Montana appears poised to become the 29th state, plus the District of Columbia, to expand Medicaid under the Affordable Care Act.

A Republican-sponsored bill to do so survived a crucial vote Thursday and is now expected to move quickly to the Democratic governor’s desk for his signature.

Hard-line conservatives made multiple attempts to amend or kill the bill when it hit the Republican-controlled House floor Thursday, but a coalition of 13 Republicans and all 41 Democrats agreed to end debate swiftly and vote. The bill picked up two more Republican supporters in the House than it had on Wednesday.

The bill previously passed the state Senate with seven Republican votes. It faces one more vote Friday, but opponents now appear outnumbered. Gov. Steve Bullock is expected to sign it.

If that happens, Montana’s Medicaid expansion plan will still need approval from the federal Department of Health and Human Services. Its provisions requiring recipients to pay premiums and participate in “workforce development” programs will require federal waivers.

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Despite its rocky launch, the federal health insurance exchange did better than the exchanges run by individual states at both enrolling new people in Obamacare and hanging onto previous enrollees during the 2015 open enrollment period that ended in February, according to a recent analysis.

Enrollment for 2015 on the federal exchange increased by 61 percent over 2014, to 8.8 million. On the state-based exchanges, enrollment increased 12 percent, to 2.8 million, according to the analysis by the consulting firm Avalere Health.  In addition, the federal exchange re-enrolled 78 percent of its enrollees from the previous year, while the state-based exchanges re-enrolled 69 percent.

Several factors may have contributed to the disparities in enrollment and retention, says Elizabeth Carpenter, a director in the health reform practice at Avalere, which conducted the analysis based on federal enrollment data released in March for the federal and state-based exchanges.

The many website and other glitches that bedeviled the 2014 launch of healthcare.gov, the federal portal for Obamacare coverage in about three dozen states, may have contributed to its stronger enrollment showing this year, Carpenter says.

“Some folks have pointed to the technological problems with healthcare.gov, saying that there may have been people who didn’t get through the enrollment process last year” because they couldn’t get the website to work, Carpenter says. In 2015, instead of error messages and frozen screens, healthcare.gov functioned smoothly for the most part, even during periods of heavy use.

It may also be that the federal exchange covers more states that have a larger proportion of lower income people, Carpenter says. More than 85 percent of people who bought health insurance on the state and federal marketplaces were eligible for premium tax credits that were available to people with incomes up to 400 percent of the federal poverty level ($46,680 for an individual).

As for retention differences, it’s possible that more people over-reported their income on state-based exchanges for 2014 coverage and were subsequently shifted to the Medicaid program this year. Twenty-eight states have expanded Medicaid to adults with incomes up to 138 percent of the federal poverty level (about $16,100). In those states, if someone applies for a marketplace plan, the exchange will move them into Medicaid if their income falls below that threshold.

Such shifting could make it appear that some states had lost enrollees when instead they just moved to Medicaid. Avalere didn’t incorporate Medicaid eligibility shifts into its analysis.

But it’s not clear why state-based exchanges would experience such shifts to a greater degree than states where the exchange is run by the federal government.

The takeaway? “The numbers underscore that significant growth year over year is not necessarily a given,” Carpenter says. “The question for all exchanges is how to continue to grow over time and attract healthier enrollees.”

Please contact Kaiser Health News to send comments or ideas for future topics for the Insuring Your Health column.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

As consumers increasingly are being asked to pay a larger share of their health bills, a coalition of insurers, pharmaceutical companies, and provider and consumer advocacy groups launched Thursday a new push for greater transparency regarding the actual costs of services.

The group includes AARP, Novo Nordisk, the National Consumers League, the Ambulatory Surgery Center Association, the National Council for Behavioral Health and Aetna.

Health care transparency, long a buzz word, means all consumers — whether they are covered by Medicare, work-based insurance or without coverage at all — have access to information enabling them to estimate accurately the cost of health services, and compare physician quality rankings and outcomes.

The initiative, “Clear Choices,”  will add to private and government efforts already underway to get more such information to patients, including Medicare’s Physician Compare, and the Health Care Cost Institute’s ‘Guroo,’ which culls data from private insurers to provide average prices regionally.

The group’s first priority is advancing the Medicare doctor payment legislation pending in the Senate because it includes a provision requiring Medicare to release for broader use a substantial amount of data on claims at the provider level.

“We have data, but it’s a random sample across entire nation. So you can’t use it to do what Clear Choices and other organizations want to do — to analyze the cost and quality of individual providers within the Medicare program,” said Francois de Brantes, executive director of the Health Care Incentives Improvement Institute, a nonprofit group that studies and promotes payment reform. It is not affiliated with the initiative.

Another priority is to push states and the federal government to enforce the part of the health care law that requires exchange plans to give consumers very specific information about provider networks and covered drugs.

“Insurance company rates are negotiated, so each patient would be subject to a different rate,” said Caroline Steinberg, vice president of trends analysis at the American Hospital Association, which is not involved in the campaign. That negotiated rate means a consumer will likely pay less money for an in-network doctor or hospital. But they need a way to find out that information.

Some states already have moved in this direction.

For example, Connect for Health Colorado, Colorado’s state exchange, provides a tool for shoppers to compare insurers based on what drugs are covered, and what providers are in network.

The coalition’s most lofty goal is to change the health system so that patients can know upfront the cost of a medical procedure. This is a complicated proposition because so many components – among them facility-use fees, physician charges, deductibles and co-payments – are factored into the bill a patient eventually receives.

Wanda Filer, a physician based in York, Penn., says even health care providers are often confused by pricing.

“Physicians don’t even know where to refer people and they don’t know what to tell them,” said Filer, who is on the board of directors of  the American Academy of Family Physicians, which is part of the coalition.

Representatives of Clear Choices have framed the campaign as being simple – if a consumer can get a sticker price for a television, so should they for health care. But others say this is much harder than it might appear.

“It’s like asking what the price [will be] for the repair of a leaky roof before the roofer has figured out the cause of the leak,” said Mark Pauly, professor of health care management at the University of Pennsylvania. “It’s harder for the insurer to tell you what you will end up paying until you have precise information on what services you will be using—which patients (and, for that matter, doctors) do not always know in advance.”

The group’s other objectives include:

– Improving quality measures for doctors and hospitals so that patients will be armed with more comparative information.

– Requiring hospitals to be clearer regarding what may or may not be included in their cost estimates for care.

– Creating better tools for consumers to make medical decisions based on price, quality and safety of medical services.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

Medicine has changed a lot in the past 100 years. But medical training has not.

Until now.  Spurred on by the need to train a different type of doctor, medical schools around the country are tearing up the textbooks and starting from scratch.

Most medical schools still operate under a model pioneered in the early 1900s by an educator named Abraham Flexner.

“Flexner did a lot of great things,” said Raj Mangrulkar, associate dean for medical student education at the University of Michigan Medical School. “But we’ve learned a lot and now we’re absolutely ready for a new model.”

And Michigan is one of many schools in the midst of a major overhaul of its curriculum.

For example, in a windowless classroom, a small group of second year students are hard at work. They’re not studying anatomy or biochemistry or any of the traditional sciences. They’re polishing their communications skills.

In the first exercise, students paired off and negotiated the price of a used BMW. Now they’re trying to settle on who should get credit for an imaginary medical journal article.

“I was thinking, kind of given our background and approach, that I would be senior author. How does that sound to you?” asks Jesse Burk-Rafel.

It may seem like an odd way for medical students to be spending their class time. But Erin McKean, the surgeon teaching the class, says it’s a serious topic for students who’ll have to communicate life and death matters during their careers.

“I was not taught this in medical school myself,” says McKean. But she says today communication is more important than ever. “We haven’t taught people how to be specific about working in teams, how to communicate with peers and colleagues and how to communicate to the general public about what’s going on in health care and medicine,” she says.

It’s just one of many such changes. And it’s dramatically different from the traditional way medicine has been taught. Flexner’s model is known as “two plus two.” Students spend their first two years in the classroom memorizing facts and their last two shadowing other doctors in hospitals and clinics. Mangrulkar says when the curriculum was instituted it was a huge change from the way doctors were taught in the 19th century.

“Literacy was optional, and you didn’t always learn in the clinical setting,” he says. Shortly after Flexner published his landmark review of the state of medical education, dozens of the nation’s medical schools closed or merged.

But today, says Mangrulkar, the two-plus-two model doesn’t work. For one thing, there’s too much medical science for anyone to learn in two years – and most information can be quickly accessed from a smartphone or tablet. At the same time, medicine is constantly in flux. What Michigan and many other schools are trying to do instead is prepare doctors for the inevitable changes they’ll see over their practice lives.

“We shouldn’t even try to predict what that system’s going to be like,” he says. “Which means we need to give students the tools to be adaptable, to be resilient, to problem solve, push through some things, accept some things, but change other things.”

One big change at many schools is a new focus on learning not just how to treat patients, but about how the entire health system works.

Susan Skochelak is a vice president with the American Medical Association, in charge of an AMA effort that is funding changes to medical school programs at 11 schools around the country. She says the new focus has had an added benefit: Faculty members are learning right along with the students about some of the absurdities in the system as it is today.

Only because they have to guide students through the system do they discover, for instance, that some hospitals schedule patients for tests like MRIs around the clock. “And one of my patients had to come and get their MRI at 3 am. How do they do that? They have kids! ” she says faculty members have told her.

Sometimes it’s not doctors who are the best teachers about how the system works.

Doctors tend to focus on patient care, since that’s what they know, she says, but when it is time to learn about the system as a whole, it can be more fruitful to hook students up with the clinic managers.

Another major change is making sure the next generation of doctors is ready to work as part of a team, rather than as unquestioned leaders.

In another classroom at the University of California-San Francisco, several groups of students are practicing teamwork by working together to solve a genetics problem.

Joe Derisi, who heads the biochemistry and biophysics department at UCSF, is more guiding than teaching, as he gently suggests a student’s tactic is veering off course: “I would argue that it may not be as useful as you think, but I’m obliging.”

Onur Yenigun, one of the students in the class, says that working with his peers is good preparation .

“When I’m in small group I realize that I can’t know everything. I won’t know everything,” he says. “And to be able to rely on my classmates to fill in the blanks is really important.”

The medical schools that are part of the AMA project are already sharing what they’ve learned with each other. Now plans are in the works to begin to share some of the more successful changes with other medical schools around the country.

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

A California bill that would allow parents to opt out of mandatory school vaccinations for their children only if they have a medical condition that justifies an exemption was endorsed by a state Senate committee but still has a long, controversial path before becoming law. The bill was introduced in the California Senate in response to a measles outbreak at Disneyland in late December that’s now linked to almost 150 infections.

With several hundred protesters outside the Capitol building in Sacramento Wednesday, the bill sparked a debate about individual rights and responsibilities.

Vaccine opponents, who have been relatively quiet during the measles outbreak, turned out in force. They wore American flags, and one child held a sign that said, “Force my veggies, not vaccines.” The opponents say eliminating California’s current exemption that allows parents to refuse vaccinations for their children based on personal beliefs will threaten their ability to do what’s right for their kids.

“I think that everybody should be able to make their own choice,” said Lisa Cadrain of Los Angeles, who fears vaccines would harm her daughter. “I am afraid that her big beautiful blue eyes will not focus on me anymore, and she won’t be the kid that she is.”

Some opponents fear that the vaccinations are linked to an increase in the number of cases of autism in the country, but scientific studies show no link between vaccines and autism spectrum disorder.

Inside the hearing, parents who support the bill also talked about protecting their kids — from children who aren’t vaccinated. Democratic state Sen. Lois Wolk is on the Senate Health Committee and said she’s a strong proponent of vaccinations.

“Our individual rights aren’t without limits, and in this particular case, your insistence on your right really could harm my children or my grandchildren,” Wolk said.

Parents also testified in support of the bill, including Ariel Loop, whose baby son Mobius contracted measles in the Disneyland outbreak. Now 7 months old, he was too young to be inoculated when he was exposed to the virus.

“I understand being skeptical and wanting to research and do what’s best for your child,” Loop said. “I had actually looked into the alternate [vaccination] schedules myself. But there’s no science in support of it, and I’ve got to go with science. I don’t know better than all of these doctors.”

Children typically receive their first measles, mumps and rubella vaccine between 12 and 15 months of age. When enough of a given population is inoculated “herd immunity” protects babies less than a year old and other people who can’t be vaccinated from being exposed to the diseases.

The Senate health committee passed the bill 6 to 2 on Wednesday. That was just the first step – the legislation has many more hearings before it could become law. Meanwhile, Washington, Oregon and North Carolina have also considered legislation to limit families’ rights to opt out of mandatory vaccinations, and all of those efforts have stalled. West Virginia and Mississippi are the only states that allow no exemptions to their vaccine laws for personal beliefs or religion.

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

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.