Churches immediately qualified for an exemption in the law. But religiously affiliated hospitals, universities and other institutions often were not able to meet all of the three required conditions:Ìýthey had to prove that their main purpose is to teach others about religion, and that their employees and the people they serve share the same beliefs. For example, the hundreds of Catholic hospitals serve patients of all religions.

HHS, however, finalized aÌýÌýfor these groups June 28, in a so-called “Safe Harbor” rule that outlined how they could avoid directly providing contraception coverage. Employees and their families would have access to the women’s contraceptive coverage, but theÌýprice tag would be borne not by employers with religious objections but by their insurance companies.ÌýSomeÌýorganizations that have a religious connectionÌýstill found this approach to be a .

With high emotions and vast implications, the cases challenging the contraception coverage mandate raise fundamental questions:

• Is a company a “person” with religious liberties protected by the First Amendment and the Ìý(¸é¹ó¸é´¡)?

• Are some typesÌýof contraception a form of de-facto abortion and therefore especially objectionable to some religious groups?

• Should a company owner’s religious values govern its workers’ personal choices?

To help guide you through the maze of decisions, appeals and possible future directions of the lawsuits, we’ve selected someÌýnotable cases that could ultimately bring the contraception coverage requirement to the Supreme Court.

CorporationsÌý

Some businesses, which do not fall under the “religious employer” exemption, are seeking relief from the contraception coverage mandate because it is against the owner’s religious beliefs. The following two cases are examples of corporate challenges currently winding their way through the court system.

• – U.S. District Court, 10^th Circuit, in Oklahoma City, filed Sept. 12, 2012

Plaintiff: , is a retail arts and crafts store based in Oklahoma City with more than 500 locations across the country. David Green, the CEO and founder, and his company are committed to “honoring the Lord in all [they] do by operating the company in a manner consistent with biblical principles,” according to the Hobby Lobby website. The Green family owns , also a plaintiff in the case. Hobby Lobby employs more than 13,000 full-time employees and Mardel employs 372.

Summary of the lawsuit: The Green family claims that, even though they are not a religious employer, providing health insurance coverage of certain kinds of birth control drugs or devices that, in its view, induce abortion wouldÌý on a deeply personal scale. They argued the mandate violatesÌýtheir personal rights to freedom of religion, and that of the corporation as a person-like entity.

What’s the deal? A federal district court denied Hobby Lobby’s request for a preliminary injunction, but was overruled when the 10th Circuit Court of Appeals in Denver from the coverage requirement and allowed the case to move forward. The court found that the Green family does have standing to assert its rights becauseÌýproviding coverage for particular types of birth control would go against the family’s religious beliefs. The court noted that the company would have to pay $1.3 million in fines daily for not providing coverage, deemed a “substantial” burden.

Current Status: The is stayed until Oct.Ìý 1 — the deadline for the federal government to appeal the court’s decision to let Hobby Lobby challenge the mandate on religious grounds. The company does not have to comply with the mandate or pay penalties while the case is pending.

• – U.S. District Court, 3^rd Circuit, in Philadelphia, filed Dec. 4, 2012

Plaintiff: is a manufacturer of wood doors and components for kitchen cabinets based in East Earl, Penn. The company employs about 950 people and is privately held. Norman Hahn and his family, Mennonite Christians, own Conestoga.

Summary: Conestoga argued that by mandating the company provide health insurance for contraception and Plan B, its rights under the RFRA and the Constitution were violated. It cited the Supreme Court’s , which broadly construed corporations’ free speech rights, and the company argued the same applies to Freedom of Religion. The Third Circuit Court disagreed and denied the company’s requestÌýfor an injunction, meaning the company has to provide the coverage or face a penalty while the lawsuit proceeds.

What’s the deal? The that there is to support the notion that a company has a “personal right” toÌýthe freedom to exercise religion. This runs counter to a separate court’s decision in the Hobby Lobby — issued just days before — and leads some experts to the issue will ultimately be resolved by the Supreme Court.

Current Status: The company petitioned the court after the July 26 3rd Circuit ruling by a three-judge panel for a rare “en banc”Ìýre-hearing of the case. The request was based on the argument that the 10th Circuit’s Hobby Lobby case was also decided en banc, meaning all the judges of the court were involved in the decision, rather than a select panel of them. The petition, however, was denied, leaving anÌý to be the plaintiff’s next step.

Other notable cases:

, U.S. Court Of Appeals, 8^th Circuit, St. Louis, Mo.

, U.S. Court of Appeals, 6^th Circuit, Cincinnati, Ohio

, U.S. District Court, Washington, D.C.

Organizations

Many cases that were initially brought by churches, faith leaders or religious groups have been dismissed as a result of the Safe Harbor rule or the religious employer exception. Some faith-based organizations, though, continue to argue that designating an outside party to provide contraception coverage for their employees still violates their religious beliefs.

TheÌý announced in July that it is satisfied with the administration’s new rules on the mandate but many archdioceses, as well as religiously affiliated hospitals, nursing homes, community clinics and charities, are fighting the mandate.

• , U.S. District Court, 2^nd Circuit, in Brooklyn, N.Y. – May 21, 2012

Plaintiff: The class-action case involves the archdiocese as well as numerous Catholic-affiliated organizations in New York including the Catholic Health Care System, and . The is one of the largest in the country.

Summary: In their 2012 court filing, the Catholic organizations made several arguments about the administration’s policy infringing on their religious freedom, including that Catholic hospitals and charities believe it is their mission to serve both Catholics and non-Catholics, which keeps them fromÌýqualifying for anÌýexemption to the contraceptive mandate. They also argue that the mandate is contrary to Catholic doctrine, which forbids artificial interference with the creation of life, including through abortion, sterilization and contraceptives.

What’s the deal? In aÌýÌýreleased last July, just days after the Obama administration finalized the rules for the mandate and offered religious organizations the Safe Harbor option, Cardinal Timothy Dolan, who heads the New York archdiocese and the U.S. Conference of Bishops, making clear the new regulations did not meet the concerns of some Catholic groups, although he said the bishops were evaluating the changes.

Current Status: The isÌý in theÌý in Brooklyn.

Other notable, similar cases:

, U.S. District Court, 11^th Circuit, Birmingham, Ala.

, U.S. District Court, Washington, D.C.

Religious Colleges/Universities

A number of religious-affiliated colleges and universities are challenging the requirement that they provide free contraception coverage to their employees.ÌýÌýis the only school that won a preliminary injunction. Liberty University initially received a favorable decision only to have that decision reversed almost immediately.

• – U.S. Court of Appeals, 4^th Circuit, Richmond, Va., 2/27/13

Plaintiff:ÌýLiberty University, in Lynchburg, Va., is the “largest Christian university in the world,” according to . Court documents indicate that more than 1,800 employees currently choose to participate in Liberty’s insurance plan. It maintains that providing contraception coverage would be subsidizing abortions and believes that “abortions, except where necessary to save the life of the pregnant mother, are murder and morally repugnant,” according to court .

Summary: Liberty University originally questioned the constitutionality of the individual and employer mandate but later amended its lawsuit to include a challenge to the contraceptive coverage requirement, too.

What’s the deal? There are numerous technicalities that derailed aspects of this lawsuit. Specifics of the case – such as the plaintiff’s failure to discuss the contraception issue upfront and their equating contraception with de-facto abortion – may be significant factors should this case go to the Supreme Court. The 4^th Circuit Court of Appeals initially granted Liberty a stay from enforcement of the contraception coverage mandate,Ìýbut the court then reversed itself a day later.

Current Status: For now, LibertyÌý with the birth control coverage mandate or face a penalty. The school has until early October to file its appeal, which could take the case to the high court, according to .

Other notable cases:

, U.S. District Court, Washington, D.C.

, U.S. District Court, Washington, D.C.

, U.S. District Court, 10th Circuit, Denver, Colo.

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This KHN story was produced in collaboration with

As states are setting up their online health insurance marketplaces, officials are watching for look-alike websites that can lead consumers to be the victims of fraud or simply, confusion.

States are on the lookout for websites created by interest groups, private insurance companies and sometimes scammers that have similar web addresses and the appearances of the official state exchange websites. Officials are intervening in some cases and trying to make sure consumers are able to spot a fake site before they give out private information.

“These exchanges could range from deceptive but relatively benign marketing devices for legitimate insurance companies to malicious devices that are designed to steal your identity or insurance information,” said James Quiggle, communications director for the .

In California, for example, typing in Ìýtakes a user to an informational website, with a fine print disclaimer that it is not the state-run site . State insurance officials monitor the website — run by the Health Exchange Consulting group as a source of information on the state exchange — because consumers may easily type in the wrong web address. Because the site is not being used for commercial purposes, however, the state has not interfered.

“We have been monitoring various sites to make sure they are not doing anything illegal or misrepresenting themselves as an agent of Covered California,” said Larry Hicks, spokesperson for the state’s exchange. “We do periodic searches and domain searches to see what pops up.”

Pennsylvania insurance officials intervened in July when a private insurance company welcomed consumers to the “Pennsylvania Health Exchange” with the state seal in the corner. The company took the website down immediately and apologized.

“We believe it was not done in a malicious manner,” said Melissa Fox, spokesperson for the Pennsylvania Insurance Department. “We do have an enforcement bureau to make sure that the folks that are selling, soliciting and negotiating insurance are complying with regulations.”

But the agency does take tips from consumers on top of their own monitoring.

The new state marketplaces, also called exchanges, were mandated by the federal health law and will open in every state on Oct. 1. They will allow consumers to compare insurance options available to them and choose a policy, akin to purchasing a plane ticket online. The process, however, will be intensive, and ask for such as Social Security numbers, employment information and tax records.Ìý

Sixteen states and the District of Columbia are creating their own marketplaces while the remaining states are defaulting to the federal government to run their exchange. is the administration’s main hub for information and purchasing options for the federal exchanges.

Experts suggest that to avoid confusion, consumers first head to Healthcare.gov. On that site, they can find out if they will be using the federal exchange or they can get the link to their .

Consumers should look out for sites with little information or graphics or those that appear to have the sole purpose of getting individuals to sign up, said Quiggle. They should also be wary of providing information that seems unlikely to be needed to connect with the buying an insurance plan.

If they see something odd, consumers should notify their state insurance departments.

“Consumers have a responsibility to pay very close attention to the communications and alerts by the exchanges so they are certain of the identity of their site, whether it’s a federal or state exchange,” Quiggle said.Ìý “Know just what your exchange site is supposed to ask and what information you need in order to complete the transaction.”

Shortly after the law was enacted in 2010, Department of Health and Human Services Secretary Kathleen Sebelius sent to state insurance commissioners and attorneys general warning of scam artists who “may be using the passage of these historic reforms as an opportunity to confuse and defraud the public.”

“The potential for fake exchanges to rear up is very serious and real,” said Quiggle.

He said scam artists could prey on consumers’ lack of experience in purchasing insurance and on the confusion accompanying the inauguration of the exchanges to lure people to a website that looks like the real thing.

“Deceptive websites have enrollment engines that ask for your personal information including credit card and other health identifiers that form the core of identity theft,” Quiggle said. “They also might try to install malware on your website to steal sensitive information on the fly.”

Eight percent of medical identity theft occurs because consumers give their personal health information, such as blood type or medical history, to a fake or “spoofed” website, according to Bill Barr, development coordinator for the .

Scammers can take this information, pair it with a false license number, and sell your identityÌýon the black market, Barr said. It is often difficult to tell which websites are fake, he added.

“These spoofed websites can be very convincing, scammers often copy from the real website,” Barr said.

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Catchy jingles? Splashy videos? Multi-million-dollar public education campaigns?

For theÌý16 states and the District of Columbia that have to run their own online health insurance marketplaces, these are among the toolsÌýbeing usedÌýto make sure residents know the exchanges will be open for business Oct. 1. (Other states will either operate exchanges in partnership with the federal government, or willÌýturn the task completely over to it.)ÌýÌý

These marketplaces, which were created as part of the health law, are key to the overhaul’s goal of expanding coverage to millions of uninsured people. But for that to happen, those same people have to use them. That’s why states are stepping up to the plateÌýto sell the concept. Here’s an alphabetical list of state exchanges and a sampling of their strategies, ranging from clever advertising to unique health exchange names:Ìý

	will  through April 2015 and has hired two PR firms, Weber Shandwick and Ogilvy, according to  by the San Francisco Business Times. Here is  on the advertisements.
	is following the example of Massachusetts in 2007 by during the Colorado Rockies baseball games. Similarly, the Department of Health and Human Services featured Washington Nationals’ presidential mascot Teddy Roosevelt in  during HHS Night at the park.
	(Connecticut) is opening brick-and-mortar stores in malls and urban areas to target those most in need of health insurance. This is the only state opening storefronts, according to  in the Hartford Courant though some insurers are also using this .
	In late September,  is  in person and online to get District-based insurance brokers up to speed on the marketplace. The D.C. Health Benefit Exchange Authority is also  to speak with residents directly.
	The  is partnering with 34 nonprofit community health organizations statewide for education and outreach, according to .
	With key parts of the health law scheduled to take effect in less than six weeks, the state  the name of its online marketplace — .
	, the Kentucky marketplace, will use an  to explain the state’s health care options and used the Kentucky state fair as a .
	The  explains its health exchange with a . (Washington state has a similar video on its exchange website.) Exchange officials unveiled  Sept. 4. The Baltimore Ravens will include the health insurance spots on their Gameday TV show as well as the team’s Web site and Facebook page.
	In 2007, as part of its landmark state health reform law,  teamed up with the Boston Red Sox, running advertisements in between innings. It now serves as a model for many marketing approaches in other states. Here’s an .
	, Minnesota’s exchange, has enlisted two well-known icons, , to help spread the word about the insurance marketplace. In a series of print, radio and TV advertisements, the characters find themselves in precarious situations that require health coverage.
	is taking a hands-on community approach to advertising its exchange by showing real-life anecdotes of the uninsured in ads and going door-to-door, the Associated Press .
	awarded a  two months before the marketplace opens for business. Among other strategies, the state will provide  to federally recognized Native American tribes, including a specific website for this population in the state.
	The  will roll out its advertising right before enrollment begins Oct. 1, the , though one ad was posted to YouTube when the marketplace’s .
	is using TV ads, notably  catchy tune, to advertise the insurance marketplace by singing about living long in Oregon. A set of ads — “,” “” and “” — were rolled out Aug. 26 to explain elements of the state’s exchange.
	(Rhode Island), with the tag line “Your Health, Your Way,” will use this  to show the health insurance marketplace on a personal level.
	has created a customized health exchange experience, according to the . Here’s their first .
	In Washington state, the  is considering unconventional methods such as printing ads on prescription drug bags and advertising on the Pandora Internet radio site,  reports.

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Under the Affordable Care Act, states have the option of allowing health plans participating in online insurance marketplaces to charge smokers than non-smokers. This provision, however, is not required, and some states and the District of Columbia are . In addition, California, Massachusetts, New Jersey, New York, Rhode Island, Vermont and D.C. have declared they will not charge smokers higher premiums, .ÌýThere is no provision in the ACA for charging overweight individuals more.

Attitudes toward smokersÌýhave changed little since 2003, when 65 percent said a higher rate is justifiable because of higher health costs. Smokers, not surprisingly, areÌýless likely to agree with being charged more,Ìýthe newÌýpoll found. Of those who had smoked cigarettes within a week of being surveyed, only 28 percent thinkÌýhigher rates are a good idea, while 65 percent of non-smokers supportÌý higher premiums.

that charging smokers more for health insurance will discourage them from smoking. Some think the higher rates will cause smokers to drop their coverage altogether and some , akin to pricing health insurance differently based on gender or medical conditions.

The poll, part of the annual Consumption Habits survey, surveyed 2,027 adults in all 50 states and D.C. from July 10-14 and has a margin of error of +/- 3 percentage points.

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And, as the population ages, the need for people to provide those services is sharply increasing, even as the affordability and availability of long-term care insurance is diminishing.

The Affordable Care Act tried to provide a solution: the CLASS Act, which stood for Community Living Assistance Services and Supports. That part of the law would have created a federal long-term care insurance program, but it faced opposition as financially unworkable and the Obama administration dropped it.

Some states are trying to step into the breach, testing their own ideas about how to address residents’ needs for services and to minimize the strain on Medicaid budgets. (Medicaid, the federal-state health insurance program for the poor, is “.”)

Dawn Lambert (Photo by Arielle Levin Becker/).

Recently, Connecticut launched ,” an information hub to complement the state’s online insurance marketplace, which will be up and running Oct. 1. It includes a website, call center and advertising campaign, as well as career opportunities for caregivers. It asks consumers about their needs and shows how they can pay for care and also lists housing and transportation options.

“The overall goal is that we want people in our state to be able to make an informed choice and we want to have quality infrastructure in place to support that,” said Dawn Lambert, project director for Connecticut State Department of Social Services’ Money Follows the Person Program, a federal demonstration program run by Medicaid that seeks to eliminate barriers in state law, state Medicaid plans and budgets to let people choose the setting in which they receive long-term care. The program provides partial funding for the initiative as part of the state’s strategic plan to rebalance these services in a cost-effective way.

Lambert discussed the initiative with KHN’s Kelsey Miller. Here is an edited transcript of the interview.

Q:Ìý Why focus on long-term care in the state?

A:Ìý In Connecticut,Ìý of our Medicaid population receives long-term care. At first glance, it may not seem like a lot of people, but those people utilize 47 percent of expenditures. Also, we know that population is going to grow about 25 percent over the next few years. We did , we looked at this projection and we mapped it out. That speaks to how many more accessible and affordable housing units we need, how much more workforce we need, if we have the right amount of nursing home beds, etc.Ìý

Q: How does the new website, ad campaign and call center make it easier for consumers to access long term care?

A: The website will, by 2015, link directly to the department’s ConneCT Medicaid site and we’ll help navigate the person through the site. If it is Medicaid that you need, we’ll make sure that you’re linked behind the scenes or if you actually need health insurance you’ll end up in the health exchange. My Place is building on more of the community and local health services.Ìý

Q: How does your initiative work with the Affordable Care Act, especially in terms of funding?

A: We see [My Place CT] as being totally integrated with the Affordable Care Act. We see it all under the ACA as access to health care. It’s critical for those things to be connected because if you have someone with long-term needs and you’re not seeing the person as a whole, then you’re going to be missing something.Ìý

Q: Part of the initiative focuses on the , helping to connect those interested in becoming caregivers to training and job opportunities. Why is this a prominent part of the initiative?

A: If we don’t grow that workforce people won’t have a choice. That’s an important thing to do first. If you speed the connection to services first, you won’t have that infrastructure in place. Right now, phase one of the website offers descriptions of the different classification of workers that we know we need to grow initially. It offers links to the existing training and a way to link to the personal care directory. In phase two, it will actually link the employer to the employee.

Q: The site has been up for a few weeks now, what are the initial responses to the initiative?

A: We’ve had really favorable responses and have had several meetings about how we can constantly improve the website. We do envision that the website will electronically link in a secure way to both our Medicaid access database as well as our health insurance marketplace.

We envision that you will be able to go and complete your needs assessment to connect with formal services and informal services. As far as workforce, the campaign is rolling out and we expect there will be videos on the site giving people more of an idea what that job is like. The website is the primary communication tool, it’ll constantly be changing.

This article was produced by Kaiser Health News with support from .

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“We want to spend our time seeing patients, not doing paperwork,” said Dr. Jason Mitchell the director of the Center for Health IT at the American Academy for Family Physicians.

The Sunshine Act requires drug companies and medical device makers to report payments, gifts and investments to Centers for Medicare and Medicaid Services. Though the act is nowÌýin effect, a complete set of records are not due until March 2014 and will .

Consumer advocates and other stakeholders favor openness when it comes to the large amounts of money medical and pharmaceutical companies spend to influence a doctor’s choices, according to a Pew Health Center . Holding both parties accountable with a clear reporting system would allow consumers to spot potential bias.

Mitchell, who is also a practicing familyÌýphysician in Missouri, does not anticipate many immediate changes for doctors – aside from fewer lunches with pharmaceutical representatives.

He predicts that because of the increased attention placed on these small meetings that make up a majority ofÌýthe reportable interactions, doctors will likely shy away from them – which could be problematic. If doctors minimize their working relationships with pharmaceutical and medical representatives, their knowledge could be “less of a resource,” Mitchell said. It’s important for doctors to keep up with drug and product information in other ways, he added.

In an effort to simplify the reporting of these payments, a number of iPad and iPhone Apps have been developed. Doctors and industry professionals can enter data by hand or scan documents which are filed into easy lists and spreadsheets.

The Centers for Medicare and Medicaid Services created different Apps designed specifically for and others for , both of which have to remain accountable for these transactions.

Though it’s up to the companies to do the reporting, doctors are encouraged to keep their information up to date and to follow up on what transactions are being reported.

“There’s no reason to believe it will be erroneously reported,” Mitchell said. “We don’t have anything to hide. We certainly are very conscious of conflicts of interest.”

“Transparency is a good thing,” Mitchell said. “But we certainly don’t want an increased burden.”

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“There’s a handful of people who drive most of our spending,” said , the executive director of the . These patients, called or “frequent flyers,”ÌýoftenÌýgo to a hospital to get treated for a recurring health issue that can be treated more effectively in other ways, he said.

can bring down costs in the long run.

“It’s not just physical health services,” Crippen said. “There are a lot of non-physical health services that can help these folks out.”

These patients make upÌý 5 to 10 percent of hospital patients, according to Crippen.

States leaders will first meet as a group — then officials will spend 18 months implementing the plans in their communities.ÌýAlaska, Colorado, Kentucky, New Mexico, Puerto Rico, West VirginiaÌýandÌýWisconsin are the states participating in the project.

Officials from each of those states will work with the association and national health care experts to develop a plan that will redirect these patients to care that is less costly, more efficient and more accessible. The effort will also explore non-medical issues that these patients often confront, such as transportation and housing problems. For example, Crippen noted, asthma patients may be able to control their condition and avoid costly trips to the doctor or the hospital if they have an air conditioning unit at home, but often state programs don’t have the authority to spend money on such non-medical interventions.

Additionally, patients who are given prescriptions sometimes don’t fill them because they don’t have transportation to a pharmacy, Crippen said. By coordinating delivery or mail-order prescriptions, he added, experts say individuals will have to visit ERs less often.

“Our current health care system doesn’t pay for those as health care costs,” Crippen said, and this effort by the states would seek to find ways to solve a patient’s multiple issues at one time.

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Researchers from the Centre for Research in Geriatric Medicine at the University of Queensland, Australia, studiedÌýpatients 75 years or older in emergency departmentsÌýaround the world to paint a picture of the unique problems they face — and how ERs can change to better serve them.

Lead author Dr. Leonard C. GrayÌýsaidÌýolder people who arrive atÌýemergency departments are more likely to have “geriatric syndromes” such as immobility, confusion and incontinence. The findings also indicated that for many, functional and cognitive issues increased afterward.

“These problems increase the complexity of care, and require specific interventions to ensure the best results,” Gray said in an email.

Researchers studiedÌý2,282 patients in 13 different emergency departments in seven countries including Australia, Belgium, Canada, Germany, Iceland, India and Sweden. They looked at medical records, talked to hospital staff and interviewed the patients directly about their cognitive function, mood, comprehension and more. Researchers also tracked theÌýpatients’ progress for 28 days after their ER visit.

Before coming to the ER,Ìý54 percent were independent and didn’t require help for daily activities. After, only 33 percent were still listed asÌý“completely independent.”

The number of patients studied who displayed symptoms of cognitive impairment rose 6 percent after their trips to theÌýER, and the number of those who could not walk without assistance rose 23 percent.

Though the study fails to look into specific reasons why these older patients were negatively affected byÌýER visits, researchers say the numbers should be a signal forÌýhospitals. “With population aging, and relative reductions in severe health problems among younger age groups, the proportion of patients in the [emergency department] who are older is likely to increase,” Gray said. “Therefore, the case for designing the [emergency department] to cater for the needs of older people will escalate continuously.”

Such stepsÌýcould include simple changes in furniture or lighting or more complex changes such as staff training and risk minimization.

“It seems not a matter of ‘if,’ but rather ‘when’ adjustments should be made,” Gray said.

This article was produced by Kaiser Health News with support from .

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