinics and less expensive than what is available today," said Dayton during an announcement of his annual budget plan last week.

Dayton said allowing people with higher incomes to buy MinnesotaCare coverage, paying full-freight, would reduce prices and increase competition on the individual market.

Supporters of the "public option" say it could provide better coverage for less cost because the government can leverage its massive buying power to negotiate optimal deals from insurance companies.

Opponents said expanding government's role in health care is a bad idea. As he campaigned for the presidency, Donald Trump said he opposed a national "public option" because it would drive away private insurers, "leaving Americans with fewer options and eventually no choices but a government-run plan."

The one-time bailout is just the beginning of what are expected to be broader health insurance reform efforts in Minnesota. Among them is a renewed call for state-sponsored single payer insurance that is not likely to be well-received in the state's Republican legislature.

This story is part of a partnership that includes Minnesota Public Radio, NPR and Kaiser Health News.

Rigorous cleaning practices don't ensure that medical scopes are free of contamination, and many of these reusable devices have scratches and dents that could harbor blood, tissue and bacteria, a new study found.

This article first appeared January 31, 2017 on Kaiser Health News.

By Chad Terhune

The seven-month study, published Tuesday in the American Journal of Infection Control, found that 12 of 20 gastroscopes and colonoscopes examined tested positive for bacterial growth, even after being disinfected using the current guidelines or additional measures.

In addition, 17 of the scopes were pulled from use at the end of the study and returned to the manufacturer for repair due to serious defects. Photos in the study show numerous scratches and dents on the ends of the scopes that could trap organic material as well as brown stains, debris and residual fluid stuck inside scope channels.

The scopes were relatively new at the beginning of the study and all were manufactured by Tokyo-based Olympus Corp., the leading maker of gastrointestinal scopes used in the United States and worldwide.

"Physicians, other caregivers, hospitals and regulators should be paying keen attention to this issue, as patients have a right to assume that clean instruments are being used on them," said Cori Ofstead, the study's lead author and an epidemiologist in St. Paul, Minn.

Since 2015, federal prosecutors, lawmakers and government regulators have been investigating a series of outbreaks of antibiotic-resistant "superbugs" across the country tied to scopes. Most of the scrutiny has been focused on a specific device known as a duodenoscope, which is used to inspect and treat problems in the gastrointestinal tract. It has been tied to at least 35 deaths in the past four years.

But this study and other outbreak reports suggest a broader problem affecting other types of scopes, which could put more patients at risk of dangerous infections nationwide. However, the bacteria this latest study found weren't the drug-resistant superbugs that can be deadly for patients.

The research was limited to a small number of scopes at one surgery center affiliated with the University of Minnesota Health System. But outside experts said the research was rigorous and raised serious concerns.

"It was quite shocking to see the pictures in this study," said Michelle Alfa, a professor in the department of medical microbiology at the University of Manitoba and an adviser to U.S. regulators on scope testing.

"Those scopes shouldn't be in use. I'm amazed the gastroenterologist could even see anything because the lens was covered in so much crud. The insides look pretty gruesome, too," Alfa said.

Alfa said the staining and discoloration inside the scopes indicated a buildup of biofilm, a slimy material that shields bacteria and other microbes from being removed during cleaning. "It's like your roast pan that gradually gets brown crud baked on it and you can't pick it off," she said.

The U.S. Food and Drug Administration, which regulates medical devices, said it's aware of the study's findings and urges hospitals to immediately remove from service any scopes that show signs of damage.

"The FDA continues to actively monitor challenges associated with reprocessing reusable medical devices and to look for ways to reduce the risk of infection with reprocessed endoscopes," said agency spokeswoman Deborah Kotz.

Since the recent outbreaks and subsequent government warnings, many hospitals have adopted a variety of new safety measures to combat scope-related infections.

But Ofstead said subjecting scopes to additional rounds of manual cleaning, automated washing and a different disinfectant didn't have much impact. "The findings suggest that cleaning wasn't working, perhaps because cleaning doesn't work when endoscopes are damaged," said Ofstead, chief executive of the medical research firm Ofstead & Associates.

This study focused on widely used colonoscopes and gastroscopes, which have somewhat simpler designs than duodenoscopes and are believed to be easier to disinfect. The study didn't track patients and there was no evidence of infection among people treated at the study site.

At the surgery center, researchers split the 20 scopes into two groups. One group got regular cleaning and high level disinfection with glutaraldehyde. The other group received additional cleaning and tests to verify that the scopes were clean before disinfection with peracetic acid.

The colonoscopes, which peer at the inner lining of the large intestine, presented fewer problems than gastroscopes, designed to examine the upper gastrointestinal tract. When the clinic's technicians performed tests to detect contamination, they found the first manual cleaning worked 99 percent of the time for colonoscopes. (Subsequent testing showed further contamination.)

For gastroscopes, only 48 percent were deemed clean after the first try. And 11 percent never reached the benchmark for clean even after two rounds of manual scrubbing and two rounds of automated cleaning and high-level disinfection.

The researchers said gastroscopes may be incurring more damage and becoming more resistant to cleaning due to exposure to stomach acid and bile in the upper gastrointestinal tract. They said more research is needed to determine the reasons and to identify more effective cleaning methods.

Olympus, the device manufacturer, issued repair reports on 14 of the scopes and it said 13 of them had at least one critical defect, according to researchers.

In a statement, the company said it "welcomes additional research and perspectives as helpful to the entire medical community and our own efforts to increase patient safety related to endoscopes."

In October 2015, the FDA ordered Olympus and two other scope manufacturers, Pentax and Fujifilm, to study the effectiveness of their cleaning protocols for duodenoscopes at clinical sites in the field.

Ofstead said medical providers are still waiting for that critical information while problems in the field persist. "They haven't yet published any real-world results showing their protocols work even though the FDA told them to do these studies," Ofstead said.

Those studies appear to be in the early stages, according to data on the FDA website. Olympus said it's planning for its duodenoscopes to be tested for bacterial growth after reprocessing at four different sites.

Linda Greene, a registered nurse and president of the Association for Professionals in Infection Control and Epidemiology, agreed manufacturers need to address the safety issues posed by scope defects.

"The concerns about damage in frequently used scopes begs questions about design issues," said Greene, the manager of the infection prevention program at the University of Rochester's Highland Hospital in New York.

This story was produced by Kaiser Health News, which publishes California Healthline, an editorially independent service of the California Health Care Foundation.

"These short-term plans are not regulated like Obamacare plans, so carriers have a lot of flexibility in benefits and pricing," said the executive director of Agile Health Insurance. "It's almost like the old individual market before the ACA."

This article first appeared January 31, 2017 on Kaiser Health News.

By Michelle Andrews

Short-term health plans have been around for decades, bridging coverage gaps for people who are between jobs or have recently graduated from school, among other things. After the health law passed, some people gravitated toward them because they were willing to trade comprehensive coverage for a cheaper sticker price — even if it meant paying a tax penalty for not having the comprehensive coverage required in the law. Sales increased.

Now, as Republicans look for ways to weaken the health law's coverage requirements and explore the possibility of not enforcing the requirement that people have health insurance, short-term plans may be poised to grow even more. If that happens, consumer advocates warn it could be bad for consumers.

As their name suggests, short-term plans provide coverage for a limited period of time, often six months or less. They generally don't cover such things as preexisting conditions, maternity services or prescription drugs. The policies typically have maximum coverage limits of about $1 million. Insurers can turn people down if they're sick and may decide not to renew someone's policy. All of these practices are prohibited in plans that qualify as individual insurance under the Affordable Care Act.

Precisely because of these limitations, however, the premiums are typically a lot cheaper than those for ACA-compliant coverage. In the fourth quarter of 2016, the average monthly premium a shopper would pay for a short-term plan sold through online insurance vendor ehealth.com was $124, compared with $393 for someone who bought a regular Obamacare plan and didn't qualify for premium subsidies.

When the health law passed, insurers increasingly began offering short-term plans that stretched the definition of "short," sometimes providing coverage for as long as 364 days.

"Carriers were exploiting a loophole in the law that defined a health insurance plan as one that was 365 days," said Sabrina Corlette, a research professor at Georgetown University's Center on Health Insurance Reforms. "If they were shorter they didn't have to comply with ACA protections."

Short-term plans serve a tiny but growing proportion of the roughly 22 million people who have coverage on the individual market. At the end of 2013, before the health law's major reforms took effect, there were approximately 108,800 people covered by these policies, which earned premiums of $97.5 million, according to figures from the National Association of Insurance Commissioners. Two years later, roughly 148,100 people had short-term plans and premium earnings have grown to $160.5 million.

Some insurers have taken notice. Online health insurance vendor Health Insurance Innovations launched Agile Health Insurance in the spring of 2015 to focus on sales of short-term plans. In the third quarter 2016, Agile sold 21,000 short-term policies.

"These short-term plans are not regulated like Obamacare plans, so carriers have a lot of flexibility in benefits and pricing," said Sam Gibbs, Agile's executive director. "It's almost like the old individual market before the ACA."

And that's just the problem, said some policy experts.

"To many consumers it looks like health insurance, except it's cheaper," said Karen Pollitz, a senior fellow at the Kaiser Family Foundation. But the plans don't protect people when unforeseen events occur such as a car accident or a cancer diagnosis. With a short-term plan, if you get sick or you're in the hospital when your plan comes up for renewal, "it won't be renewed," Pollitz said. (KHN is an editorially independent program of the foundation.)

Not all insurers embrace widespread sale of short-term plans. "The big health insurance companies are really mixed on this," said Timothy Jost, emeritus professor at Washington and Lee University School of Law and an expert on the health law. "They see this as a seriously destabilizing force in the market, this crap coverage."

Last October, the Obama administration issued a final rule that would make it more difficult for consumers to buy short-term plans to substitute for regular Obamacare plans. The regulation, which takes effect April 1, said short-term plans must be less than three months in duration. People can request a renewal of the policies, but insurers can turn them down. The policies and related materials also have to prominently display a warning that they don't satisfy the law's requirement that people have health insurance.

Some hope that the rule may be changed or rescinded by the Trump administration or overturned by the new Congress under the little-used Congressional Review Act. Neither option can happen at the stroke of a pen, however.

Health insurance brokers and agents are one group that would like to continue to sell longer term short-term plans.

"Our folks do a lot of business with short-term plans," said Marcy Buckner, vice president of government affairs at the National Association of Health Underwriters, an industry group. The regulation is one that the group will request that the Trump administration rescind.

"In most areas [a short-term plan] is cheaper, and it's some consumers' way of saying, 'I don't need all of those things,' " said Buckner.