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In the aftermath of the Affordable Care Act's passage, some stakeholders expressed concern that rural hospitals would struggle to meet the law's requirements and would be forced to shut down or merge with larger health systems. However, nearly four years later, the jury is still out on how rural hospitals have been affected by the law. (Drost, 10/29)

A second wave of people who purchased health insurance through HealthCare.gov but have unresolved immigration verification problems will lose their coverage at the end of this month, and notices have been sent to inform those consumers of the upcoming terminations, CMS has told consumer advocate groups. (Pradhan, 10/29)

A fast-growing, short-term alternative to ObamaCare that allows customers to get cheap, one-year policies could put the government-subsidized plan into a death spiral. The plans ... generally cost less than half of what similar ObamaCare policies cost, and are increasing in popularity as uninsured Americans learn they are required to get health coverage. (Lott, 10/29)

Small companies are starting to turn away from offering health plans as they seek to reduce costs and increasingly view the health law’s marketplaces as an inviting and affordable option for workers. In the latest sign of a possible shift, WellPoint Inc. said Wednesday its small-business-plan membership is shrinking faster than expected and it has lost about 300,000 people since the start of the year, leaving a total of 1.56 million in small-group coverage. (Wilde Mathews, Loten and Weaver, 10/29)

U.S. small businesses are dropping health insurance for their workers, as Obamacare lets them send employees to new marketplaces where they can often get subsidies from the government to buy coverage. WellPoint Inc. (WLP)’s small business insurance products lost 300,000 people this year, the company said today. Business owners are dropping coverage they previously bought through WellPoint and other insurers, and instead sending employees to shop for it on the government exchanges created under the Patient Protection and Affordable Care Act known as Obamacare. (Chen and Gilblom, 10/29)

Small businesses throughout Washington — those with 50 or fewer employees — can now shop for and enroll in health insurance plans through the state’s insurance exchange. The exchange got off to a slow start for businesses this year when only one insurance provider, Kaiser Health Plan of the Northwest, agreed to sell plans in the marketplace and only in Clark and Cowlitz counties. For coverage beginning January 2015, small employers statewide can shop the exchange for coverage from Moda Health, and Kaiser will continue selling in the two southern counties. A total of 23 different plans are available from the two insurance companies. (Stiffler, 10/29)

The fate of President Barack Obama’s health-care law is again in the hands of the U.S. Supreme Court. Two years after upholding the law by a single vote, the justices are weighing whether to hear a Republican-backed appeal that would block people in 36 states from getting tax subsidies to buy insurance. The justices are scheduled to discuss the matter tomorrow, with an announcement coming as soon as Nov. 3. (Stohr, 10/30)

A federal judge in Florida on Tuesday jumped into the latest round in the legal wrangling over a Patient Protection and Affordable Care Act provision involving birth-control coverage and how it applies to religious institutions. (Schencker, 10/29)

In the country’s unhealthiest state, the failure of Obamacare is a group effort. ... The first year of the Affordable Care Act in Mississippi was, by almost every measure, an unmitigated disaster. In a state stricken by diabetes, heart disease, obesity and the highest infant mortality rate in the nation, President Barack Obama’s landmark health care law has barely registered, leaving the country’s poorest and perhaps most segregated state trapped in a severe and intractable health care crisis. (Varney, 10/29)

Kentucky and Arkansas, unlike other Southern states, adopted the Affordable Care Act’s expansion of Medicaid, adding more people to the program. Although the two states took different approaches, hospital officials in both say it is working better than expected. (Craig, 10/29)

Health and Human Services (HHS) Secretary Sylvia Mathews Burwell met with leading health insurance executives on Wednesday to discuss ObamaCare's second open enrollment period. Twelve executives met with Burwell, including two representatives of the industry's trade association, America's Health Insurance Plans, the department said. The healthcare law's exchanges are scheduled to open for sign-ups in less than three weeks, and the Obama administration is intent on avoiding technical fumbles like those that plagued the system last year. Both sides are hoping to present a united front. (Viebeck, 10/29)

Alastair “Al” Fitzpayne, a top Treasury Department aide with extensive contacts on Capitol Hill, will be the next chief of staff at the Department of Health and Human Services, working with secretary Sylvia Mathews Burwell. In selecting Mr. Fitzpayne, Ms. Burwell tapped a well-connected administration aide who has worked on some of the most high-stakes fiscal battles in recent years but has relatively little health care experience. (Paletta, 10/ 29)

Although the politics of Obamacare have cooled down this year — and even with declining interest in this year's midterms — the upcoming election will have a bigger influence on the direction of health care than you may think. That's the major takeaway from a new Harvard University analysis of 27 public opinion polls from 14 organizations on President Obama's signature law. The analysis, published in the New England Journal of Medicine, offers a pretty comprehensive view of how the Affordable Care Act — less than a year into its major coverage expansion — will shape the agenda for the next Congress and potentially the 2016 presidential race. (MIllman, 10/29)

On Fox News yesterday, Senate Minority Leader Mitch McConnell -- who is hoping to become Majority Leader Mitch McConnell -- admitted that full repeal of the Affordable Care Act isn’t in the cards if the GOP takes control of the Senate. (Todd, Murray and Dann, 10/29)

Senate Minority Leader Mitch McConnell says Republicans won’t be able to repeal Obamacare anytime soon. Tempering the expectations of conservatives a week before the elections that could install him as the first Republican majority leader in eight years, the Kentucky Republican said in a Fox News interview Tuesday that a repeal of the health care law simply wasn’t in the cards for now. (Lesniewski, 10/29)

House Speaker John Boehner’s still-unfiled lawsuit against President Barack Obama for exceeding his constitutional power is in more trouble. For the second time in two months, a major law firm has backed out of an agreement to pursue the case, sources say. ... Boehner’s office also suggested the suit, which planned to challenge Obama’s failure to implement aspects of his health care reform law, could be broadened if Obama goes forward, as promised, with plans for executive action on immigration. (Gerstein and Haberman, 10/29)

Most Americans don’t want to get rid of Obamacare. They just don’t share its fundamental goal of universal coverage anymore. And not only did the political benefits that Democrats thought the 2010 law would eventually bring them not materialize, opposition has only grown, according to an analysis of multiple polls taken between 2010 and last month. (Wheaton, 10/29)

More than $24 million in TV advertising already has aired in the state with a week to go before Election Day, according to the nonpartisan Center for Public Integrity, which is tracking ad spending across the country. National conservative group Crossroads GPS, co-founded by GOP operative Karl Rove, aired a new ad Tuesday, hitting Landrieu for her vote for President Barack Obama’s signature health care law. The 30-second TV commercial said the Democratic incumbent’s vote was a betrayal of Louisiana, a continuing theme of GOP advertising that has framed Landrieu as a rubber stamp for the president. Despite the negative ads, Landrieu continued to embrace the health overhaul... (Deslatte and Elliott, 10/20)

Though many of the major problems were fixed within a few months, calls for Obamacare's repeal haven't disappeared. They are, however, a little more muted than voters may have expected. (Condon, 10/30)

Political ads trashing Obamacare have vastly outnumbered the spots praising it this year. But there have been even more ads trying to get Americans to use the law — nearly 374,000 of them as of mid-October. (Wheaton, 10/30)

What a difference a year makes. The nation’s biggest health insurers entered last fall cautious about a major coverage expansion initiated by the health care overhaul, the federal law that aims to cover millions of uninsured people. ... But a year later, these challenges are starting to appear manageable, and investors see much less uncertainty ahead for the sector. Insurers have cut costs and raised prices to help mitigate added expenses from the law. They’ve also added new business. (10/29)

Cigna Corp. again raised its guidance as fee and premium revenue grew along with its customer base. The health insurer’s results easily topped analysts’ expectations. The company again raised its earnings outlook for the year, this time to a range of $7.25 to $7.45 a share, from $7.20 to $7.40. Fellow health insurers WellPoint and Aetna had also raised their guidance this week. (Calia, 10/30)

The Indianapolis insurer's big quarter comes after competitors Aetna Inc. and UnitedHealth Group Inc. also topped quarterly expectations and raised their annual forecasts. Insurers began the year cautious about a major coverage expansion initiated by the overhaul, the federal law that aims to cover millions of uninsured people. Late last year, the U.S. introduced state-based public health insurance exchanges that promised to give insurers millions of new customers by making it easier for people to buy coverage, sometimes with help from income-based tax credits. But the overhaul also heaped additional costs onto the balance sheets of insurers, including an industrywide tax that is non-deductible. It trimmed funding for Medicare Advantage plans and altered the manner in which insurers operate by preventing them from excluding high-risk patients. (10/29)

Magellan Health experienced a more than 40% drop in net income during the third quarter that ended Sept. 30, attributable to a higher tax rate that resulted from the health insurance fee outlined in the Patient Protection and Affordable Care Act, the Avon, Conn.-based healthcare management company reported. Full-year expense related to the fee will be approximately $21 million, the company estimated. (Dickson, 10/29)

When Honeywell International Inc. recently asked workers to participate in voluntary screenings of their cholesterol, body-mass index and other health measures, it made a persuasive case: Employees who choose not to sit for the screenings—part of the company’s wellness program—could face up to $4,000 in surcharges and lost incentives in 2015. (Weber, 10/29)

A federal agency is suing Honeywell over new company rules that penalize employees who don't submit to biometric and medical testing. The tests required by the company would measure blood pressure, cholesterol and glucose levels, as well as check for evidence of smoking. Lawyers for the federal agency are asking the court to immediately order the company not to impose any costs on employees who don't take the tests. The Equal Employment Opportunity Commission suit filed this week in Minneapolis argues that Honeywell's new policy violates the Americans with Disabilities Act (ADA). Agency lawyers argue that a company can ask employees to undergo voluntary testing, but it can't impose a penalty on those who decline. (Collins, 10/29)

Two retirees have sued General Electric in federal court alleging that the company violated federal law by dropping its supplemental health coverage and placing retirees in a health care exchange. In a lawsuit filed in the Eastern District of Wisconsin, the pair allege that GE breached its promise to keep the benefits indefinitely only to announce in September 2012 and last month that the company would drop its Medicare plans and switch non-union retirees to private coverage. (Schneider, 10/29)

A nurse who cared for Ebola patients in Sierra Leone was headed for a legal showdown with the State of Maine on Wednesday over whether the state can quarantine her against her will. The dispute is heightening a national debate over how to balance public health and public fears against the rights and freedoms of health care workers, and troops, returning from West Africa. (Zernike and Fitzsimmons, 10/29)

A nurse who vowed to defy Maine's voluntary quarantine for health care workers who treated Ebola patients followed through on her promise Thursday, leaving her home for a bike ride. Kaci Hickox and her boyfriend stepped out of their home Thursday morning and rode away on bicycles, followed by state police who were monitoring her movements and public interactions. Police couldn't detain her without a court order signed by a judge. (Bukaty, 10/30)

California's top health officer has ordered a 21-day home quarantine for all returning medical workers or travelers who have had contact with a confirmed case of Ebola in West Africa, and invoked the possibility of imprisonment and fines if the restrictions are disobeyed. The order, issued Wednesday by California Department of Public Health Director Dr. Ron Chapman, is the latest in a series of measures issued by state governments in response to widespread — and some say unwarranted — public fear. (Morin and Flores, 10/29)

The Spanish flu pandemic a century ago prompted the last large-scale quarantines in this country. Now the Ebola outbreak is raising new questions about whether ordering quarantines is an effective way to fight deadly disease in the U.S. (10/30)

If Iowa Democrats can’t hang on to control of the state Senate, Gov. Terry Branstad (R) will be freer to pursue an ambitious agenda. If Arkansas Republicans keep control of the state House and win the governor’s mansion, the future of that state’s unique approach to Medicaid expansion under the Affordable Care Act is at risk. In Kentucky, Sen. Rand Paul (R) could take advantage of a Republican state legislature to change a law that prevents him from running for president and re-election to the U.S. Senate at the same time. (Wilson, 10/29)

An antiabortion referendum is turning into this state’s most contentious campaign this fall, as groups for and against the measure work to get out the vote in an otherwise ho-hum election season. (McWhirter, 10/29)

A year after the federal Affordable Care Act took effect, California voters are now considering another major change to health care: a ballot measure that would give state officials the authority to veto health insurance rate increases for individual and small group plans. Proposition 45 would hand broad new control of the individual health insurance market to the state insurance commissioner, who could reject rate increases deemed excessive. The measure is designed to keep costs down for consumers in a state where health care premiums have spiked in recent years, raising public ire. (Lovett, 10/29)

A new ad from the Republican Governors Association attacking Democratic gubernatorial candidate Mark Schauer over the Affordable Care Act is largely factual but includes key statements that are highly misleading. Claim: "Now Michigan seniors are facing higher costs, fewer benefits, and loss of their doctors." Reality: Partly false and highly misleading. Health care costs were rising dramatically prior to the passage of the Affordable Care Act and growth in per capita health care costs has slowed since its passage. Though some seniors on Medicare Advantage plans -- about a third of the total -- have lost access to their doctors, the ad's statement is too sweeping. Many seniors who were in the gap known as the "doughnut hole" are saving on prescription drugs as a result of the ACA. (Egan, 10/29)

If Republicans win control of the Senate next week, they will have a rare opportunity to design a unified congressional economic plan that reworks things like health-care spending, tax policy, labor rules, and adjustments to social-welfare programs. For the past few years, a number of states led by GOP governors have served as incubators for some of these ideas with mixed results. Those experiences could influence which strategy GOP lawmakers adopt. Many of these governors inherited large projected budget deficits and made tax and spending changes to balance the budget (as they are often required to do by law). Sometimes, the changes resonated well with voters. But the jury is still out in a number of states. (Paletta, 10/29)

The Los Angeles County Board of Supervisors ordered the public health department this week to provide an update on the nursing home inspection process, responding to a Kaiser Health News report that draft penalties in three patient deaths had been reduced without explanation. The supervisors unanimously approved the motion to have the acting public health director report back with a “detailed description” of procedures for reviewing nursing home penalties recommended by on-site inspectors. The vote followed an article published Saturday in the Los Angeles News Group newspapers, which described three fatal cases in which sources said inspectors’ draft citations had been downgraded. (Gorman, 10/29)

Louisiana Gov. Bobby Jindal on Saturday called congressional Republican leaders "fearful" of acting to fully repeal President Barack Obama's health care law. Jindal, a second-term Republican governor weighing a 2016 presidential candidacy, said the GOP had failed to act on their signature issue in the 2014 midterm elections. Republicans overtook Democrats in the Senate and broadened their majority in the House.

There is little doctors can do for those suffering serious brain injuries from car crashes, athletics and battle, other than wait and treat the symptoms, but a unique collaboration between those who study mental illness and those who treat the disorders offers hope for new therapies. The first goal of the new Towson-based institute formed by researchers at the Lieber Institute for Brain Development and doctors at Sheppard Pratt Health System is to reformulate an old Parkinson's drug to soothe aggression and aid memory in people suffering from such brain injuries. Officials expect the new institute, announced Wednesday, to eventually translate discoveries of their own and others in genetics and brain functioning into better treatments for those suffering not just head injuries but schizophrenia, bipolar disorder, autism and other mental illnesses affecting millions of Americans. (Cohn, 10/29)

A consultant hired to find a way to divert the mentally ill from Los Angeles County's jail system found that not enough law enforcement officers were trained to handle people undergoing a mental health crisis. In a report made public Wednesday, the consultant found that more resources were needed to train police officers, dispatchers and other criminal justice workers on how to deal with people with mental illness, and that law enforcement agencies should expand the use of special teams that respond to people in crisis. (Sewell, 10/29)

We know that about 10 million more people have insurance coverage this year as a result of the Affordable Care Act. But until now it has been difficult to say much about who was getting that coverage — where they live, their age, their income and other such details. Now a large set of data — from Enroll America, the group trying to sign up people for the program, and from the data firm Civis Analytics — is allowing a much clearer picture. The data shows that the law has done something rather unusual in the American economy this century: It has pushed back against inequality, essentially redistributing income — in the form of health insurance or insurance subsidies — to many of the groups that have fared poorly over the last few decades. (Kevin Quealy and Margot Sanger-Katz, 10/29)

The Upshot at the New York Times has a terrific set of graphs and charts on the Affordable Care Act that explains something important: In the real world, Obamacare is more or less doing what it was supposed to do. About 10 million more people have insurance now than a year ago (and this doesn't count young people newly added to their parents’ insurance). The takeaway is just how big a deal Medicaid expansion is -- and what the consequences are of delaying it, thanks to the Supreme Court decision giving states the ability to opt out and the willingness of some Republican governors to do so. (Jonathan Bernstein, 10/29)

om Politico and Kaiser Health News comes this jaw-dropping look at Mississippi, the national graveyard of the Affordable Care Act's promise. ... The author, Kaiser Health News correspondent Sarah Varney, ascribes the state's failure to errors, ignorance, racism and tea party-style ideology, among other distasteful qualities. The majority of the 138,000 Mississippians left stranded by the state's refusal to opt in to Medicaid expansion are black. Hospitals, which were counting on the expansion to make up for federal funding they'll be losing as the ACA takes hold, are unable to serve the uninsured even as charity cases. What makes Mississippi typical among Medicaid-refusing states is that its health statistics are dismal. What makes it stand out is that its socio-economic statistics are the worst in the nation. (Michael Hiltzik, 10/29)

A lengthy piece at Politico.com about Mississippi further highlights the Republican hypocrisy that has characterized the fight against President Barack Obama and the Affordable Care Act. Reporter Sarah Varney says that officials in Mississippi, the sickest state in the nation where a quarter of residents don't have health coverage, began working on a plan to expand healthcare coverage there in 2007, the year before Obama was elected. ... Then came Phil Bryant, ... who proudly proclaims his support from [the tea party]. The end result is that 138,000 Mississippians who would get Medicaid with an expansion won't be getting it. (Jarvis DeBerry, 10/29)

Even though it's been the law of the land for over four years now, Republicans cannot stop campaigning on the promise that they're somehow going to repeal the Affordable Care Act. Claiming that you're going to repeal "every word" continues to be a major applause line with conservative audiences and many Republican governors are still resisting the Medicaid expansion, at least long enough to get those anti-ACA voters to the polls. But denouncing "Obamacare" is already running out of steam as a political strategy and by 2016, it may be entirely kaput. So Republicans should enjoy riding that horse now, because by the next cycle, it will be too lame to be mounted. (Amanda Marcotte, 10/29)

Maine’s current governor is Paul LePage, a Republican elected in the 2010 Tea Party wave whose defining legacy ... will be his profound antipathy to the social safety net that so many people rely on in Maine, New England’s poorest state. ... he has vetoed—not once, but thrice—the expansion of Medicaid under the Affordable Care Act, which would cover nearly 70,000 people in the state—that is, more people than live in Portland, the state’s largest city. (Alec MacGillis, 10/29)

Congress should renew funding for the successful Child Health Insurance Program in the coming lame duck session — a year in advance to forestall any possible lapses in the crucial service. Currently, about 60,000 Colorado children and 900 pregnant women rely on CHIP for health coverage, a program that fills a gap for those who earn too much to qualify for Medicaid and not enough for private health plans. Known in Colorado as Child Health Plan Plus, the program has won bipartisan federal support since its creation in 1997. (10/29)

The best way to protect the United States against Ebola is to control the epidemic in West Africa. Washington isn’t waiting for Islamic State to attack the United States. It has taken proactive, defensive measures to address these militants in the Middle East. Similarly, the United States can’t wait for the virus to spread beyond Guinea, Sierra Leone and Liberia — as it inevitably will if Americans don’t fight Ebola at its source. The West has to enlist more healthcare workers in this fight, but mandatory quarantines will only discourage doctors from volunteering. (Celine Gounder, 10/28)

What looks like political wrangling or confusion in federal and state officials’ Ebola responses is a reflection of our complex public health system, which gives certain authorities to the federal government and others to the states. But however explainable as a product of American federalism, officials’ contradictory actions do little to reassure the public in a fast-changing environment where, here in the U.S., fear is as much an enemy as the virus itself. (Drew Altman, 10/29)

What remains frustrating about how the United States manages epidemics — as we are rediscovering with the Ebola crisis — are the hazy lines of authority and fierce internecine battles among local, state and federal health agencies, as well as individual hospitals and healthcare systems. Equally discouraging are the distracting criticisms of health officials, doctors and nurses trying to do a complicated job under difficult conditions while subjected to intense media scrutiny. (Howard Markel, 10/30)

The absolute hysteria surrounding the Ebola crisis underscores what is wrong with our politics and the policies they spawn. On Ebola, the possible has overtaken the probable, gobbling it up in a high-anxiety, low-information frenzy of frayed nerves and Purell-ed hands. (Charles M. Blow, 10/29)