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For the second year in a row, California is posting robust initial numbers of legal residents signing up for health insurance under the nation's new health care law, according to figures released Wednesday. (Seipel, 12/10)

With less than a week until the deadline to buy individual health insurance that begins Jan. 1, experts say sign-ups are on course to hit or exceed the Obama administration’s projection of about 9 million enrollees in 2015. Several weeks into the second year of the Affordable Care Act’s insurance exchanges, about 1.5 million people have enrolled in coverage, according to data from state and federal exchanges. (Galewitz, 12/11)

California's insurance exchange said 48,950 new people signed up for Obamacare coverage during the first three weeks of open enrollment. The latest figures span Nov. 15 to Dec. 3, and state officials said about 160,000 people have also applied for Medi-Cal, the state's Medicaid program for low-income residents. (Terhune, 12/10)

Oregon health insurers on Wednesday urged state lawmakers to act quickly in dissolving Cover Oregon and transferring its authority to other state agencies. Insurance companies need certainty as they plan their 2016 insurance rates, which must be filed with the state in the spring, lobbyists for several companies told a legislative committee formed to oversee the potential unwinding of the health insurance exchange. (Cooper, 12/10)

About a quarter of Maryland residents who need to re-enroll in the state’s health insurance marketplace to get their correct subsidies by Jan. 1 have done so, Maryland officials said Wednesday. Now, they are urging the rest of roughly 66,000 individuals who enrolled earlier to sign up again before next week’s deadline to get coverage by the first of the year. (12/10)

Buried in the spending deal that congressional negotiators announced on Tuesday are several nuggets that should be of interest to hospitals, home health providers and pharmaceutical companies. They won't have any immediate impact but could lay the groundwork for significant policy changes. Congress is seeking answers from the CMS about its requirement that home healthcare agencies provide face-to-face certifications by a physician before the agency will cover in-home care for Medicare and Medicaid beneficiaries. The spending deal asks the agency to detail in its 2016 budget request how that requirement has prevented fraud, increased access to healthcare and affected costs for the Medicare and Medicaid programs. It also calls on the agency to present a plan for how the face-to-face certification requirement can be simplified. (Demko, 12/10)

A provision tacked onto the $1.1 trillion fiscal 2015 spending package would allow Blue Cross and Blue Shield health plans, which cover 100 million people, to count so-called health quality spending toward government requirements on insurance profits while maintaining favorable tax treatment. The medical loss ratio requirement under the 2010 health care law generally obligates large group health plans to pay out refunds if they don't spend at least 85 percent of their premiums on medical claims or so-called health-quality improvement plans. (O'Donnell, 12/10)

The $1.1 trillion spending bill pending on Capitol Hill includes two bipartisan changes to Obamacare, both technical corrections that so far have drawn little attention. The changes, involving expatriate health insurance plans and the tax status of nonprofit health insurance plans, represent relatively minor adjustments to the massive Affordable Care Act. But the fact that it is has taken this long to get them to the finish line shows how difficult it is to make even bipartisan changes amid the political turmoil that still surrounds the law. (Haberkorn, 12/10)

Republicans didn’t manage to get the big conscience protections on abortion and contraception they wanted into Congress’ bipartisan spending agreement — but they did get a few small wins. The bill contains language directing HHS to clarify within 30 days how insurance plans in ACA exchanges should disclose whether they cover elective abortions. Both abortion rights supporters and opponents acknowledge — and research has shown — that it’s hard for shoppers to find that information the way plan benefits are currently displayed. (Winfield Cunningham, 12/10)

For months, the U.S. has been without a surgeon general, a largely ceremonial position affectionately dubbed "the nation's top doctor." That could change with the Senate Democrats' final days in office. (Kaplan, 12/10)

Sen. David Vitter finally got a win on his eponymous amendment — sort of. The Louisiana Republican’s proposal to force members of Congress and their staffs onto the Obamacare health exchanges was approved by the Senate Republican Conference during a closed-door meeting Wednesday afternoon. Earlier Wednesday, Vitter said he was unsure whether the controversial measure would be approved, but the toothless provision easily passed by voice vote, drawing little opposition. ... Privately, congressional aides have fumed about Vitter’s proposal every time it comes up, because leaving the subsidized federal health insurance program might require them to pay more and change their doctors. It’s unclear if Vitter’s amendment will force GOP senators to change their aides’ insurance plans, but at least one colleague said even before the vote that he would take Vitter’s cue. (Kim and Everett, 12/10)

Aetna Inc. on Wednesday issued a weaker-than-expected profit forecast for next year, a day ahead of an investor conference. The Hartford, Conn., insurer said it expects to make at least $6.90 a share on revenue of at least $62 billion in 2015, compared with estimates of $7.17 a share on $61.7 billion in revenue, according to Thomson Reuters. (Armental, 12/10)

Philadelphia’s transit agency has sued Gilead Sciences Inc., accusing the company of “price-gouging” on the sale of its $1,000-per-pill hepatitis C drug Sovaldi, the latest salvo in a battle between health-care payers and the pharmaceutical industry over prices. (Loftus, 12/10)

Nearly 20 percent of U.S. consumers — 42.9 million people — have unpaid medical debts, according to a new report by the Consumer Financial Protection Bureau. The findings suggest that many Americans are being trapped by debt because they are confused by the notices they get from hospitals and insurance companies about the cost of treatment. As a result, millions of Americans may be surprised to find they are stuck with lower credit scores, making it harder for them to borrow to buy a home or an automobile. (Boak, 12/10)

After this year, the CBO is forecasting that deficits will resume rising for the rest of the decade as baby boomers retire and Social Security and Medicare costs rise. The CBO and other budget experts have warned that the current trajectory for the deficit is unsustainable and eventually could lead to a fiscal crisis. (12/10)

The federal government has recovered nearly $5 billion in misspent healthcare dollars over the last fiscal year, about 15 percent less than the same period last year. Investigations within the Department of Health and Human Services (HHS) led to roughly 1,000 criminal charges and 500 civil charges, according to a report Wednesday. The department also barred more than 4,000 people from federal healthcare programs. (Ferris, 12/10)

Boston Medical Center and Tufts Medical Center are considering a merger, a deal that, if approved, would be the biggest union of Boston teaching hospitals in nearly two decades. A merger would link two nonprofit hospitals that both treat many low-income patients and have endured financial struggles. BMC, the state’s largest “safety net” hospital, has an especially high number of patients on Medicaid, the government health insurance program for the poor. Tufts has tried to carve a place for itself in a city rich with world-renowned hospitals. (McCluskey and Weisman, 12/11)

The wave of Massachusetts hospital consolidations is building. Tufts Medical Center and Boston Medical Center (BMC) issued statements Wednesday night confirming that the two not-for-profit institutions are discussing a merger. (Bebinger, 12/10)

A Department of Veterans Affairs hospital project near Denver came to a standstill this week after federal judges ruled the VA was in breach of contract, hundreds of millions of dollars over budget and devoid of a plan to adequately fund the facility. The billion-dollar project is one of four large VA construction plans that in recent years have faced cost and schedule overruns, as well as scrutiny by legislators and government auditors. The agency is moving to upgrade its facilities amid the growing number of veterans returning from more than a decade of war. (Kesling, 12/10)

Kansas Department for Aging and Disability Services decision last week to limit admissions to Osawatomie State Hospital has had an immediate effect on the state’s mental health system. Marilyn Cook, executive director at COMCARE, the community mental health center in Wichita, said the state’s decision to suspend admission of voluntary patients and more closely screen involuntary admissions at the Osawatomie facility recently prevented the center from transferring several patients thought to be a danger to themselves or others. KDADS last week announced an immediate suspension of voluntary admissions to Osawatomie after federal surveyors threatened to block a significant portion of its Medicare payments. The agency also said involuntary admissions would be “aggressively triaged” and that would-be patients were not to be sent to Osawatomie unless their transfer had been pre-approved by an “admissions officer” or an on-duty physician. The new policy is designed to reduce the number of patients at Osawatomie, which in recent months has often exceeded its licensed capacity. (Ranney, 12/10)

A panel charged with reviewing Texas government voted Wednesday to recommend the state combine all health and human services programs into one mega-agency and limit the power of Medicaid abuse investigators to pursue less serious cases. The recommendations, if adopted by the Legislature next year, would dramatically change the structure of health and human services in the state. However, it is unclear how services would be affected. The combination of the departments of State Health Services, Family and Protective Services, Aging and Disability Services and Assistive and Rehabilitative Services into the state Health and Human Services Commission would continue a consolidation that has been going on for years and improve efficiency, said state Sen. Jane Nelson, a Flower Mound Republican who chairs the panel known as the Sunset Advisory Commission. (Rosenthal, 12/10)

In a letter being sent to insurance companies this week, the governor said that because state law requires insurance coverage for the diagnosis and treatment of psychological disorders, people who are found to have a mismatch between their birth sex and their internal sense of gender are entitled to insurance coverage for treatments related to that condition, called gender dysphoria. (Hartocollis, 12/10)

The Massachusetts Medicaid program spent $35 million on questionable claims for health care provided to low-income immigrants, according to a critical report released Wednesday by state Auditor Suzanne Bump. The findings reflect “serious weaknesses” in the agency’s claims processing system, Bump concluded, and illustrate the need for tighter controls. (Lazar and Anderson, 12/11)

Florida’s tough new safety rule for medical-office surgery, years in the making, has been delayed at the last minute by an outcry from obstetrician-gynecologists. The OB-Gyns appeared Friday at the Florida Board of Medicine, which was to have passed the safety rule that day, to ask for an amendment to spare them from some of the provisions. Board members decided instead to postpone the issue while they figure out what to do. The physicians protesting the move say it would force them to stop doing certain common procedures in an ordinary medical office, which the rule calls “Level One.” They would have to add staff and equipment to become “Level Two” offices, which they claim would boost the cost of the procedures beyond many women's ability to pay. (Gentry, 12/10)

Veterans' health care facilities should strive to provide immediate mental health care for any who request it, the leader of the Department of Veterans Affairs said Wednesday in Atlanta amid concern in neighboring Alabama that average wait times are too long. Secretary Robert McDonald spoke with reporters while in the city to attend a conference for veterans who own businesses. McDonald's visit came after U.S. Rep. Martha Roby of Montgomery's criticism of the average wait time of 67 days for an appointment in mental health care at the Central Alabama Veterans Health Care System in recent federal statistics. A June audit found the wait was around 57 days. The system has disputed those figures because of incorrect appointment record-keeping. (Foody, 12/10)

Florida Healthcare Plus, a Medicare HMO with 10,000 members, was declared insolvent Wednesday and turned over to state authorities. In such cases, state and federal officials help patients move into other health plans or to traditional Medicare. More information is expected on that today or Friday. The three-year-old company was already reeling. In September, the state suspended the plan from signing up any more members, only weeks before Medicare open enrollment. Worse was to come in November with a federal indictment of 11 people, including two former executives and four other plan ex-employees, in an alleged Medicare and Medicaid fraud ring. (Gentry, 12/11)

Hundreds of nursing homes and other assisted living facilities in Kansas will be required to participate in a fund meant to spread the risk of malpractice lawsuits starting next month. Advocates for those facilities say the change is a positive, but it has insurance agents scrambling to find liability coverage for their assisted living clients in a limited market. For more than two decades, health care facilities in Kansas have been required to participate in the Health Care Stabilization Fund, a pot of money derived from a surcharge on their private malpractice insurance that provides additional coverage for malpractice claims. The fund makes it less likely that a few expensive claims could sink a facility financially. (Marso, 12/10)

The Northern Arapaho tribe filed a federal lawsuit Tuesday alleging that proposed Internal Revenue Service rules could cause Native Americans to pay higher insurance premiums or lose health care benefits. Tribal leaders said the recently proposed IRS interpretation of the large-employer mandate would unlawfully exempt Native Americans working for the tribe from receiving tax credits and cost-sharing benefits specifically outlined by new federal health laws. (12/10)

Two years ago, a coterie of biotechs began lobbying state legislatures to pass laws that would make it more difficult to substitute lower-cost biosimilars for brand-name biologic medicines. The plan was to require pharmacists to notify doctors when substituting one drug for the other, which would act as a deterrent by slowing the process. Generic drug makers responded with a counterattack. (Silverman, 12/10)

A Supreme Court ruling this spring could upend health insurance markets in at least 34 states, eliminating the federal subsidies that make coverage affordable for millions of Americans. State governments, theoretically, have ways to forestall this outcome. But few have taken action. If they wait until the court rules, it may already be too late for a state to get started on an exchange so that it is ready for 2016. (Margot Sanger-Katz, 12/11)

The 2014 elections altered the ACA's political environment in a way that could produce changes in the law, but its core will remain in place. Now the question is, once again, whether Obamacare will emerge intact from the Supreme Court. If the Court dramatically narrows the ACA's scope, the political calculus will change substantially in 2015 and beyond. The law's recent momentum will be reversed, the fight over Obamacare will intensify, and the future of health care reform will be highly uncertain. (Jonathan Oberlander, 12/10)

The U.S. Supreme Court's surprise announcement on November 7 that it would hear King v. Burwell struck fear in the hearts of supporters of the Affordable Care Act (ACA). ... the states in question may not want to operate their own exchanges. The political climate is hostile to the ACA in nearly all of them. Just seven of them will be led by Democratic governors in 2015; ... ACA opponents' commitment to resisting the temptation of federal money should not be underestimated: witness the refusal of nearly two dozen states to expand Medicaid even though the federal government would cover almost all the costs. ACA supporters thus have good reason to worry. (Nicholas Bagley, David K. Jones and Timothy Stoltzfus Jost, 12/10)

The success of health care reform in the United States depends on the proper functioning of our market-based health care system. Antitrust laws play a crucial role in ensuring that consumers benefit from robust market competition. ... The FTC supports the key aims of health care reform, and we recognize that collaborative and innovative arrangements among providers can reduce costs, improve quality, and benefit consumers. But these goals are best achieved when there is healthy competition in provider markets fostering the sort of dynamic, high-quality, and innovative health care that practitioners seek and patients deserve. (Edith Ramirez, 12/11)

IN American medicine today, “variation” has become a dirty word. Variation in the treatment of a medical condition is associated with wastefulness, lack of evidence and even capricious care. To minimize variation, insurers and medical specialty societies have banded together to produce a dizzying array of treatment guidelines for everything from asthma to diabetes, from urinary incontinence to gout. (Sandeep Jauphar, 12/10)

Toward the end of his life, my father tried to engage me in conversations about our shared profession. ... “Seen any great cases?” he'd ask. This question set my teeth on edge. ... I'd explain — again — that I was a general internist, not a specialist as he had been, and derived my professional satisfaction from long and close relationships with patients and not from making obscure diagnoses. ... The reminiscence I bristled at most, though, was about ladies — always they were “ladies” — with something he called la maladie du petit papier: the disease of the little paper. They would come to his office and withdraw from their purses tiny pieces of paper that unfolded into large sheets on which they'd written long lists of medical complaints. (Dr. Suzanne Koven, 12/11)

During World War II, the U.S. armed forces faced a surprising obstacle to recruiting sufficient field-ready personnel for the war effort: 10% of potential recruits failed service requirements related to oral health (such as having six opposing teeth), and many who met the requirements had severely compromised teeth ... So at the end of the war, “many dentists, military officers, political leaders, and others vowed to solve the Nation's rampant dental problems.” ... Of course, the ultimate goal is care, not insurance, but we know that incorporating coverage of oral health into health insurance reduces costs and improves health. (Dr. Bruce Donoff, John E. McDonough and Christine A. Riedy, 12/11)

As it happened, the 2008 election was the first time Jim and I were bitterly divided on candidates. Jim foresaw healthcare reform as an addition to the federal deficit more worrisome than any health benefit. When I told him about Obama’s victory, he grumbled, “I guess I can’t blame Obama for breaking my heart.” But, he worried that he would eventually be able to blame the president “for keeping me from getting better.” The transition to Obamacare – at least for a 59-year-old man and a 56-year-old woman in south Orange County – wouldn’t be quite that bad. But it would be, in three big ways, far rougher and more frustrating than I’d ever dreamed. (Catherine Keefe, 12/10)

Before Obamacare foes made a big deal about consultant Jonathan Gruber's videotaped statement that Democrats capitalized on “the stupidity of the American voter” to win passage of the healthcare reform law, they made a big deal about his videotaped comment about who would and would not qualify for a federal premium subsidy. Much was made of the remark by the Massachusetts Institute of Technology economist that “if you're a state and you don't set up an exchange, that means your citizens don't get their tax credits.” ... Gruber said during a congressional grilling Tuesday that his statement about subsidies and exchanges was taken out of context and that he had built his economic models based on the assumption that subsidies would be available in every state. (Harris Meyer, 12/9)

One of my sharpest memories of elementary school is the way that teachers – the young, pretty, married ones – would occasionally just disappear. One day they would be in the classroom, looking as they always did, and the next day they would be gone, replaced by a substitute – in reality, the new teacher. Over the summer or during the next school year, you might catch a glimpse of the mysteriously vanished teacher at the grocery store, pushing a baby carriage. Where had the baby come from? The pattern became clear: Once a teacher even began thinking about having a baby, the classroom was no place for her – or any like-minded woman. (Linda Greenhouse, 12/10)