Click here for a transcript of the episode.

President Joe Biden released his budget proposal for 2023 this week, and it calls for a nearly 27% increase in funding for the Department of Health and Human Services. That includes $28 billion for the Centers for Disease Control and Prevention to implement a preparedness program for future pandemics and $40 billion for HHS to invest in making vaccines and other medicines.

Also, the FDA and the CDC authorized a second booster shot for most people 50 and older. But federal officials offered little advice to consumers about who might need that shot and when.

This week’s panelists are Mary Agnes Carey of KHN, Amy Goldstein of The Washington Post, Jennifer Haberkorn of the Los Angeles Times, and Rachana Pradhan of KHN.

Among the takeaways from this week’s episode:

• Biden’s advocacy for funding preparations for a future pandemic reinforces his sense of urgency in bolstering the public health infrastructure, but whether Congress will take that track is unknown. Already, some lawmakers are balking at the administration’s request for more money to help fund additional covid-19 testing and vaccine efforts.
• A bipartisan group of senators has been meeting in the past several days hoping to find a compromise to restore funding for testing and vaccinations. Republicans have complained that earlier appropriations for covid have been spent too recklessly and that there isn’t enough transparency about where it has gone. They would like some of the funds that haven’t been spent to be clawed back. There is no indication yet that the group of senators has a plan for moving forward, but the upcoming spring recess for Easter and Passover may provide a deadline that helps focus the debate.
• The administration originally sought more than $20 billion for testing and vaccines. Congress appeared ready to spend about $15 billion before hitting the impasse. Some reports suggest that the Senate negotiators are talking about $10 billion, which may provide funding for only several months.
• The Centers for Medicare & Medicaid Services also announced this week that a new analysis shows the growth in health spending in the U.S. has slowed.
• Millions of Americans are expected to lose Medicaid coverage once the covid emergency ends and states will be able to disenroll people who no longer meet eligibility requirements. Advocates warn that some of those people will not move to other coverage options, such as insurance offered on the Affordable Care Act’s insurance marketplaces.
• One priority of the ACA was to help drive down health costs, and the law established an innovation center to fund projects looking for ways to do that. Experts at the time suggested that value-based care could make a difference, and the center has made that a guiding principle in its research. But there is little evidence so far that such efforts are producing meaningful results.

Also this week, Julie Rovner interviews KHN’s Julie Appleby, who reported and wrote the latest KHN-NPR “Bill of the Month” installment about a very expensive air ambulance ride. If you have an outrageous medical bill you’d like to share with us, you can do that here.

Plus, for extra credit, the panelists recommend their favorite health policy stories of the week they think you should read, too:

Mary Agnes Carey: ,” by David Owen

Amy Goldstein: Stat’s “,” by Lev Facher

Jennifer Haberkorn: The New York Times’ “” by Christina Jewett

Rachana Pradhan: The Washington Post’s “‘’” by William Wan

Also discussed on this week’s podcast:

The Wall Street Journal’s “,” by Philip Krause and Luciana Borio

To hear all our podcasts,Ìýclick here.

And subscribe to KHN’s What the Health? on , , , or wherever you listen to podcasts.

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Some employers say that, in a tight labor market, offering a more generous plan with a deductible that’s less than four figures can be an attractive recruitment tool. Plus, a more traditional plan may appeal to workers who want more predictable out-of-pocket costs, even if the premium is a bit higher.

That’s what happened at , a 650-person global e-commerce payment processing business based in Minnetonka, Minn.

Four years ago, faced with premium increases approaching double digits, Digital River ditched its traditional preferred provider organization plan in favor of three high-deductible plans. Each had different deductibles and different premiums, but all linked to health savings accounts that are exempt from taxes. This year, though, the company added back two traditional preferred provider plans to its offerings for workers.

Even with three plan options, “we still had employees who said they wanted other choices,” said KT Schmidt, the company’s chief administrative officer.

Digital River isn’t the only company broadening its offerings. For the third year in a row, the percentage of companies that offer high-deductible plans as the sole option will decline in 2020, according to a survey of large employers by the National Business Group on Health. A quarter of the firms polled will offer these plans, sometimes called consumer-directed plans, as the only option next year, down 14 percentage points from two years ago.

That said, consumer-directed plans are hardly disappearing. of covered employees worked at companies that offered at least one high-deductible health plan in 2019, according to an annual survey of employer health benefits released by the Kaiser Family Foundation last month. That was second only to the 76% of covered workers who were at firms that offered a PPO plan. (KHN is an editorially independent program of the foundation.)

When Digital River switched to all high-deductible plans for 2016, the firm put some of the $1 million it saved into the new health savings accounts that employees could use to cover their out-of-pocket expenses before reaching the deductible. Employees could also contribute to those accounts to save money for medical expenses. This year the deductibles on those plans are $1,850, $2,700 and $3,150 for single coverage, and $3,750, $5,300 and $6,300 for family plans.

The company put a lot of effort into educating employees about how the new plans worked, said Schmidt. Premiums are typically lower in high-deductible plans. But under federal rules, until people reach their deductible, the plans pay only for specified preventive care such as annual physicals and cancer screenings and some care for existing chronic conditions.

Enrollees are on the hook for everything else, including most doctor visits and prescription drugs. In 2020, the minimum deductible for a plan that qualifies for a tax-exempt health savings account is $1,400 for an individual and $2,800 for a family.

As their health savings account balances grew, “more people moved into the camp that could see the benefits” of the high-deductible strategy, Schmidt said. Still, not everyone wanted to be exposed to costs upfront, even if they ended up spending less overall.

“For some people, there remained a desire to pay more to simply have that peace of mind,” he said.

Digital River’s PPOs have deductibles of $400 and $900 for single coverage and $800 and $1,800 for families. The premiums are significantly more expensive than those of the high-deductible plans.

In the PPO plan with the $400/$800 deductible, the employee’s portion of the monthly premium ranges from $82.37 for single coverage to $356.46 for an employee plus two or more family members. The plan with the $2,700 deductible costs an employee $21.11 for single coverage and the $5,300 deductible plan costs $160.29 for the employee plus at least two others.

But costs are more predictable in the PPO plan. Instead of owing the entire cost of a doctor visit or trip to the emergency room until they reach their annual deductible, people in the PPO plans generally owe set copayments or coinsurance charges for most types of care.

When Digital River introduced the PPO plans this year, about 10% of employees moved from the high-deductible plans to the traditional plans. Open enrollment for 2020 starts later this fall, and the company is offering the same mix of traditional and high-deductible plans again for next year.

Adding PPOs to its roster of plans not only made employees happy but also made the company more competitive, Schmidt said. Two of Digital River’s biggest competitors offer only high-deductible plans, and the PPOs give Digital River an edge in attracting top talent, he believes.

According to the survey by the National Business Group on Health, employers that opted to add more choices to what they offered employees typically chose a traditional PPO plan. Members in these plans generally get the most generous coverage if they use providers in the plan’s network. But if they go out of network, plans often cover that as well, though they pay a smaller proportion of the costs. For the most part, deductibles are lower than the federal minimum for qualified high-deductible plans.

Traditional plans like PPOs also give employers more flexibility to try different approaches to improve employees’ health, said Tracy Watts, a senior partner at benefits consultant Mercer.

“Some of the newer strategies that employers want to try just aren’t [health savings account] compatible,” said Watts. The firms might want to pay for care before the deductible is met, for example, or eliminate employee charges for certain services. Examples of these strategies could include direct primary care arrangements in which physicians are paid a monthly fee to provide care at no cost to the employee, or employer-subsidized telemedicine programs.

The so-called , a provision of the Affordable Care Act that would impose a 40% excise on the value of health plans that exceed certain dollar thresholds, was a driving force behind the shift toward high-deductible plans. But the tax, originally supposed to take effect in 2018, has been pushed back to 2022. The House passed a in July, and there is a companion bill in the Senate.

It’s unclear what will happen, but employers appear to be taking the uncertainty in stride, said Brian Marcotte, president and CEO of the National Business Group on Health.

“I think employers don’t believe it’s going to happen, and that’s one of the reasons you’re seeing [more plan choices] introduced,” he said.

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The Cadillac tax is a 40% tax on the — those that cost more than $11,200 for an individual policy or $30,150 for family coverage. It was supposed to take effect in 2018, but Congress has delayed it twice. And the House recently voted overwhelmingly — — to repeal it entirely. A Senate companion bill has 61 co-sponsors — more than enough to ensure passage.

The tax was always an unpopular and controversial part of the 2010 health law because the expectation was that employers would cut benefits to avoid paying the tax. But ACA backers said it was necessary to help pay for the law’s nearly $1 trillion cost and help stem the use of what was seen as potentially unnecessary care. In the ensuing years, however, public opinion has shifted decisively, as premiums and out-of-pocket costs have soared. Now the biggest health issue is not how much the nation is spending on health care, but how much individuals are.

“Voters deeply care about health care still,” said Heather Meade, a spokeswoman for the , a coalition of business, labor and patient advocacy groups urging repeal of the Cadillac tax. “But it is about their own personal cost and their ability to afford health care.”

Stan Dorn, a senior fellow at Families USA, in the journal Health Affairs that the backers of the ACA thought the tax was necessary to sell the law to people concerned about its price tag and to cut back on overly generous benefits that could drive up health costs. But transitions in health care, such as the increasing use of high-deductible plans, make that argument less compelling, he said.

“Nowadays, few observers would argue that [employer-sponsored insurance] gives most workers and their families excessive coverage,” he wrote.

The possibility of the tax has been “casting a statutory shadow over 180 million Americans’ health plans, which we know, from HR administrators and employee reps in real life, has added pressure to shift coverage into higher-deductible plans, which falls on the backs of working Americans,” said Rep. Joe Courtney (D-Conn.).

Support or opposition to the Cadillac tax has never broken down cleanly along party lines. For example, economists from across the ideological spectrum supported its inclusion in the ACA, and many continue to endorse it.

“If people have insurance that pays for too much, they don’t have enough skin in the game. They may be too quick to seek professional medical care. They may too easily accede when physicians recommend superfluous tests and treatments,” wrote N. Gregory Mankiw, an economics adviser in the George W. Bush administration, and Lawrence Summers, an economic aide to President Barack Obama, . “Such behavior can drive national health spending beyond what is necessary and desirable.”

At the same time, however, the tax has been bitterly opposed by organized labor, a key constituency for Democrats. “Many unions have been unable to bargain for higher wages, but they have been taking more generous health benefits instead for years,” said Robert Blendon, a professor at the Harvard T.H. Chan School of Public Health who studies health and public opinion.

Now, unions say, those benefits are disappearing, with premiums, deductibles and other cost sharing rising as employers scramble to stay under the threshold for the impending tax. “Employers are using the tax as justification to shift more costs to employees, raising costs for workers and their families,” said a from the Service Employees International Union.

Deductibles have been rising for a number of reasons, the possibility of the tax among them. According to a by the federal government’s National Center for Health Statistics, nearly half of Americans under age 65 (47%) had high-deductible health plans. Those are plans that have deductibles of at least $1,350 for individual coverage or $2,700 for family coverage.

It’s not yet clear if the Senate will take up the House-passed bill, or one like it.

The senators leading the charge in that chamber — Mike Rounds (R-S.D.) and Martin Heinrich (D-N.M.) — have to Senate Majority Leader Mitch McConnell to urge him to bring the bill to the floor following the House’s overwhelming vote.

“At a time when health care expenses continue to go up, and Congress remains divided on many issues, the repeal of the Cadillac Tax is something that has true bipartisan support,” the letter said.

Still, there is opposition. A from economists and other health experts argued that the tax “will help curtail the growth of private health insurance premiums by encouraging employers to limit the costs of plans to the tax-free amount.” The letter also pointed out that repealing the tax “would add directly to the federal budget deficit, an estimated $197 billion over the next decade, according to the Joint Committee on Taxation.”

Still, if McConnell does bring the bill up, there is little doubt it would pass, despite support for the tax from economists and budget watchdogs.

“When employers and employees agree in lockstep that they hate it, there are not enough economists out there to outvote them,” said former Senate GOP aide Rodney Whitlock, now a health care consultant.

Harvard professor Blendon agrees. “Voters are saying, ‘We want you to lower our health costs,’” he said. The Cadillac tax, at least for those affected by it, would do the opposite.

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• Why [does] the health care debate in the U.S. seem to be focused on “Medicare for All” or strengthening the ACA, but no one is suggesting a universal multipayer system with price controls, as in France or Germany?
• Can you please explain the policies that prevent the majority of Medicare patients from using third-party and manufacturers’ coupons for medications?
• I know that you all talked about the update on the Cadillac tax, but I was wondering, what are the reasons why there is bipartisan support to repeal it?

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• Biden’s health proposal seeks to lower out-of-pocket costs for many people in several ways. For example, it would make federal premium help available to all who buy their own insurance, not just those with low and middle incomes. It would also change how federal premium subsidies are determined. It would base the assistance on the cost of a gold plan, rather than the current practice of using the second lowest priced silver plan. Since gold plans are more generous, using that standard could lower the amount of deductibles and copayments people getting subsidies have to pay.
• The ACA’s Cadillac tax has been strongly endorsed by health economists, who view it as a way to cut the amount of unnecessary care some people with generous plans seek. But many employers, consumers and labor unions don’t want to tinker with the current tax system of job-based insurance.
• The administration’s decision to go forward with its new rules for the Title X family planning program — while critics are challenging those regulations in the courts — will have a significant effect on Planned Parenthood’s finances. But the group gets even more government money through the Medicaid program.
• Despite two setbacks last week in the administration’s efforts to reduce drug prices, President Donald Trump is continuing to hint that he wants to go forward with a plan to tie some Medicare drug prices to what people in other countries pay for the medications.
• Federal officials have announced that opioid deaths have declined, but it is not clear that opioid overdoses or addiction has declined.

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Companies have slowed enrollment in such coverage and, in some cases, reinstated more traditional plans as a strong job market gives workers bargaining power over pay and benefits, according to research from three organizations.

This year, 39 percent of large, corporate employers surveyed by the National Business Group on Health (NBGH) offer high-deductible plans, also called “consumer-directed” coverage, as workers’ only choice. For next year, that figure is set to drop to 30 percent.

“That was a surprise, that we saw that big of a retraction,” said Brian Marcotte, the group’s CEO. “We had a lot of companies add choice back in.”

Few if any employers will return to the much more generous coverage of a decade or more ago, benefits experts said. But they’re reassessing how much pain workers can take and whether high-deductible plans control costs as advertised.

“It got to the point where employers were worried about the affordability of health care for their employees, especially their lower-paid people,” said Beth Umland, director of research for health and benefits at Mercer, a benefits consultancy that also conducted a survey.

The portion of workers in high-deductible, job-based plans peaked at 29 percent two years ago and was unchanged this year, according to new from the Kaiser Family Foundation. (Kaiser Health News is an editorially independent program of the foundation.)

Deductibles — what consumers pay for health care before insurance kicks in — have increased far faster than wages, even as paycheck deductions for premiums have also soared.

One in 4 covered employees now have a single-person deductible of $2,000 or more, KFF found.

Employers and consultants once claimed patients would become smarter medical consumers if they bore greater expense at the point of care. Those arguments aren’t heard much anymore.

Because lots of medical treatment is unplanned, hospitals and doctors proved to be much less “shoppable” than experts predicted. Workers found price-comparison tools hard to use.

High-deductible plans “didn’t really do what employers hoped they would do, which is create more sophisticated consumers of health care,” Marcotte said. “The health care system is just way too complex.”

At the same time, companies have less incentive to pare coverage as Congress has the Affordable Care Act’s “Cadillac tax” on higher-value plans.

Although deductibles are treading water, total spending on job-based health plans continues to rise much faster than the overall cost of living. That eats into workers’ pay in other ways by boosting what they contribute in premiums.

Employer-sponsored group health plans, which insure 150 million Americans — nearly half the country — tend to get less attention than politically charged coverage created by the ACA.

For these employer plans, the cost of family coverage went up 5 percent this year and is expected to rise by a similar amount next year, the research shows.

Insuring one family in a job-based plan now costs on average $19,616 in total premiums, the KFF data show. The American worker pays $5,547 of that in a country where the median household .

The KFF survey was published Tuesday; the NBGH data, in August. Mercer has released preliminary results showing similar trends.

The recent cost upticks, driven by specialty drug costs and expensive treatment for diseases such as cancer and kidney failure, are an improvement over the early 2000s, when family-coverage costs were rising by an average 7 percent a year. But they’re still nearly double recent rates of inflation and increases in worker pay.

Such growth “is unsustainable for the companies I have been working with,” said Brian Ford, a benefits consultant with Lockton Companies, echoing comments made over the decades by experts as health spending has vacuumed up more and more economic resources.

For now at least, many large employers can well afford rising health costs. Earnings for corporations in the S&P 500 have increased by double-digit percentages, driven by federal tax cuts and economic growth. Profit margins are near all-time highs.

But for workers and many smaller businesses, health costs are a heavier burden.

Premiums for family plans have gone up 55 percent in the past decade, twice as fast as worker pay, according to KFF.

Employers’ latest cost-control efforts include managing expenses for the most expensive diseases; getting workers to use nurse video-chat services and other types of “telemedicine”; and paying for primary care clinics at work or nearby.

At the “top of the list” for many companies are attempts to manage the most expensive medical claims — cases of hemophilia, terrible accidents, prematurely born infants and other diseases — that increasingly cost as much as $1 million each, Umland said.

Employers point such patients to the highest-quality doctors and hospitals and furnish guides to steer them through the system. Such steps promise to improve results, reduce complications and save money, she said.

On-site clinics cut absenteeism by eliminating the need for employees to drive across town and sit in a waiting room for two hours to get a rash or a sniffle checked or get a vaccine, consultants say.

Almost all large employers offer telemedicine, but hardly any workers use it. Thirty-nine percent of the larger companies covering telemedicine now make it comparatively less expensive for workers to consult doctors and nurses virtually, the KFF survey shows.

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Q:ÌýI have a rare disease, and there is literally only one specialist in my area with the expertise needed to treat me. I am self-employed and have to buy my own insurance. What do I do next year if there are zero insurance plans availableÌýthat allow me to see my specialist? IÌýcannot “break up” with my sub-specialty oncologist. I must be able to see the doctor that is literally saving my life and keeping me alive.

KHN contributing columnist Michelle Andrews writes the series , which explores health care coverage and costs.

To contact Michelle with a question or comment, .

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If the plan you pick covers out-of-network providers, you can continue to see your cancer specialist, although you’ll have to pay a higher percentage of the cost than if you were seeing someone in your plan’s network.

But many plans these days don’t provide any out-of-network coverage. This is certainly true of plans sold on the health insurance exchanges.

The situation you’re concerned about — that a specialist you consider crucial to your care isn’t in a plan’s provider network — isn’t uncommon, said Sabrina Corlette, a research professor at Georgetown University’s Center on Health Insurance Reforms.

If this happens, you can contact your plan and make the case that this particular provider is the only one who has the expertise to meet your needs. (Unfortunately, you probably can’t get this coverage assurance before you sign up.) Then ask your plan to make an exception and treat the out-of-network specialist as if she were in network for cost-sharing purposes. So, if in your plan an in-network specialist visit requires a $250 copayment, for example, the plan would agree that’s what you’d be charged to see your out-of-network specialist.

Or not. It’s up to the plan officials, and they may argue that someone in network has the expertise you need. If you disagree, you can appeal that decision.

But it may not come to that, said Corlette.

“Plans are prepared for this — the good ones are, anyway,” she said. “My understanding is that it’sÌýpretty routine to grant exceptions for narrow subspecialties.”

Q: My company has asked employeesÌýto pay the Cadillac taxÌýrather than putting the burdenÌý on the company. They are also telling us not to worry because it will never happen, but want us to agree that if it does we will take on the cost. Can they do that?

Let’s step back for a minute. The so-called is a 40 percent surcharge on the value of health plans above the thresholds of $10,200 for single coverage and $27,500 for family plans.

A few months ago when it looked as if the ACA was going to be replaced, many employers believed, as yours apparently still does, that the Cadillac tax would never become effective. Both the House and Senate bills , and a lot can happen between now and then.ÌýWith the collapse of efforts to repeal the ACA, however, the tax is on the front burner once again, said J.D. Piro, who leads the health and law group at benefits consultantÌýAon Hewitt. It’s set to take effect in 2020.

Under the law, insurers or employers would be responsible for paying the tax, but experts say the costs would likely be passed through to enrollees (whether or not you explicitly agree to absorb them).ÌýSo it may not matter how you respond to your employer.

Also, employers who don’t want to pay the surcharge mightÌýsidestep the issue by reducing the value of the plans they offer, said Piro. For example, they could increase employee deductibles and other cost-sharing, make coverage less generous or shrink the provider network.

“That’s simplest way to avoid the tax,” he said.

Q: I need to purchase affordable health insurance for my two daughters who are 19 and 17. Is Trump insurance available yet? I need something I can afford and everything is so expensive.

President Donald TrumpÌýnever put forward a proposal to replace the ACA. Instead, he backed the House and Senate replacement versions, which ultimately failed. But those versions might not have addressed your concerns, and you could have several options through the ACA.

“Coverage wouldn’t necessarily have been cheaper,” said Judith Solomon, vice president for health policy at the Center on Budget and Policy Priorities.

Under the Senate bill,Ìýfor example, the nonpartisan that average 2018 premiums for single coverage would be 20 percent higher than this year’s. In 2020, however, premiums would be 30 percent lower than under current law, on average.ÌýBut deductibles and other out-of-pocket costs would be higher for most people under the Senate bill, according to the CBO.

Premiums for young people would generally have declined. The bill would have allowed insurers to vary rates to a greater degree based on age, resulting in lower premiums for young people. In addition, premium tax credits generally would have increased for of the poverty level.

Your current coverage options under the ACA depend on your family situation. If you have coverage available to you through your employer, you can keep your daughters on your plan until they turn 26. For many parents, this is the most affordable, comprehensive option.

If that’s not a possibility, assuming the three of you live together and you claim them as dependents on your taxes, you may qualify for subsidized coverage on the health insurance marketplace next year.ÌýYour household income would need to be no more thanÌý400 percent of the federal poverty level (about ). You can apply for that coverage in the fall.

If you live in one of the 31 states plus the District of Columbia that have expanded Medicaid coverage to adults with incomes below 138 percent of the poverty level (about $28,000 for a family of three), you could qualify for that program. You don’t have to wait for open enrollment to sign up for Medicaid.

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Q: I’ve heard that Republicans plan to change the system so that I’d have to pay income taxes on my health insurance benefits. Is it true?

It’s way too soon to predict what may happenÌýas Republicans move to overhaul the health law and several early Republican plans have included this option. But legislation unveiled MondayÌýnight by the key House Ways and Means Committee would instead keep the health law’s “Cadillac tax” on insurers and employers that provide generous coverage rather than tax the workers who receive it.

Starting in 2020, Obamacare imposes aÌý on employers’ plans that cost more than $10,200 for individuals and $27,500 for families.ÌýThe Ways and Means Committee’s proposal would impose the tax but delay it until 2025.

KHN contributing columnist Michelle Andrews writes the series , which explores health care coverage and costs.

To contact Michelle with a question or comment, .

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The Republican proposal wouldn’t alter current federal taxÌýprovisions that exclude the amounts that workers pay for health insurance from federal income and payroll taxes. For decades, lawmakers have flirted with the idea of capping or eliminating that tax break.

A number of the recent Republican health plan proposalsÌýhave takenÌýaim at it, too. For example, theÌýÌýthat Health and Human Services Secretary Tom Price introduced when he was in Congress would have capped the amounts that could be excluded from taxes at $8,000 for single coverage and $20,000 for family coverage.ÌýThe idea is also in House Speaker Paul Ryan’sÌý.

Eliminating theÌýtax exclusion and imposing the Cadillac tax are similar in some ways.Ìý“The difference is that one is paid by the employer/insurer and the [other] is paid by the employee,”Ìýsaid Tracy Watts, a senior partner at human resources consultant Mercer.

The tax exclusion for workers is the ,Ìýaccounting for more than $250 billion annually, according to theÌý.ÌýSome economists and policy experts say it discourages people from paying attention to health care costs. But they’ve faced strong resistance from employers and labor unions, who argue that employers would stop providing health insurance if the tax break were trimmed or scrapped.

It’s early days yet, and what’s on the table today may be off it tomorrow. If you’re wondering how generous your own benefits are,Ìýcheck out Box 12 on your annual W-2 wage and tax statement. The health law required thatÌýÌýon the form. But remember: That figure is for your information only, you don’t owe tax on any part of it. Not yet, anyway.

Q: I want to be screened for lung cancer. I’m 60 years old and, with my smoking history, I think I meet the guidelines for screening. But my employer plan refused to cover it. Is there anything I can do?

You can appeal the denial to your health plan and, if necessary, an independent panel of experts.

Under the health law, health plans must cover preventive care that’s recommended by the U.S. Preventive Services Task Force without charging consumers for it. The only exception is for plans that are grandfathered under the law because they were in existence in 2010 and haven’t reduced benefits or increased costs to consumers significantly since then.

The task force for current smokers and those who quit within the past 15 years if they are ages 55-80 and smoked for at least 30 “pack years” — a pack a day for 30 years, two packs a day for 15 years or a similar calculation.

You’re clearly within the age range for the test. If you meet the smoking guidelines as well, follow the instructions on your health plan’s website for filing an appeal and enlist your doctor to write a letter explaining that the screening is medically appropriate, recommendedÌýErika Sward, assistant vice president for national advocacy at the American Lung Association.

If your health plan still says no to the screening, under the health law you’re by an outside, independent reviewer.ÌýSward suggests contacting your state insurance commissioner as well if your internal appeal is denied.

“People don’t realize that the insurance commissioner has a health policy staff that should be able to help people work through an appeal,” she said.

All of this assumes that you don’t have any symptoms of lung cancer — you’re not coughing up blood or have a persistent cough, for example. If you have symptoms, the CT scan should still be covered by your plan.ÌýBut because it would be considered a diagnostic rather than a preventive procedure, you could be on the hook for a copayment or other cost sharing.

Q: Do any states allow pharmacists to prescribe prescription drugs to patients?

Yes, although what they’re allowed to do varies widely. Depending on state law, pharmacists may be permitted to prescribe drugs independently, prescribe drugs as part of a collaborative practice agreement with a physician or prescribe under a “standing order” or other state protocol that allows them to prescribe such drugs as emergency contraception, for example, or naloxone, which counteracts opioid overdoses.

Pharmacists support state laws that expand what they’re allowed to do beyond dispensing drugs. “We’re clinically trained medication experts who are often underutilized,” said John Norton, a spokesman for the National Community Pharmacists Association, which represents independent pharmacies.

Physician groups aren’t so sure. They say that pharmacists are an important part of the team that cares for a patient but generally oppose pharmacists prescribing drugs because it could lead to fragmentation of care.

“We want to make sure care is coordinated and integrated for the patient,” said Dr. Michael Munger, president-elect of the American Academy of Family Physicians.

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Republicans will seek to ensure that “no one is worse off,” said House Speaker Paul Ryan, R-Wis., in with a Wisconsin newspaper earlier this month. “The purpose here is to bring relief to people who are suffering from Obamacare so that they can get something better.”

But that may be difficult for one big reason —ÌýRepublicans have also pledged to repeal the taxes that Democrats used to pay for their health law. Without that funding, Republicans will have far less money to spend on whatever they opt for as a replacement.

“It will be hard to have comparable coverage if they start with less money,” Gail Wilensky, a health economist who ran the Medicare and Medicaid programs under President George H.W. Bush, said in an interview.

“Repealing all the ACA’s taxes as part of repeal and delay only makes a true replacement harder,” wrote Loren Adler and Paul Ginsburg of the Brookings Institution in a out this week. It “would make it much more difficult to achieve a sustainable replacement plan that provides meaningful coverage without increasing deficits.”

The health law’s subsidies to individuals buying insurance and the Medicaid expansion are funded by two big pots of money.

However, the Congressional Budget Office in early 2016 that repealing those provisions would reduce taxes by an estimated $1 trillion over the decade from 2016-2025.

The other big pot of money that funds the benefits in the health law comes from reductions in federal spending for Medicare (and to a lesser extent, Medicaid). Those include trims in the scheduled payments to hospitals, insurance companies and other health care providers, as well as increased premiums for higher-income Medicare beneficiaries.

in 2015 that cancelling the cuts would boost federal spending by $879 billion from 2016 to 2025.

The GOP, in the that passed in January and was vetoed by President Barack Obama, proposed to cancel the tax increases in the health law, as well as the health premium subsidies and Medicaid expansion. But it would have kept the Medicare and Medicaid payment reductions. Because the benefits that would be repealed cost more than the revenue being lost through the repeal of the taxes, the result would have been net savings to the federal government —Ìýto the tune of about $317.5 billion over 10 years, .

But those savings —Ìýeven if Republicans could find a way to apply them to a new bill —Ìýwould not be enough to fund the broad expansion of coverage offered under the ACA.

If Republicans follow that playbook again, their plans for replacement could be hampered because they will still lose access to tax revenues. That means they cannot fund equivalent benefits unless they find some other source of revenue.

Some analysts fear those dollars may come from still more cuts to Medicare and Medicaid.

“Medicare and Medicaid face fundamental threats, perhaps the most since they were established in the 1960s,” said Edwin Park of the liberal Center on Budget and Policy Priorities, in a webinar last week.

Republicans in the House, however, have identified one other potential source of funding. “Our plan caps the open-ended tax break on employer-based premiums,” said , called “A Better Way.”

House Republicans say that would be preferable to the Cadillac Tax in the ACA, which is scheduled to go into effect in 2020 and taxes only the most generous plans.

But health policy analysts say ending the employer tax break could be even more controversial.

Capping the amount of health benefits that workers can accept tax-free “would reduce incentives for employers to continue to offer coverage,” said Georgetown University’s Sabrina Corlette.

James Klein, president of the American Benefits Council, which represents large employers, said they would look on such a proposal as potentially more damaging to the future of employer-provided insurance than the Cadillac Tax, which his group has against.

“This is not a time one wants to disrupt the employer marketplace,” said Klein in an interview. “It seems perplexing to think that if the ACA is going to be repealed, either in large part or altogether, it would be succeeded by a proposal imposing a tax on people who get health coverage from their employer.”

Wilensky said that as an economist, getting rid of the tax exclusion for employer-provided health insurance would put her “and all the other economists in seventh heaven.” Economists have argued for years that having the tax code favor benefits over cash wages encourages overly generous insurance and overuse of health services.

But at the same time, she added, “I am painfully aware of how unpopular my most favored change would be.”

Republicans will have one other option if and when they try to replace the ACA’s benefits —Ìýnot paying for them at all, thus adding to the federal deficit.

While that sounds unlikely for a party dedicated to fiscal responsibility, it wouldn’t be unprecedented. In 2003 the huge was passed by a Republican Congress —Ìýwith no specified funding to pay for the benefits.

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That remains difficult with Democrats still commanding enough power in the Senate to block the 60 votes needed for a full repeal. Republicans could use fast-track budget authority to make some major changes to the law, although that could take some time. In the short term, however, to make some major changes on his own.

Beyond the health law, Trump also could push for some Republican perennials, such as giving states block grants to handle Medicaid, allowing insurers to and establishing a for people who are ill and unable to get private insurance.

But those options, too, would likely meet Democratic resistance, and it’s unclear where health will land on what could be a jam-packed White House agenda.

One of those taxes, a fee levied on , is suspended for 2017, while a 2.3 percent tax on was suspended for 2016 and 2017. Both industries lobbied heavily for the changes — arguing that the taxes boosted the prices of their products — and would like to permanently kill the taxes.

Also on hold is the most controversial health law tax of all, the so-called “” that levies a 40 percent penalty on very generous health insurance plans. The idea is to prevent consumers who pay little out of pocket because of their coverage from overusing health care services and driving up overall health costs.

The tax was technically put off from 2018 to 2020, but experts say pressure will begin to mount next year for reconsideration because employers will need a long lead time if they are to change benefits to avoid paying it. While are virtually unanimous in their support for the tax on high-end health plans, both strongly oppose it.

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Ìý

Children’s Health Insurance Program

The , a federal-state partnership that Hillary Clinton helped set up in negotiations with Congress during her husband’s administration, is up again for renewal in 2017. CHIP covers more than 8 million children from low- and moderate-income householdsÌýand has made a huge dent in the number of uninsured children. According to the , nearly 95 percent of children had insurance coverage in 2015.

When the federal health law passed in 2010, many policymakers thought CHIP would quietly go away because most of the families whose children are eligible for the program became eligible for tax credits to help them purchase plans for the entire family in the health law’s marketplaces. But it turned out that CHIP in most states remained more popular because it provided than did plans through the ACA.

In 2015, Congress compromised between those arguing to extend CHIP and those who wanted to end it, by renewing it for . That ends Oct. 1, 2017. In practice, if Congress wants to extend CHIP, it needs to act early in 2017 because many states have fiscal years that begin in July and need lead time to plan their budgets.

Prescription Drug And Medical Device User Fees

Also expiring in 2017 is the authority for the Food and Drug Administration to collect “user fees” from makers of prescription drugs and medical devices.

The , known as PDUFA (pronounced pah-doof-uh), was originally passed in 1990 in an effort to speed the review of new drug applications by enabling the agency to use the extra money to hire more personnel. The user fees were later expanded to speed the review of (2002), of brand-name drugs (2012) and medicines (2012).

PDUFA gets reviewed and renewed every five years, and its “must-pass” status makes it a magnet for other changes to drug policy. For example, in 2012 the renewal also created a program aimed at addressing of some prescription drugs. Earlier renewals also included separate programs that gave pharmaceutical firms incentives to study the effect of .

Some policy-watchers think this year the bill could serve as a vehicle for provisions to help bring down drug prices, although it is not clear how well many of the would work.

“I think [Congress] will talk a lot about it and do very little,” said Robert Reischauer of the Urban Institute, who called the drug price issue “incredibly complex.”

Medicare’s Independent Payment Advisory Board

One more issue that might come up is a controversial cost-saving provision of the federal health law called the Independent Payment Advisory Board, or IPAB. The board is supposed to make recommendations for reducing Medicare spending if the program’s costs rise significantly faster than overall inflation. Congress can override those recommendations, but only with a two-thirds vote in each of the House and Senate.

So far the trigger hasn’t been reached. That’s lucky because the board has turned out to be so , who say it will lead to rationing, that no one has even been appointed to serve.

The lack of an actual board, however, does not mean that nothing will happen if the requirement for Medicare savings is triggered. In that case, the responsibility for recommending savings will fall to the secretary of Health and Human Services. Medicare’s trustees predicted in their that the targets will be exceeded for the first time in 2017.

That would likely touch off a furious round of legislating that could, in turn, lead to other Medicare changes.

Ñî¹óåú´«Ã½Ò•îl Health News is a national newsroom that produces in-depth journalism about health issues and is one of the core operating programs at KFF—an independent source of health policy research, polling, and journalism. Learn more about .

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This story can be republished for free (details).