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The Supreme Court is expected to rule soon on the legality of insurance subsidies in 37 states that use the federal HealthCare.gov site. Some states have discussed creating their own exchanges in the wake of the court’s decision, but those may not be fiscally sustainable. The Los Angeles Times reported last week that Covered California, the Golden State’s exchange, “is preparing to go on a diet,” cutting its budget 15% for the fiscal year beginning July 1 because of lower-than-expected enrollment. Earlier this month, Hawaii’s state exchange prepared plans to shut down this fall amid funding shortfalls. (Chris Jacobs, 5/22)

So the proposed 2016 Obamacare rates have been filed in many states, and in many states, the numbers are eye-popping. Market leaders are requesting double-digit increases in a lot of places. Some of the biggest are really double-digit: 51 percent in New Mexico, 36 percent in Tennessee, 30 percent in Maryland, 25 percent in Oregon. The reason? They say that with a full year of claims data under their belt for the first time since Obamacare went into effect, they're finding the insurance pool was considerably older and sicker than expected. (Megan McArdle, 5/25)

Historically, hospital productivity has grown much more slowly than the overall economy, if at all. That’s true of health care in general. ... But to finance coverage expansion, the Affordable Care Act made a big bet that hospitals could provide better care for less money from Medicare. Hospitals that cannot become more productive quickly enough will be forced to cut back. If the past is any guide, they may do so in ways that harm patients. (Austin Frakt, 5/25)

While politicians debate the future of Medicare and Medicaid, few question that those programs are here to stay. It's easy to forget how controversial the idea of government healthcare programs was for most of the 20th century, and how many decades it took to enact the programs. Supporters of the Affordable Care Act, which arrived in a more polarized era, hope it will eventually receive similar public acceptance. The history of Medicare and Medicaid offers some reasons to think the ACA will become a fixture of the healthcare landscape—and some to think it won't. (Harris Meyer, 5/23)

Health care policy sometimes presents conflicts between the needs of patients and the conscience of those who care for them. The Affordable Care Act brought that issue into sharp relief by requiring religiously affiliated institutions like universities and hospitals to provide medical insurance covering contraception. ... A different issue has arisen in Illinois, which has one of the country's broadest laws protecting the right of medical professionals to decline to provide services that violate their beliefs. Under this statute, a physician may not be compelled to participate "in any form of medical practice or health care service that is contrary to his or her conscience." (5/25)

Both houses of Congress are moving to reform the notoriously weak Toxic Substances Control Act, which is supposed to ensure the safety of chemicals used in a wide range of consumer and industrial products. The measures under consideration have strong bipartisan support and are thus likely to provide the first significant reforms to the law since it was enacted nearly four decades ago. The measures are a substantial improvement over the current abysmal lack of enforcement, but neither would provide the public with what it needs most: speedy evaluations of the most worrisome chemicals among tens of thousands that have never been tested for safety. (5/25)

Lawsuits filed in April against VA over disability claims, coupled with the Justice Department’s 2014 criminal investigation of VA facilities nationwide, highlight the chronic obstacles veterans face in obtaining treatment. Less obvious is the reality that, absent an effective VA system, it is families who are fulfilling the government’s responsibility to care for our vets. They face their own daunting challenges and desperately need support. (Meredith Ludlow, 5/24)

The health care professionals entering my sister’s hospital room, or answering my questions in the corridor, had perfected a polite method of ascertaining whether I was entitled to information about her condition. ... “I’m her sister and her health care proxy,” I would say. That was sufficient; we went on to discuss test results or her morphine dose. ... My sister Debra was the third family member I have accompanied, with as much dignity and comfort as we could arrange, through her last days. She was 62 when she died last month of a progressive neurological disease in a New Jersey hospital. I thought I would pass along some personal lessons. (Paula Span, 5/26)

In the past 20 years, more than 100 campaigns to legalize assisted suicide have been introduced in various states. All but three have failed. ... California is the latest place where the wheels appear to be coming off the assisted-suicide bandwagon. ... The bill was expected to fly through the California Senate, but now SB 128 is stalled. ... The bill’s opposition is a truly grass-roots effort that includes groups like the Disability Rights Education & Defense Fund, California Foundation for Independent Living Centers and the Autism Self Advocacy Network. Californians are realizing that assisted suicide represents the slipperiest of slopes. (Dr. Aaron Kheriaty, 5/22)

The governor made Medicaid expansion and balancing the budget cornerstones of his election. Expansion is a red herring and discussing expansion deflects attention from the real issue: Medicaid in its current, nonexpansion form, is unsustainable and the state cannot balance its budget without reform. Once Medicaid reform has occurred, expansion can be explored. And when expansion is explored I believe it will be shown to be bad for Alaska. (Rep. Wes Keller, 5/22)

The [House] minority is committed to raising state employee pay, expanding the Medicaid system, and raising education funds. Some think those positions “sound good.” The positions sound good, but we have to analyze what they really mean, and what costs would be incurred. There are already expanding costs, hidden costs, and not-so-hidden costs that may create substantial financial risk for Alaska. (Chad Hutchison, 5/23)

If you want to see just how long an academic institution can tolerate a string of slow, festering research scandals, let me invite you to the University of Minnesota, where I teach medical ethics. Over the past 25 years, our department of psychiatry has been party to the following disgraces: a felony conviction and a Food and Drug Administration research disqualification for a psychiatrist guilty of fraud in a drug study; the F.D.A. disqualification of another psychiatrist, for enrolling illiterate Hmong refugees in a drug study without their consent; the suspended license of yet another psychiatrist, who was charged with “reckless, if not willful, disregard” for dozens of patients; and, in 2004, the discovery, in a halfway house bathroom, of the near-decapitated corpse of Dan Markingson, a seriously mentally ill young man under an involuntary commitment order who committed suicide after enrolling, over the objections of his mother, in an industry-funded antipsychotic study run by members of the department. (Carl Elliott, 5/26)

Baltimore’s riots are last week’s news, but the underlying problems have not gone away. Violence, poverty and health disparities have many inputs. In Baltimore, the District and many other places across the country, these are closely tied to substance use and mental health problems, and to historical policies of mass arrest and incarceration. Consider these statistics. Among Baltimore’s population of 622,000, more than 73,000 arrests are made every year. The most common reason for arrest is a drug offense. Eight out of 10 people behind bars use illegal substances; four out of 10 have a diagnosed mental illness. (Baltimore Commissioner of Health Leana S. Wen, 5/22)

Medicaid provides health insurance to about 500,000 Iowans. For decades, the government program has been operated by the state, which is not beholden to shareholders. Spending has been held down by reducing fraud, paying lower reimbursements to providers and giving seniors alternatives to expensive nursing homes. On average, the annual cost to insure an Iowan with Medicaid is significantly less than insuring an individual with private coverage. Yet Gov. Terry Branstad is seeking to hand over administration of the huge health insurance program to for-profit managed care companies. With $4.2 billion on the line, businesses are salivating at the idea of landing one of these contracts with the state. (5/23)

[T]he United States continues to have one of the highest teen birth rates and some of the highest rates of sexually transmitted disease in the industrialized world. Every hour in this country, 70 teenagers become pregnant, 1,100 youth acquire an STD and one young person contracts HIV. The newspapers are full of accounts of sexual assaults on college campuses, and violence and harassment continue to plague many of our gay and gender-nonconforming youth. Perhaps most distressing is that our national response continues to misunderstand the challenge. In fact, just last month Congress increased to $75 million a year funding for programs that promote sexual abstinence until marriage. (Richard Carmona, Joycelyn Elders and David Satcher, 5/22)

“We need a national debate on nicotine,” said Mitch Zeller. Zeller is the director of the Center for Tobacco Products, a division of the Food and Drug Administration created in 2009 when Congress passed legislation giving the F.D.A. regulatory authority — at long last! — over cigarettes. In addition, the center will soon have regulatory authority over other tobacco products, including electronic cigarettes, which have become enormously controversial even as they have gained in use. Through something called a “deeming rule,” the center is in the process of asserting that oversight over e-cigarettes. (Joe Nocera, 5/26)

The federal ban on the funding of NSEPs [needle and syringe exchange programs], sponsored by the late Senator Jesse Helms (R-NC), dates back to the Health Omnibus Programs Extension of 1988. As written, the law precludes local authorities from using the Public Health Emergency Fund to provide “individuals with hypodermic needles or syringes so that such individuals may use illegal drugs.” ... serious consideration must be given at the national level to repealing the federal ban on the funding of NSEPs. What happened in rural Indiana can and will happen elsewhere. Failure to act would constitute a tragic and costly opportunity missed. (Josiah D. Rich and Eli Y. Adashi, 5/22)