WASHINGTON – Department of Health and Human Services (HHS) Secretary Sylvia M. Burwell and Attorney General Loretta E. Lynch announced today a nationwide sweep led by the Medicare Fraud Strike Force in 17 districts, resulting in charges against 243 individuals, including 46 doctors, nurses and other licensed medical professionals, for their alleged participation in Medicare fraud schemes involving approximately $712 million in false billings.

The U.S. Supreme Court is poised to issue a decision this month in a case that could again threaten a key aspect of President Barack Obama’s health law.

But this time around, unlike three years ago when the court rejected a constitutional challenge to the law’s individual mandate, the case, King v. Burwell, focuses primarily on statutory interpretation.

The issue is whether section 36B means what it seems to say if read literally and in isolation from the rest of the law: that Affordable Care Act subsidies are available only to people “enrolled … through an exchange established by the state.”

And the different interpretations have proven dicey — so much so that each side in the case is having trouble explaining away the evidence supporting the contrary position.

Solicitor General Donald Verrilli and other defenders of the subsidies have failed to suggest any very plausible reason — other than sloppy draftsmanship, on which Verrilli has not much relied — why Congress said “established by the state” if it intended that subsidies also be available in the federally established exchange.

On the other hand, ACA opponents who read “established by the state” literally have produced little evidence that the law’s drafters deliberately and quietly planted in an obscure subclause the words that could become the seeds of the law’s destruction.

Plaintiffs in the case suggest that the drafters inserted these four words in order to pressure states to establish their own exchanges. But the legislative history offers scant evidence of this intent. And the three dozen states in question either failed to notice or disregarded it.

How these explanations sway the justices — or at least five of them — will determine whether the language drafted by Congress means that nearly 6.4 million low-and-middle-income people are not eligible for the overhaul’s tax subsidies because they live in a state that chose to rely on the federal government’s healthcare.gov, rather than establish its own online insurance marketplace. The subsidies make insurance affordable to many of the people who seek Obamacare coverage because they don’t get health coverage through their employers.

If the court rules that the subsidies are available only in states — mostly blue — that established their own exchanges, insurance markets in the other three dozen or so states might collapse. Unless Congress or the states reliant on healthcare.gov were to move fast to limit the damage, few people in those states would buy individual insurance. Those who did would likely have health problems and premiums would soar.

Many ACA opponents say that section 36B “means what it says,” as conservative Justice Antonin Scalia implied at the March 4 oral argument, even if the wording “may not be the statute [Congress] intended” and even assuming that it might “produce disastrous consequences.”

To the contrary, say Verrilli and other supporters, the law’s overall text, structure, design and history make clear that Congress intended to make subsidies available in all 50 states. They say the challengers’ interpretation would defeat the law’s purpose of making health insurance widely affordable. The Internal Revenue Service came to the same conclusion in an interpretive rule, to which Verrilli argued the justices should defer if in doubt.

As in 2012, the stakes in King v. Burwell are so high that Obama has made it clear that he would attack any decision that would cripple the health law as legally indefensible and politically motivated.

“[T]his should be an easy case,” Obama said June 8. “Frankly, it probably shouldn’t even have been taken up … based on a twisted interpretation of four words. … I’m optimistic that the Supreme Court will play it straight.” The next day, he added (without specific reference to the court) that “it seems so cynical to want to take health care away from millions of people.”

These shots across the court’s bow came even though Scalia and Justice Samuel Alito had strongly suggested during the argument that they would vote against the administration’s position.

Alito also suggested the possibility of delaying until 2016 the effective date of any decision against the administration. Such a delay, he said, would give the states and Congress time to avoid the disruption that would be caused if the court ruled the premium subsidies now available in the three-dozen states using healthcare.gov are illegal.

Justice Clarence Thomas, who was silent as usual during the arguments, is expected to vote with Scalia and Alito. The four liberal justices — Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayor and Elena Kagan — seemed poised to line up with Obama. So the president will win if either Chief Justice John Roberts or Justice Anthony Kennedy sides with him.

While Kennedy’s vote is still up in the air, ACA supporters were cheered by his assertion to the lawyer challenging the subsidies that “there’s a serious constitutional problem if we adopt your argument.” Kennedy reasoned that the states are being unconstitutionally “coerced” if, as the challengers argue, the law requires them either to establish their own exchanges or see their residents disqualified from the subsidies.

The only way to avoid constitutional problems, suggested Kennedy, may be to resolve any ambiguities in Obama’s favor. This seemed inconsistent with the suggestions by Scalia, Alito and the challengers that the relevant language is free of ambiguity and without constitutional problems.

Roberts was sphinxlike during the argument in King v. Burwell. The case puts him in an unenviable position.

When Roberts stunned court-watchers by joining the four liberal justices and upholding the individual mandate in the 2012 decision, National Federation of Independent Business v. Sebelius, he was bitterly assailed by his usual allies — Kennedy, Scalia, Thomas and Alito — and was called a traitor by many other conservatives.

This barrage was intensified by a well-sourced news report that Roberts had initially voted to strike down the individual mandate and changed his mind — provoking a huge battle inside the court — after liberals led by Obama had preemptively denounced any decision to strike down the law as politically motivated, conservative “judicial activism.”

The conservative denunciations of Roberts will be even more bitter if he sides with Obama this time, too. On the other hand, if Roberts votes with the other four Republican appointees to gut the Democratic president’s signature accomplishment, it will feed the kind of attacks that the chief justice dreads on the Roberts court’s conservative majority as a bunch of robed politicians.

Looking to the future, a ruling against Obama could be extremely awkward politically for Republican members of Congress, presidential candidates and officials in the mostly red, affected states, even though it might be cheered (at least initially) by Republican voters.

In this scenario, the president and other Democrats would immediately demand that Republicans help them save the subsidies of millions of people at risk of losing their health insurance, by adopting new legislation.

Some Republicans say this would be an opportunity to extract compromises from Obama such as more choices for consumers – especially less expensive, less comprehensive health insurance options; the elimination of the mandate to buy insurance; or restrictions on medical malpractice lawsuits.

Others predict a humiliating and internally divisive Republican cave-in to avoid being blamed for the “disastrous consequences” that Justice Scalia hypothesized.

Whatever the outcome, the chief justice, in his tenth year on the Court, is in for a long, hot summer.

Stuart Taylor Jr. is a Washington writer, lawyer and Brookings nonresident senior fellow.

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

California health officials failed to ensure that more than 9 million residents enrolled in Medi-Cal managed care plans had access to doctors when they needed them, the state auditor said in a stinging report Tuesday. Health officials might have learned about those problems from calls to an ombudsman’s office – but thousands went unanswered every month.

Among the report’s findings:

Incorrect or missing data on provider networks meant that state health officials had no idea if the plans had sufficient doctors and specialists, or if patients got the care they needed.
An average of 12,500 calls to the program’s ombudsman went unanswered each month for nearly a year, frustrating patients’ efforts to resolve problems.
Provider directories for three health plans – Health Net in Los Angeles County, Anthem Blue Cross in Fresno County and Partnership HealthPlan of California in Solano County – contained inaccurate or outdated information, ranging from incorrect telephone numbers for providers to listings for providers who no longer participated.

Overall, state officials failed to verify insurers’ information about their networks of doctors and hospitals.

The audit’s findings come as little surprise to health advocates, who have called attention to these problems as California shifted millions of Medi-Cal recipients from traditional fee-for-service care which enabled enrollees to see most Medi-Cal providers, into managed care programs with prescribed networks of doctors and hospitals.

About 76 percent of the 12.2 million adults and children receiving Medi-Cal, California’s Medicaid program, were enrolled in managed care programs as of March 2015.

Eligibility for Medi-Cal, the state-federal health program for the poor, expanded under the Affordable Care Act. Since last year, more than 3.5 million enrollees signed up for the first time. Nearly one in three Californians now receive coverage through the program.

“The audit confirms longstanding concerns about issues of oversight of Medicaid managed care plans and of access to Medi-Cal services,” said Anthony Wright, executive director for the statewide advocacy group Health Access. “I think people on Medicaid are very appreciative of the care they get and it’s far preferable to be being uninsured. What’s troubling is the finding that we don’t even know if people have access. We’re two steps away from solving the problems that exist if we don’t know what they are.”

The agency “agrees with many of the state auditor’s recommendations” and already has begun to work on improving oversight, Department of Health Care Services Director Jennifer Kent said in a statement.

The agency is upgrading the ombudsman’s phone system to handle more calls and is taking other steps to ensure that residents can get medical care when and where they need it, she noted.

The state’s Department of Health Care Services contracts with 22 different health plans to provide managed health care services to Medi-Cal recipients, who must choose from managed care plans available in their counties.

The audit singled out the performance of the Medi-Cal Managed Care Ombudsman’s office, noting that too-few staffers, an inadequate telephone system and a glitch-prone computer system kept it from addressing complaints.

The telephone system rejected thousands of calls each month, ranging from about 7,000 to more than 45,000, between February, 2014 and January, 2015.

Even when calls got through, staffers were able to answer only a third to a half of them, the audit noted. A database to maintain information on the calls crashed frequently, resulting in further loss of data.

Efforts to improve oversight of Medi-Cal managed care plans are underway. The Department of Health Care Services is creating a “dashboard” of plan performance indicators to better identify problems in real time.

Pending legislation would require health plans to more frequently update their provider lists for all consumers, not just those on Medi-Cal.

A new state law also will require health insurers, including those serving Medi-Cal managed care patients, to provide data to regulators on how much time it takes for patients to get appointments with their physicians.

The audit noted that the Department of Health Care Services also needs to improve how it reviews primary care provider directories, which can affect children’s ability to get medical care.

“With nearly half of all children in California enrolled in Medi-Cal managed care, the state is responsible for ensuring that children are actually able to access needed health services,” said Alison Buist, director of health policy for the Children’s Defense Fund. “The audit confirms what advocates have long suspected: The state is not effectively monitoring whether health plans have enough providers to serve the Medi-Cal population, and the mechanisms to identify challenges beneficiaries face in accessing care are not working as well as they should.”

In a statement, California State Sen. Edward Hernandez, chair of the Senate’s health committee, cited lack of funding as a key factor.

“While disappointing, the results of this audit are not surprising,” Hernandez said. “The systematic underfunding of Medi-Cal is making it very difficult for plans to set up adequate networks, and DHCS is not doing enough to make sure the commitments we’ve made to beneficiaries are being honored.”

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

Nearly three in four Americans say the costs of prescription drugs are “unreasonable,” with most putting the blame on drugmakers, according to a poll released Tuesday.

The survey by the Kaiser Family Foundation found 74 percent of those taking prescription drugs find the costs unreasonable, as do 72 percent of those not taking such drugs. (KHN is an editorially independent program of the foundation.)

The poll builds on the results of an earlier Kaiser survey in April that identified high drug costs as the public’s top health care priority for Congress and the president. Drug costs have gained attention in the past year as a result of controversies surrounding Sovaldi and other new hepatitis C drugs, which can cure most cases of the deadly liver disease but at a price of $84,000 for a 12-week treatment. The high cost has strained Medicaid and Medicare budgets and left private insurers scrambling.

Half the public says they take prescription drugs. More than three quarters of those say they are easy to afford, with only one in five saying they have difficulty paying for them. But about a quarter of respondents said they or a family member have not filled a prescription in the past year, while 18 percent have cut pills in half or skipped doses to save money, the poll found.

More than three-quarters of the public cited drug company profits as the No. 1 reason for the high costs, followed by the expense of medical research (64 percent), the cost of marketing (54 percent) and the cost of lawsuits against pharmaceutical companies (49 percent).

About 10 percent of respondents also blame insurance companies, saying they require enrollees to shoulder too great a share of drug costs.

The survey also found most Americans are still not paying attention to the latest challenge to the Affordable Care Act in a case called King v. Burwell. The Supreme Court is expected to decide this month whether to cut off government subsidies to millions of people in about three dozen states that rely on a federal insurance marketplace, rather than a state-based marketplace. About 72 percent of respondents say they have heard little or nothing about the case.

However, the survey found more than half of respondents were “very” or fairly closely” following news about the 2016 presidential campaign. About 39 percent of respondents said they were closely following news about the House of Representatives banning abortions after 20 weeks of pregnancy — the most closely followed health policy issue.

The poll of 1,200 adults, conducted from June 2 to June 9, had a margin of error of plus or minus 3 percentage points.

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

Having a baby is a common women’s health event, yet insurance coverage isn’t always assured.

Although the federal government recently clarified that many insurance plans must cover prenatal care as a preventive service without charging women anything out of pocket, it didn’t address a crucial — and much pricier — gap in some young women’s coverage: labor and delivery costs.

Perhaps it shouldn’t come as a surprise. Insurers and some employers have long tried to sidestep paying for maternity care, which includes prenatal, delivery and postpartum services. Individual plans typically refused to pay for pregnancy-related services until the health law established that maternity and newborn care together are a so-called “essential health benefit” that must be included in their individual and small group coverage.

Meanwhile, large employers that provide health insurance are required to cover maternity care for employees and their spouses under the Pregnancy Discrimination Act of 1978. But that protection doesn’t extend to dependent children, even though under the health law, adult children can now stay on their parents’ plans until they turn 26.

“I suspect that a lot of this goes back to dependents being kids,” says Adam Sonfield, a senior public policy associate at the Guttmacher Institute, a reproductive rights research and education organization. “That perspective is just outdated, and was never entirely correct in terms of need for care anyway.”

In May, the federal government clarified that dependent children are covered by the health law requirement that preventive services, including preconception and prenatal care, be covered without cost sharing in all plans, except those that were grandfathered under the law.

Typically, prenatal care for a young woman for a first pregnancy would include visits to her health care provider every four weeks for the first 28 weeks of pregnancy, every two weeks until 36 weeks and weekly thereafter, according to the American Congress of Obstetricians and Gynecologists. In addition, the U.S. Preventive Services Task Force recommends pregnancy-related services, including screening for gestational diabetes, anemia and Hepatitis B.

But prenatal care is a small portion of the cost of having a baby, and families that have to pay for an adult child’s labor and delivery charges, including the hospital bill, could be on the hook for thousands of dollars.

Insurers paid $18,329 for a vaginal birth and $27,866 for a cesarean birth on average in 2010, according to a study by Truven Health Analytics. Consumers paid an average of $2,244 and $2,669, respectively, out of pocket. The payment totals include all maternity care.

Hospitalization made up between 81 and 86 percent of the total cost of maternity payments, the largest proportion by far, the study found. Prenatal care accounted for most of the remaining cost.

“The payments that are made are highly concentrated in that little window,” Carol Sakala, director of the Childbirth Connection, one of the organizations that commissioned the study. Childbirth Connection is a program of the National Partnership for Women and Families.

But labor and delivery is exactly what some health plans don’t cover for dependent children.

Continuing a slow upward trend, the average age at which women have their first baby was 26 in 2013. Meanwhile, the proportion of first births to teenagers continues to decline. In 2010, 19 percent of first births were to teenagers under age 20, compared with 36 percent in 1970.

Although the extent to which large employer plans refuse to cover maternity care for dependent children isn’t known, benefits experts say it’s common.

In 2013, the National Women’s Law Center filed sex discrimination complaints with the Office for Civil Rights of the federal Department of Health and Human Services against five employers that exclude pregnancy-related coverage for the dependent children of their employees.

The law center brought the complaints under Sec. 1557 of the health law, which protects people from discrimination on the basis of sex, race, color, national origin, age, disability, gender identity and sex stereotypes in health care plans.

“Pregnancy discrimination is per se sex discrimination,” says Dania Palanker, senior counsel at the National Women’s Law Center. The center is still awaiting a response from the civil rights office.

The HHS Office for Civil Rights can’t comment on open cases or compliance reviews, a spokesperson said.

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.

HHS Proposes Vision for the Future of Head Start, Releases New Performance Standards