Seattle Seahawks Stars Russell Wilson and Richard Sherman encourage Americans to visit HealthCare.gov and shop for coverage through the Health Insurance Marketplace

Dr. Michael Fratkin is getting a ride to work today from a friend.

“It’s an old plane. Her name’s ‘Thumper,’” says pilot Mark Harris, as he revs the engine of the tiny 1957 Cessna 182.

Fratkin is an internist and specialist in palliative medicine. He’s the guy who comes in when the cancer doctors first deliver a serious diagnosis.

He manages medications to control symptoms like pain, nausea and breathlessness. And he helps people manage their fears about dying, and make choices about what treatments they’re willing — and not willing — to undergo.

In rural Humboldt County, in the far northern reaches of California, Fratkin is essentially the only doctor in a 120-mile stretch who does what he does.

“There’s very little sophisticated understanding of the kinds of skills that really matter for people at the very end,” he says.

It takes 30 minutes to fly from Eureka, Calif., to the Hoopa Valley Indian Reservation. On this trip, Fratkin is going to visit a man named Paul James, who is dying of liver cancer.

“A good number of patients in my practice are cared for in communities that have no access to hospice services,” Fratkin says.

The plane touches down on a narrow landing strip. A loose horse runs next to the plane as we taxi down the runway.

Fratkin is here to make a rare house call. He met Paul and his wife, Cessie Abbott, at the hospital in Eureka. But the two-hour drive is too far for them to make often, so Fratkin comes to them.

It’s a visit that Cessie, in particular, has been waiting for. She and her husband know he’s dying. But it’s hard for them to talk to each other about it.

“Dr. Fratkin has kind of been my angel,” she says. Fratkin gets her husband to open up, she says, and reveal things he might not otherwise, because Paul’s “trying to be strong for us, I think.”

Cessie tells Fratkin that the pain in Paul’s belly has been getting worse.

“He’s moaning in his sleep now,” she says.

“Have you ever taken morphine tablets?” Fratkin asks Paul. Cessie explains that those tablets didn’t work for her husband. “Have you ever taken methadone?” Fratkin asks him. “We’re going to add a medicine that is long-acting.”

Fratkin believes there should be a spiritual component of these discussions, too.

“Yeah, Paul, there’s more to you than this body of yours, isn’t there?” he says, a refrain he repeats with almost all his patients.

“Oh yeah,” Paul says, and then goes quiet for a bit. He’s Yurok, and talks about how happy he is when he’s in the mountains, hunting with his grandsons.

Cessie says she can hear Paul praying when he’s alone in the bathroom. So Fratkin asks him to light some Indian root and say a prayer now.

“Great spirit, that created this earth …,” Paul begins, his eyes clenched shut.

By the time Fratkin leaves the Hoopa Valley, he’s spent half a day with one patient. This is something the hospital in Eureka just couldn’t afford to have him do.

Fratkin says he was under constant pressure to see patient after patient to meet the hospital’s billing quotas.

“It’s very hard for one doctor to manage the complexity of each individual patient and to crank it out in any way that generates productive revenue,” he says.

Fratkin decided he couldn’t, within the hospital system, easily provide the kind of palliative care he sees as his calling. So he decided to quit — and launch a startup.

“I had to sort out an out-of-the-box solution,” he says.

He calls his new company ResolutionCare. There’s no office, no clinic. Instead he wants to put the money for those resources into hiring a team of people who can travel and make house calls, so that very ill patients don’t have to get to the doctor’s office. When time is stretched, he plans to use video conferencing.

The key challenge is financing his big idea. Government programs like Medicare and Medicaid don’t pay for video sessions when the patient is at home. And they pay poorly for home visits.

So far, Fratkin has been cultivating private donors and is looking for foundation grants. He’s arranged an independent contract to sell his services back to the hospital he recently left. And he’s launched a crowdfunding campaign to back the training he’d like to do for other doctors of palliative medicine who practice in rural areas.

Down the line, Fratkin is even thinking of asking some of his more well-off patients to pay out-of-pocket for his services.

When he gets back to Eureka, after the visit with Paul James, Fratkin hops in his blue Prius and drives 30 minutes north to see Mary Maloney. She’s dying of esophageal cancer. She tried radiation and chemo for a while, but both made her feel awful. Fratkin was the one who told her it was OK to stop treatment.

“I mean, I love life,” Maloney says from the recliner in her home in Blue Lake. “I don’t want to let it go. But I don’t know if I’m willing enough to put myself through all the things I’d have to put myself through.”

Fratkin says he’s treated more than a thousand patients and, like other entrepreneurs with big ideas, thinks his startup could change the world. He knows he’s up against tough odds though — most startups don’t succeed.

Not long after Fratkin’s visit to the Hoopa Valley, Paul James passed away. We thank the family for sharing their story. This story is part of a reporting partnership that includes KQED, 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.

Lawyers for the state of Texas were in federal appeals court in New Orleans Wednesday arguing in favor of a controversial state law that requires abortion clinics to meet the standards of outpatient surgery centers.

If that provision is re-instated, ten of Texas’s remaining 17 abortion clinics would close immediately. Other provisions of the law – including one that said doctors who perform abortions need admitting privileges at nearby hospitals – have shuttered about half of Texas’ 40 abortion clinics over the past two years.

The law, known as HB2, was famously opposed by Democratic state Senator Wendy Davis, whose pink-sneakered filibuster propelled her into the national limelight and on to an ultimately unsuccessful bid for the governor’s mansion.

In a packed courtroom Wednesday, a three-judge panel of the Fifth Circuit Court of Appeals sharply questioned both sides for about 90 minutes.

Some arguments centered on women in El Paso, where only one clinic is still open. If the law closes that clinic, women would have to drive more than 700 miles to San Antonio for an abortion.

Jonathan Mitchell, the Texas solicitor general, argued that women don’t face an “undue burden” on their right to abortion just because they may have to drive farther than before.

“The undue burden has to require something more than driving distance,” he said. “People will have to travel to get abortions in Texas, but that’s always the case. People will always have to travel to get an abortion.

Judge Edward Prado pressed the point, asking: “Can you see any distance that would be an undue burden?”

Mitchell said he couldn’t give a number, because the U.S. Supreme Court itself hadn’t given much guidance to the exact definition of “undue burden.”

But Stephanie Toti, the attorney representing the clinics, later said the Texas law clearly imposed an undue burden on women in West Texas and the Rio Grande Valley: “If a woman in El Paso has to travel 500 miles to get an abortion, that’s an undue burden.”

Judge Catharina Haynes jumped in, noting that the El Paso scenario was hypothetical, because women there would simply cross the border to a closer clinic in New Mexico. “We know that nobody is going to drive 500 miles. They’re going to go to New Mexico. You’re asking us to ignore that,” she told Toti.

Later Haynes asked the lawyer for Texas, Mitchell, to deal with the same issue. “She [Toti] makes a good point on why is Texas fobbing off these women on another state, if these [safety] restrictions are so necessary?” She asked Mitchell if the clinics in New Mexico offered those women “substandard care” since they weren’t subject to the same rules as Texas clinics.

“We wouldn’t say it’s sub-standard care,” Mitchell said. “We would say it’s care that is less than optimal.”

Abortion rights advocates and opponents from Texas traveled to New Orleans for the hearing and to make their cases on the courthouse steps.

Amy Hagstrom Miller is the founder and CEO of Whole Woman’s Health, an organization that operated six clinics around the state. Two have already closed because of the law; if the 5th Circuit rules against her case, three more will close.

“I’m actually quite encouraged by the line of questioning,” Hagstrom Miller said after the hearing. “I feel the judges really understand the undue burden as applied to women in El Paso, and they seem genuinely concerned about those women’s access to safe abortion as protected by the constitution.”

Hagstrom Miller outlined for a reporter why regulations for ambulatory surgical centers need to be more stringent than those for clinics where abortions are performed: “Ambulatory surgical centers are specifically crafted for moderately complex day surgery, where there’s incisions, anesthesia, more than one physician in the facility.” The vast majority of abortion services are simpler than that, she said: “Patients are not asleep; they can walk to the recovery room. So the hallway widths related to patients being transported on stretchers, the operating room size related to having anesthesia and multiple physicians are completely irrelevant for the safety of abortion care.”

Emily Horne, an activist with Texas Right to Life, said that the law ensures women’s safety.

“The reason we’re opposed to abortion is it ends a life. And so we don’t want the woman that’s undergoing the abortion to be subject to that as well,” Horne said. “We don’t think that her life should be at risk, either. It’s consistent with our morals to protect the lives of women undergoing it as well as those lives lost by it.”

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

Statements by Secretary Lew and Secretary Burwell on preparing for the upcoming tax season

The Gold ‘N Silver Inn in Reno, Nev., has long offered health coverage to its employees — but many of the cooks, dishwashers and waiters who make close to minimum wage can’t afford the $100 monthly premium.

Last January, when Nevada became one of more than two dozen states to expand Medicaid under the Affordable Care Act, 10 of the diner’s 55 employees qualified for the government insurance program for low-income Americans.  None of them realized it, however, until the family-run restaurant hired BeneStream, a New York-based start-up funded partly by the Ford Foundation.

BeneStream uses software to quickly determine which employees are eligible for Medicaid, then helps those workers sign up for the state-federal health program that covers 70 million people.

The goal is to help employers and workers make the most of two key provisions of the health law — the Medicaid expansion that’s making millions of working adults eligible for Medicaid and the requirement that medium and large-sized employers provide coverage in 2015 or face a penalty.

“Most employers do not understand Medicaid and the eligibility requirements,” said BeneStream CEO Benjamin Geyerhahn. “We are a way to help employers manage this cost and resolve a big issue for their low-income workers.”

By enrolling in Medicaid, low-wage workers benefit from low- or no-cost health coverage since the program typically has no monthly premiums and few out-of-pocket costs. Employers benefit because they don’t have to pay a share of workers’ insurance premiums or risk incurring penalties.

BeneStream charges $40 to screen each employee for Medicaid and then $20 a month for each individual it helps get into the program.

While the idea of enrolling privately employed workers in government programs is not without controversy, it is legal, say experts.

“You are just helping people to get something they are entitled to,” said Timothy Jost, a law professor at Washington and Lee University and expert on the Affordable Care Act.

From a societal standpoint, however, it does raise questions about the fairness of having some employers provide health coverage to their employees, while others let the government pay for it.

“Is it a good thing if some employers insure their employees and some find ways to get the government to insure their employees?” Jost asked. “That’s a harder question.”

Wal-Mart, the nation’s largest private employer, and several national fast food chains have faced criticism over the large numbers of their workers who turn to taxpayer-funded health care programs such as Medicaid and the Children’s Health Insurance Program. Some contend taxpayers are subsidizing the cost-cutting measures of private employers.

But Neil Trautwein, a vice president with the National Retail Federation, said that if workers and their families qualify for Medicaid and other government health programs, there is nothing wrong with having them sign up.

Employers must consider different strategies to meet the coverage mandate, he said.

“As companies are pressed by rising health coverage costs, and some will be taking it on for the first time, they will have to look at everything within their reach,” he said.

BeneStream officials say that in 2014, the company has helped over 1,500 workers at 82 firms enroll in Medicaid. It expects to sign up several times that many in 2015 as it expands from restaurants to home health and nursing homes.

This year, employers will have an even greater incentive to get workers covered when the Affordable Care Act requires those with more than 100 full-time workers to provide affordable coverage or pay a penalty of about $2,000 per worker, excluding the first 30 full-time workers. In 2016, employers with more than 50 workers will have to comply.  If workers are on Medicaid, the company is no longer on the hook for the penalty.

In November, the for-profit firm received a $1.5 million low-interest loan from the Ford Foundation to expand the company’s reach into the 27 states that have expanded Medicaid under the health law. The foundation has for years supported efforts to help eligible people receive public benefits.

“This is a great opportunity for low-income workers to receive the health security they deserve,” said Helen Neuborne, director of quality employment at the Ford Foundation.

Traditionally, most employers have done little to promote Medicaid to their workers—most likely because few would have qualified before the health law expansion.

A survey of 750 employers last year by consulting firm Mercer found just 4 percent of employers planned to provide information to employees about Medicaid.

“It’s not a big idea that most employers are thinking about,” said Tracy Watts, a senior partner in Mercer’s Washington, D.C., office.

Tammy Campbell, who handles human resources for Gold ‘N Silver restaurant, said BeneStream has saved the company money by getting 10 of its workers onto Medicaid who would otherwise have joined the company health plan or gone without coverage.

She said the process was easy. BeneStream’s representatives met with employees and had them fill out a questionnaire about household income and family size.

And the company benefitted in another way: “It’s nice to have employees show up healthy,” she said.

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 on the move in Western states, with the governors of Utah, Wyoming and Montana all working to hammer out deals with the Obama administration to expand Medicaid in ways tailored to each state.

But getting the federal stamp of approval is just the first hurdle — the governors also have to sell it to their legislatures who have their own ideas of how expansion should go.

The latest case-in-point is Montana, where the governor and the legislature have competing proposals about how much federal Medicaid expansion cash the state should try to pull down.

Montana’s GOP-dominated legislature, which meets every other year, rejected Democratic Governor Steve Bullock’s attempts in 2013 to expand Medicaid and set up a state-based insurance exchange. This year Bullock has a different Medicaid expansion proposal aiming to reduce the Treasure State’s 17 percent uninsured rate. It would use federal dollars to contract with a third party administrator to process claims and run a provider network. So far Republican leaders are not embracing it any more than they did his 2013 plan.

Nine Republican state lawmakers last week released an alternative proposal, the “Healthy Montana Family Plan.”  It rejects the approach by Bullock and the White House that Medicaid should be offered to anyone making less than 138 percent of the federal poverty level (FPL), or $16,105 a year. That would be about 70,000 people in this sparsely populated state with just over 1 million residents.

Instead, the plan would extend Medicaid only to certain categories of people who make less than 100 percent of the federal poverty line, or $11,670. The idea is to “keep it targeted toward what it’s intended to do,” said plan co-author Sen. Fred Thomas, “take care of our most vulnerable citizens … disabled persons, low income seniors, low income parents, children.”

“Able-bodied people should be able to go out and get a job,” incoming Republican House Speaker Austin Knudsen told the Billings Gazette.

Thomas, an insurance agent by trade, says that extending Medicaid to non-disabled adults who don’t have children is “a disincentive to work.”

How should an uninsured adult without kids who makes less than $11,670 get coverage? Thomas says the focus should be on boosting that person’s  income: “Anyone that’s in that predicament, we’re gonna encourage them to get another job, get the extra hours, and qualify for the exchange, by bumping their income up a little bit.”

He points out that, under the Affordable Care Act, low income people who make at least 100 percent of FPL qualify for premium subsides through healthcare.gov, which makes health coverage “pretty economical,” or nearly free.

The plan he co-authored says: “Policymakers could employ income tax credits in certain circumstances to boost incomes of those without Medicaid access above 100 percent FPL in order to take advantage of sliding-scale exchange subsidies.”

That reliance on subsidies could hit a snag if the Supreme Court decides in June that it is illegal for those tax subsidies to flow to states that are using healthcare.gov rather than setting up their own exchanges.

The Montana Republican health plan also echoes policies advocated by former Obama administration Medicaid and Medicare leader Don Berwick. It calls for new contracts with providers that require them to take on some risk and responsibility for the health of the population. The contracts would reward hospitals and doctors based on “metrics that focus on health outcomes, patient satisfaction and cost containment,” what Berwick calls the “triple aim.” The health law enacted many of those rewards and penalties for hospitals that treat Medicare patients.

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.