The states that set up their own insurance marketplaces have nothing to lose in King V. Burwell, the big Supreme Court case that will be decided by the end of June. But that doesn’t mean those states are breathing easy.

With varying degrees of difficulty, all of the state-based exchanges are struggling to figure out how to become financially self-sufficient as the spigot of federal start-up money shuts off.

Here are dispatches from Minnesota, Colorado and Connecticut on this tricky transition.

Minnesota – Tough Politics

Even though Minnesota’s exchange –  MNsure – ran much more smoothly in its second year than its disastrous first, some Republicans opposed to Obamacare from the beginning hoped to do away with it this legislative session.“This has been an abject failure from day one to present. If you’re denying that, your head is in the sand,” said state Rep. Nick Zerwas.

His colleague, Rep. Nancy Franson, said: “We should have never gotten into the exchange. We should just move straight to the federal exchange and bypass the state of Minnesota.”

Even the Democratic architect of the law that created MNsure wanted to dissolve its board and make MNsure a state agency rather than an independent body.

In the end, lawmakers ended their session leaving MNsure intact. But they voted to ask the feds to allow Minnesotans to get tax subsidies for health insurance regardless of whether they shop on the open market or through MNsure.

The legislature also created a bipartisan task force to consider MNsure’s future. Republican Rep. Matt Dean says those relatively small measures make a big point.

“The final agreement I think that we have going to the governor right now acknowledges that there’s major trouble with MNsure, that the current situation is not sustainable,” Dean said.

Democratic Sen. Tony Lourey helped create MNsure. He likes the idea of letting Minnesotans shop outside of MNSure and still get subsidies, but, he said, “I’m not particularly optimistic that it would be approved by federal officials.  If it were approved, I think we would have to talk about then how do we structure the financing of the exchange.”

He says it would be even more difficult to fund the exchange with far fewer customers unless they could bring in new money.

One option is to add a tax to all health plans sold, not just those sold on MNsure.

Meanwhile, with fewer people signing up for plans through MNsure than anticipated, revenue is way down. That coupled with federal money drying up by year’s end has MNsure moving to cut $2.5 million from its budget over the next three years. –Mark Zdechlik, MPR

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Colorado – Glitches And Expenses

Colorado’s exchange has cleared its political hurdles for the most part, but technical glitches and financial challenges remain – as Marc Drillings knows all too well. He wanted to buy insurance on the Connect for Health, Colorado’s exchange.

But when he went online to enroll, the system mistakenly showed that his monthly premium would be $800 for him and his wife, much higher than it should have been. He tried to fix it, he said, and his application got stuck in limbo for two months.

“You enter bureaucratic hell, where no one can figure out what’s wrong, how to fix it, or who to even talk to get it done,” said Drillings.

He’s a chiropractor, so he’s used to dealing with insurance forms, but sorting it out took still took him at least 50 hours he said.

Eventually, he enrolled in a plan for about $300 a month.

As many as 10 percent of those who signed up faced such problems, says Kevin Patterson, the exchange’s interim CEO.

Fixing them chewed up staff time and cost millions, he said. “I think it’s fair to say we do have a slight hit to the brand,” Patterson said.

His predecessor, Gary Drews, pointed out the exchange’s successes. He said its enrollment numbers are strong, and the state’s uninsured rate fell from 17 percent to 11 percent. Still, Drews admitted, the takeoff has been bumpy even in the second year.

“It’s a little bit like trying to fly as you’re putting the wings on,” he said.

Although it had bipartisan support, Colorado’s exchange,  faced expensive  technical fixes, leadership turnover and questions from state auditors about its financial controls.

Add to that the big whammy:  $183 million in federal startup money is running out. So the exchange plans to tighten its belt and consumers will feel the pinch. Fees on premiums will go up next year.

“I don’t know if it’s sustainable,” said Republican state senator Ellen Roberts, who heads a legislative oversight committee.

She says another big issue for Colorado is Medicaid. The state had a smoother signup process for Medicaid than many other states, and the exchange footed much of the bill. Now the exchange is asking the feds to pick up some of those signup costs.

Roberts said it’s going to be hard for the exchange to make the transition to self-sufficiency.

“Either we’re going to try and make our best efforts to sort this out, or people will throw up their hands and walk away,” she said.

Despite the hassles he faced, chiropractor Marc Drillings said he won’t walk away. “If it works for 95% of the population, that’s still an A,” Drillings said.

– John Daley, Colorado Public Radio

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Connecticut – Success At A Price

Connecticut’s exchange did so well in the first year that it’s marketing its services to other states that are still struggling. And generally Access Health CT is having a smoother transition from start-up to established business.

“The first two years, we needed a much bigger call center to be able to answer questions and talk about how to navigate our website and things like that. We needed a much bigger technology team,” said CEO Jim Wadleigh.

The task ahead is to change and shrink the organization to match its new mission. Wadleigh said he is letting consultants’ contracts expire and he is leaving some senior positions unfilled.

“All of our teams have gotten smaller,” he said.

The exchange brings in upward of $26 million a year by charging insurers who sell individual and small group policies on or off of the exchange. That will be the biggest source of money going forward.

Selling its administrative services to other exchanges could bring in additional cash.

“We have had some conversations with probably about a half a dozen states at this point about what are some of those opportunities,” he said.

With more than $150 million in federal money gone and not coming back, Wadleigh has two goals. One is keeping consumer prices as low as they can be and the second is keeping customers satisfied. He is optimistic  the exchange can do it.

“I think we’re there,” he said.

But that confidence comes at a price: the exchange had to raise the assessment that insurers pay in order to fund smooth operations. — Jeff Cohen, WNPR

This story is part of a partnership that includes MPR, Colorado Public Radio, WNPR, 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.

MORENO VALLEY, Calif. — Jennifer Vargas’ path toward becoming a doctor took her from UCLA to Guadalajara before it ultimately led back home, to California’s vast Inland Empire east of Los Angeles.

When the Chino Hills, Calif. native graduated from medical school in Mexico, her first choice for residency training was Riverside County’s public medical center, which serves among the fastest growing and most medically deprived parts of California.

It was just what she wanted:  To serve a vulnerable patient population facing high barriers to care, particularly immigrant patients from Mexico who would benefit from a Spanish-speaking physician.

“It offered the best fit for me,” said Vargas, 32, a second-year resident in family medicine at Riverside County Regional Medical Center.

The Inland Empire – a region roughly the size of Maine, including both Riverside and San Bernardino counties — needs hundreds more like her. Officials have launched a muscular effort to educate physicians locally and entice doctors from the outside to settle in Southern California’s interior, miles from the famously alluring coast.

They’re trying to do more than fix a doctor shortage. They’re attempting to train and attract the right kind of physicians — mainly primary care providers who relate to disadvantaged patients and want to treat them in their communities, before they become critically or chronically ill.

Some see it as an experiment with lessons for other underserved regions of the country – a way to spread out and diversify the next generation of doctors.

“Today, our country is largely training the sons and daughters of wealthy people to be physicians,” said G. Richard Olds, dean of the University of California, Riverside, School of Medicine. “You wonder why we have a problem with people not serving in underserved communities; it’s because they don’t know what an underserved community looks like.”

He’s looking for students who grew up in the Inland Empire and want to stay. He also wants people who speak English as a second language, or who were the first in their families to attend college.

The Inland Empire has for decades been short of physicians as newcomers poured in. Its population swelled from 1.6 million in 1980 to 4.4 million today. In 2011, it had 43 primary care physicians per 100,000 population, a supply roughly half the level recommended by experts, according to a study published last year by the California Healthcare Foundation.

Now, with the expansion of health insurance and Medi-Cal through the Affordable Care Act, many more new patients have spilled into the system.

The flow of patients seeking primary care services at  the 12 family care clinics run by Riverside County rose 8 percent to 161,000 during the year ended last June 30, said Dr. Geoffrey Leung, the system’s chief of family medicine.

Volume has continued to rise since then and now is only limited by the system’s capacity.

“If we had more providers, we would have more patients,” Leung said.

A Bagful Of Drugs, A Long List of Ailments

On a recent Friday morning, Maria Avelino Ibarra arrived at Riverside County main campus in Moreno Valley after an hour-long bus ride.

Ibarra, a 50-year-old Corona resident with diabetes, had come to renew her insulin prescription and get treatment for pain in her right knee, which she injured in a fall last year.

But as Dr. Bakr Khalifa Al Omrani, a second-year medical resident, quizzed her about her recent medical history, she added more ailments to the list, including chronic headaches, stomach problems and high cholesterol.

As she spoke, Ibarra pulled out a square-foot size zip-lock bag with 15 medication bottles and set them on a small counter in the exam room.

“Okay, I will not be able to deal with all of the problems today,” Khalifa told her through a Spanish translator listening in by phone. “Is your knee the most urgent problem?”

It was. Khalifa tried to flex her knee, which bent only to about 90 degrees before causing sharp pain.

The appointment lasted 35 minutes, about twice as long as primary care visits usually do. It’s a common problem: Because patients have gone without care so long, doctors have to spend more time sorting out their problems. That, in turn, lengthens wait times for other patients seeking appointments.

Thinking Creatively

The shortage of doctors, and the pent-up demand for care, is a problem with deep roots.

Historically, the region has not cultivated young physicians. The Inland Empire is below the state average in producing high school graduates who go to college. And until the UC Riverside program was founded in 2013, the region had only one medical school, at Loma Linda University.

To top it off, Olds said, there aren’t enough slots to train medical residents in the region.

All of these obstacles narrow the pipeline of available doctors. “Where you come from is about 40 percent of the decision” of where to practice, the dean said. “And another 40 percent is where you completed residency.”

In addition, the Inland Empire has hardly been an attractive destination for doctors from the outside.

Reimbursement from public and private payers isn’t as high as in coastal areas, said Leigh Hutchins, CEO of North American Medical Management California Inc., an Ontario-based firm that develops and manages provider networks and helps physicians coordinate care and conduct business. .

Even existing doctor groups have trouble covering the start-up costs of bringing on a new doctor, whose practice may take three years to become self-sustaining.

“It’s a good $250,000 to $300,000 a year to support a new doctor, by the time you do salary and benefits and other payments,” Hutchins said.

The doctor shortage has hit hard at the Inland Empire Health Plan, the Medi-Cal managed care organization serving the two counties. Membership passed 1 million in February, up 60 percent from the 623,000 it had in December 2013, according to state figures.

“We’ve had to think creatively about how to get more doctors in our plan,” said Dr. Bradley Gilbert, the nonprofit’s CEO.

One way is to provide grants — to private physician groups, hospitals and even the county health systems to defray new doctors’ startup costs.

In September, the plan set aside $8 million from its reserves for that purpose, $5 million for primary care doctors and $3 million for specialists.

IEHP received applications for some 199 doctors for the grants, which will cover up to $100,000 of a primary physician’s annual costs and up to $150,000 of a specialist’s. As of last month, the health plan had approved grants for 123 physicians, 71 of them in primary care. Hiring has already begun.

To boost the long-term supply, UC Riverside is recruiting medical students through “mission-based scholarships.”  These cover the entire cost of medical school if students commit to practicing in a needed primary care discipline in the region for five years after residency.

“There’s a growing movement,” Leung said. “Young physicians are looking for work that feels meaningful and purposeful.”

‘I Need You A Lot’

Vargas knew from age 7 that she wanted to be a doctor.

One of four children of Mexican immigrant parents, she volunteered at a cancer hospital near her home when she was in high school and continued to volunteer at local hospitals while studying biology and Spanish literature at UCLA. Later, while in Mexico, she and fellow medical students made house calls in small cities and villages.

Today, her connection with her patients is obvious.

Maria Sanchez, 54, will see only Dr. Vargas.

“I understand English, but it’s better when I can express myself in Spanish,” Sanchez said. “It’s easier to understand the advice they give you.”

Sanchez, a permanent U.S. resident originally from Nayarit, Mexico, has diabetes, high blood pressure and high cholesterol. After 30 years of working in various factories packing oranges and avocados, the mother of three also suffers from lower back pain and sore feet.

But on this day she is seeing Vargas for chest pains, numbness in her right arm and an itchy bump on her cheek.

“I’m a junker,” she jokingly tells Vargas.

It can be a hassle to get an appointment, said Sanchez. “Sometimes I can be on hold for as long as 30 minutes, only to get disconnected and have to call again.”

On this day, the appointment takes 30 minutes. Vargas orders an electrocardiogram, prescribes ointment for her cheek and medication for her chest pain.

“Thanks for worrying about me,” Sanchez says in Spanish as she leaves.

“Always,” replies Vargas.

“Take care of yourself,” Sanchez adds. “I need you a lot.”

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

https://kaiserhealthnews.files.wordpress.com/2015/05/paramedics-capital-public-radio-gorman.wav>> Can’t see the audio player? Click here to download it.

Parademics pride themselves on getting patients to an emergency room quickly. But in some states, they are doing everything possible to keep people out of the ER. It’s a new approach for paramedics – one that health officials hope will lead to lower costs and better care.

Paramedic Ryan Ramsdell is part of an ambitious plan to overhaul Reno’s 911 system. The idea is to use specially trained paramedics to fill health care gaps and reduce unnecessary trips to the ER. Nevada is one of several states testing new models of emergency medicine. But long-term change won’t be easy.

Blue Shield of California Foundation helps fund KHN coverage in California.

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

The Affordable Care Act is once again before the Supreme Court.  This time it’s not about whether the government can force you to have health insurance or pay a penalty.  It can. That is so “2012.”

Now, in the case of King v. Burwell, the meaning of six words in a thousand-page law is under scrutiny. Those words could determine whether millions of Americans can afford to buy health insurance.

The law states that people who sign up for health coverage through “an exchange established by the state” qualify for government subsidies.

But what is an exchange established by the state, you ask.

The Obama administration says it’s every insurance marketplace set up by a government. That includes the federal government’s healthcare.gov. It’s used by the residents of about three dozen states.

But the lawsuit argues it’s only the 16 states and the District of Columbia that set up their own marketplaces.

If the challengers win, more than 6 million Americans would lose the subsidies that have helped them afford health insurance.  So, if you bought your policy through healthcare.gov – the federal exchange – you would no longer receive that help.

What does this mean for the health insurance system? Healthier people would likely drop coverage if they lose financial help, which means insurers would raise premiums because they would be covering fewer, but sicker people. That would impact everyone who buys their own insurance in those states.

Of course, Congress could step in to clarify the confusing words. But many think that’s unlikely.  Or some states might decide to create their own state-based insurance marketplaces. But that couldn’t happen overnight.

The justices are expected to deliver their decision in late June, just as the 2016 presidential campaign is kicking into high gear. So keep your eyes and ears open because this decision could affect you.

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