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PBS NewsHour

Bid to speed transplants with hepatitis C-infected kidneys

File photo by Getty Images

File photo by Getty Images

WASHINGTON — Some patients facing a years-long wait for a kidney transplant are jumping ahead in line thanks to a startling experiment: They’re agreeing to an organ almost sure to infect them with hepatitis C.

Knowingly transmitting a dangerous virus may sound drastic but two leading transplant centers are betting the strategy will save lives — if new medications that promise to cure hepatitis C allow use of organs that today go to waste.

Pilot studies are under way at the University of Pennsylvania and Johns Hopkins University to test transplanting kidneys from deceased donors with hepatitis C into recipients who don’t already have that virus. If the research eventually pans out, hundreds more kidneys — and maybe some hearts and lungs, too — could be transplanted every year.

“We always dreaded hepatitis C,” said Dr. Peter Reese, a Penn kidney specialist who is helping lead the research. “But now hepatitis C is just a different disease,” enough to consider what he calls the tradeoff of getting a new kidney years faster but one that comes with a hopefully treatable infection.

It’s a tradeoff prompted by the nation’s organ shortage. More than 99,000 people are on the national kidney waiting list but only about 17,000 people a year get a transplant and 4 percent a year die waiting, according to the United Network for Organ Sharing (UNOS).

“If we had enough organs, we wouldn’t do this,” said Dr. Niraj Desai, who is leading the Hopkins study. But, “most patients are pretty open to the idea once they hear what the alternatives are.”

Doctors had told Irma Hendricks, 66, to expect at least a five-year wait for a kidney transplant. Dialysis three times a week was keeping the East Stroudsburg, Pennsylvania, woman alive but left her with no energy for even routine activities. “I call it the zombie syndrome,” she said.

So she jumped at the chance to enroll in Penn’s study, even though doctors made clear they hoped for but couldn’t guarantee a hepatitis cure.

“We always dreaded hepatitis C. But now hepatitis C is just a different disease.” — Dr. Peter Reese

“My son said, ‘Mom, this is a no-brainer. Just do it,'” Hendricks said, She swallowed an anti-hepatitis pill daily for three months, in addition to the usual post-transplant medications. Testing showed the drugs rapidly cleared hepatitis C out of her bloodstream. And with her new kidney functioning well, she now has enough energy to play with her toddler grandson.

“This is giving people in my situation new hope,” Hendricks said.

Kidney transplant specialists are closely watching the research.

“It makes sense to me,” said Dr. Matthew Cooper, a transplant surgeon at MedStar Georgetown University Hospital, who is not involved in the research. He cautioned that the studies should use only kidneys that are young and otherwise high-quality, and that patients must understand the risks.

“They need to know you place their safety as the highest priority,” Cooper said. “But at the same time, recognize that we have these obstacles. We don’t want people to die on dialysis and there are not enough organs available for everybody.”

Hepatitis C is a simmering infection that, if untreated, over two to three decades can quietly destroy someone’s liver. At least 2.7 million people in the U.S. have chronic hepatitis C. Until a few years ago, it was treatable only by medications with grueling side effects and poor cure rates. Now, breakthrough drugs promise to cure 95 percent of hepatitis C cases with fewer side effects — for people who can afford them. Treatment costs tens of thousands of dollars.

Normally, hepatitis C-infected organs are transplanted only into patients who already have hepatitis C themselves, so as not to further spread the virus.

Giving hepatitis C-positive organs to hepatitis C-negative recipients is allowed if the patient agrees, but it’s rare, said Dr. David Klassen, UNOS’ chief medical officer. UNOS statistics show a few dozen such transplants, mostly kidneys, last year, presumably when doctors feared their patients wouldn’t survive the wait for a healthier organ.

More often, hospitals discard hepatitis C-infected organs. Reese and fellow Penn transplant surgeon Dr. David Goldberg found only 37 percent of hepatitis C-positive kidney donations between 2005 and 2014 were transplanted. The discards could have helped more than 4,000 patients during that time period, they reported in the New England Journal of Medicine last year.

And the opioid epidemic is prompting a jump in donations from people who died of drug overdoses — typically young organs that, absent an infection risk, would be sought after.

The small Penn and Hopkins trials are a first step; much larger studies are needed to prove if more routine use of these organs in immune-suppressed transplant recipients really works.

Cost also is a question. Merck & Co. is helping to fund the pilot trials, donating its medication Zepatier, which costs $54,000 for a round of treatment. That’s still cheaper than a lifetime of a dialysis, which costs about $75,000 a year, UNOS’ Klassen noted.

While the studies began with kidneys because of their demand, “I don’t think there’s any reason, if it proves safe and effective in kidneys, that we wouldn’t want to try it in other organs,” noted Penn’s Goldberg.

Even if the hepatitis C-infected organs prove useful, the nation still is “desperate for more donors,” cautioned Hopkins’ Desai. “It’s a practical solution to help some of the people. It won’t solve the problem.”


Associated Press Writer Michael Rubinkam contributed to this report.

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America’s HIV outbreak started in this city, 10 years before anyone noticed

Marchers on a Gay Pride parade through Manhattan, New York City, carry a banner which reads 'A.I.D.S.: We need research,
         not hysteria!', June 1983. Photo by Barbara Alper/Getty Images

Marchers on a Gay Pride parade through Manhattan, New York City, carry a banner which reads ‘A.I.D.S.: We need research, not hysteria!’, June 1983. Photo by Barbara Alper/Getty Images

HIV arrived in New York City precisely 10 years before doctors first noticed the disease, a conclusion that’s based on new research published today in Nature. The finding solves a 35-year-old mystery surrounding the origins of America’s outbreak, the first in the world to be noticed by doctors.

It indicates the virus passed from the Caribbean to New York in the early 1970s, where the disease gained a foothold for at least half a decade, before triggering outbreaks in places like San Francisco. The study also clears the name of Gaëtan Dugas, so-called “Patient Zero,” who had been wrongly blamed for bringing the virus to U.S. shores.

“This is the clearest scientific debunking of the myth around ‘Patient Zero,’” said Dr. Anthony Fauci, director of the National Institute of Allergy and Infectious Diseases at the NIH, who wasn’t involved with the new study. “It’s definitely clear that when ‘Patient Zero’ got infected, it was after already spreading throughout.’

New York’s earliest strains most resemble those from the Caribbean, where researchers believe the disease first landed in the Western Hemisphere.

An international team of geneticists, microbiologists and medical historians solved this case through detective work. In 1981, UCLA physician Michael Gottlieb reported the first cases of HIV/AIDS — initially described as an infectious cancer — among gay men living in Los Angeles. But based on what’s now known about HIV, these couldn’t have been the first cases. For instance, research found eventually it takes 10 years, on average, for an infected person to show symptoms.

So Michael Worobey, an evolutionary biologist at the University of Arizona, stepped back into the past. They spent years tracking down blood samples taken prior to 1981 that contain signs of the virus. He and his colleagues stumbled upon two Hepatitis B virus studies from 1978-1979 — one in New York, the other in San Francisco — that had collected blood samples from gay men. Back then, though no one knew it, people with a high-risk of catching Hepatitis B turned out be high-risk for HIV, Worobey said during a press conference on Tuesday.

They whittled 11,000 blood specimens down to a set of 33 New York samples and 83 samples with signs that those patients had mounted an immune response against HIV. But to trace the history of the outbreak, the team needed genetic material, whereupon they encountered a big problem. The archived specimens hadn’t been stored using the best practices for preserving genetic material, leaving major holes in the genetic codes of the HIV virus from each patient.

The early patterns of HIV-1 spread in the Americas. The map summarizes the main patterns of spread inferred from the
         comparison of HIV genomes collected in different location. The map inset shows the initial introduction of HIV-1 subtype B
         lineage into the Caribbean from Africa. From there, the virus spreads first to NY and subsequently to different locations
         in the United States. Photo by Worobey et al., Nature, 2016

The early patterns of HIV-1 spread in the Americas as outlined in Worobey et al., Nature, 2016. The map summarizes the main patterns of spread inferred from the comparison of HIV genomes collected in different location. The map inset shows the initial introduction of HIV-1 subtype B lineage into the Caribbean from Africa. From there, the virus spreads first to NY and subsequently to different locations in the United States. Photo by Worobey et al., Nature, 2016

Imagine your friend gifts 10 storage bins to you, each with a shredded copy of the Declaration of Independence inside of it. Then your friend grabs one handful of shreds from each bin and says, “Piece together the document, please!” This task is hard even with all the pieces.

To surpass this barrier, the researchers developed a “jackhammer” gene sequencing approach. It amplifies the signal from each cut up piece of genetic code, making it easier to notice the fragments that might overlap. Over the course of years, they found enough overlapping fragments to build the complete genomes of HIV viruses from eight patients — three from San Francisco and five from New York.

“It is true, it’s not a huge number,” Worobey said. “But it tells you a whole lot, if you’re looking at the geographical patterns.”

That’s true thanks to genetic diversity.

Genetic diversity — or different mutations among a set of genomes — can pinpoint when a population arrived in a certain place. Put one person on an deserted island, and the genomic diversity is low and defined just by them. Add a second person, and you’ve doubled the diversity. If you know when the two arrived — and of course you do since you put them there — then you can chart how genetic diversity changed over time. But if you can also work backwards, with just the people — or in this case, different patients’ copy of the HIV — if you know how common mutations are in the genomes.

“This is, in my mind, the last piece of the puzzle.”

Worobey and his colleagues found genetic diversity was higher in the New York samples, suggesting the virus landed there first.

“We can date the jump into the U.S. at about 1970, or 1971, and you see a very telltale pattern of extensive genetic diversity in New York City, suggesting that New York City was the key hub of diversification for the virus,” Worobey said. “Restricted genetic diversity in San Francisco, suggesting San Francisco was a later dispersal out of this New York City hub.”

Their analysis traced the bulk of HIV infections in San Francisco to a single introduction from New York by around 1976, before the virus quickly spread across the country.

No blame left to give

Gaëtan Dugas, who died March 30, 1984 due to complications with HIV/AIDS, was mistakenly branded as "patient 0"
         or the first cases in America's HIV outbreak. Photo via Wikimedia

Gaëtan Dugas, who died March 30, 1984 due to complications with HIV/AIDS, was mistakenly branded as “patient zero” or the first cases in America’s HIV outbreak. Photo via Wikimedia

“This is, in my mind, the last piece of the puzzle,” said Beatrice Hahn, a virologist at the University of Pennsylvania, who first discovered that HIV originated in chimpanzees and other primates before infecting humans.

“We now have a very detailed understanding where HIV came from, the number of times it got introduced into the human population, the location where that occurred, how the virus then moved around within Africa, and started to spread, and then how the virus was then transferred to other places around the world, including the United States,” she said.

Based on genetic heritage analysis conducted in the new study, New York’s earliest strains most resemble those from the Caribbean, where researchers believe the disease first landed in the Western Hemisphere. But HIV, as we know it, started sometime in the early 20th century in Africa, Worobey said, and it wasn’t a one-time event.

“This pandemic strain that we call the main group of HIV-1 is one of several non-human primate viruses that have crossed over,” Worobey said. “It’s not the only one, it’s just the most successful one.”

He said one of these HIV variants — HIV-1 subtype B — successfully emerged out of Africa, sometime in the mid- to late-1960s, and took hold in the Caribbean by 1967. A Haitian HIV strain from 1969 is the closest relative to those that first dropped into New York, suggesting it may have been the source of America’s outbreak. However, this virus had been circulating among Haiti, Dominican Republic, Jamaica, Trinidad and Tobago and Haitian immigrants, making it difficult to pin to a single Caribbean nation.

“How the virus moved from the Caribbean to the U.S., and New York City in the 1970s is an open question,” Worobey said. “It could have been a person of any nationality.”

Plus, it’s also important to distinguish between tracing the origins of a virus and placing blame, he said, because no one should be blamed for spreading a virus that no one even knew about.

This advice could also apply to Gaëtan Dugas. Dugas was a flight attendant for Air Canada and an early AIDS patient who, in the mid-1980s, the Centers for Disease Control and Prevention linked to a network of HIV transmission between 10 American cities. In the case report on the network, investigators initially labeled Dugas as “Patient O” to indicate he lived “Out(side)-of-California.” However, when disease detectives later transcribed his entry into a separate report, they used “patient 0,” i.e. zero.

“Patient zero” is a term typically used by epidemiologists to denote the first-known case of an outbreak. Popular media, such as the 1987 best-selling book “And The Band Played On” by journalist Randy Shilts, spread this inaccurate information — even going as far as to suggest Dugas brought HIV to America.

“Yes, Randy’s book clearly promoted the idea [of ‘Patient Zero’],” director Fauci said. “And since it was so popular, it became folklore.”

An annotated clipping sent to San Francisco AIDS Foundation of a People Magazine story about Gaëtan Dugas circa 1988.
         Photo via NIH

An annotated clipping of a People Magazine article about Gaëtan Dugas sent to San Francisco AIDS Foundation circa 1988. Photo via NIH

Today’s study clears Dugas’ name, once and for all, by comparing his HIV sample with those collected from San Francisco and New York in 1978-1979.

“That’s really a spectacular part of the story. It removes the sense of blame and shame from him [Dugas],” said Paul Volberding, head of the Center for Aids Research at the University of California San Francisco, who saw some of the first HIV patients in America, including Dugas. “Dugas was having sex and spreading the virus. But this study makes the point that a number of the people that he was having sex with were already symptomatic when he first had contact.”

Volberding said the hyperbolic confusion over Dugas is representative of what can happen during the early days of modern outbreaks. The early days of any outbreak are hectic for doctors and public health officials on the best days, and a total garbage fire on the worst. Remember the fervor over Thomas Eric Duncan in Dallas during the Ebola outbreak?

You can’t tell an outbreak is happening until people get sick, so doctors are inherently one step behind. Yet even without the internet, Volberding recalled that the first reports of AIDS in 1981 quickly passed between U.S. physicians’ letters to medical journals, as they recognized the symptoms in their patients.

“The day that I saw my first patient on July 1, 1981, I was making rounds in the hospital with a new trainee, who had just arrived in New York,” Volberding said. “He said, ‘I think we saw some of those patients there.’ News spread from New York to San Francisco kind of instantaneously.”

Volberding wrapped up by explaining that studies like Worobey’s are a marker of the future, because they pair epidemiology with new-age technology to solve outbreaks.

“Epidemics will continue to happen, and the better we can understand them in real-time, the better we can possibly respond,” Volberding said.

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Women are fast catching up to men in alcohol consumption — and abuse

Excessive drinking is responsible for one in ten U.S. deaths, the CDC found. Photo by Flickr user JOH_8513

Women are catching up to men’s alcohol consumption, reserach suggests. Photo by Flickr user JOH_8513

Women worldwide are catching up to men when it comes to alcohol consumption.

Previous research has suggested that men are not only more likely than women to drink alcohol — they’re also more likely to abuse alcohol and to drink so much that they harm their health. But a new analysis published Monday in BMJ Open finds that gap could be narrowing.

“Across the board, when we talk about any alcohol use, binge drinking, or alcohol-use disorder, generally males have a higher prevalence than females,” said study author Tim Slade of Australia’s National Health and Medical Research Council.

“But there’s a change in patterns of substance use — there’s a convergence between males and females,” Slade said.

Slade and his colleagues culled data from 68 studies on alcohol use among men and women across the globe. The studies spanned from 1948 to 2014, running up a sample size of more than 4 million people. Many were longitudinal: 16 followed subjects for at least 20 years, while another five tracked subjects for at least 30 years.

The researchers broke that data up into five-year increments to create birth cohorts. Then, they looked at three distinct data points: any alcohol use, problematic alcohol use like binge drinking, and prevalence of alcohol-related health problems.

The gap between men and women on alcohol consumption — the question, do you drink at all? — shrank steadily over the last 70 years. Men born in the early 1900s were more than twice as likely to drink alcohol than women. Men born in the late 1900s are only slightly more likely to drink alcohol than women.

The gap has also narrowed when it comes to the prevalence of alcohol abuse and alcohol-related health problems. That’s most evident among young adults, Slade said, which suggests health officials should keep tabs on today’s millennials as they age to monitor shifting alcohol use patterns.

It’s not clear whether men are drinking less alcohol or women are drinking more, though some of the studies point to the latter. While the study wasn’t designed to evaluate what’s driving the shift, the researchers speculate that women’s changing roles over the past century might play a part.

“It could be that increased participation in higher education and the work force came with increased pressure to drink,” Slade said. “It could be that women are under more strain or experiencing more stress. We’re not sure.”

But the researchers agree on one takeaway of the new data: Public health campaigns to combat alcohol abuse should be designed to appeal to both men and women.

“We can no longer think about alcohol-related problems as just problems for men,” Slade said.

This article is reproduced with permission from STAT. It was first published on Oct. 24, 2016. Find the original story here.

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How Obamacare premium hikes affect politics and your wallet

Arminda Murillo, 54, reads a leaflet on Obamacare at a health insurance
         enrollment event in Cudahy, California, U.S. March 27, 2014.     REUTERS/Lucy Nicholson/File Photo - RTX2PMAL

Watch Video | Listen to the Audio

JUDY WOODRUFF: And late today, The Washington Post reported that the Trump campaign has ended its joint fund-raising with the Republican Party. That could hurt the party’s get-out-the-vote efforts.

And as we just heard, the state and fate of the health insurance law, or Obamacare, is front and center today. That’s because, as the new enrollment season for coverage is about to begin, the administration announced that premiums will rise by 25 percent on average for a benchmark mid-level plan through the federally run market.

At the same time, choices are decreasing. One in five consumers will have a single insurer to choose from. It’s not a simple picture. Federal subsidies for most people getting coverage this way will increase.

To help us understand more about it, and how this all plays into the campaign, I’m joined by two following this closely. Mary Agnes Carey covers the marketplace for Kaiser Health News, and Reid Wilson covering the politics of it for The Hill newspaper.

We welcome you both.

So, Mary Agnes, to you first.

How many people are affected by this? What percent of the population overall?

MARY AGNES CAREY, Kaiser Health News: Of all the people who buy health insurance, 5 percent buy on the ACA exchanges. Most of us get our coverage either through work or through the Medicaid program or the Medicare program.

So it’s about 20 million people on the individual market. About two-thirds of those get marketplace plans. It’s important to them, of course, but you have to look at it in perspective with the overall numbers.

JUDY WOODRUFF: And these are people who live across the country?

MARY AGNES CAREY: Across the country, all 50 states. The federal government sells — of the health insurance exchange, there are plans are in about 38 states, and rest and the District of Columbia are state-run plans.

JUDY WOODRUFF: And the range of — the percentage of increase differs from state to state?

MARY AGNES CAREY: All over the place.

For example, in Arizona, you had 116 percent increase in premiums, monthly premiums, $196 to $422. And we should say these are before the subsidies kick in. And these are premiums for a 27-year-old male. So we have to look at it from that perspective.

Nebraska, we’re talking about a 51 percent increase. Ohio, a 2 percent increase. Massachusetts, actually a 3 percent decrease. So it’s really depending on where you live. If you live in an urban area or a rural area, that’s also going to affect the number of providers and the networks and that sort of thing.

JUDY WOODRUFF: So, Reid, as we see, this is already having an effect on the presidential campaign. We heard Donald Trump a few minutes ago saying this is the end of Obamacare.

REID WILSON, The Hill: And it’s played a role in Republican campaigns who are running for Senate and House seats around the country.

In New Hampshire, Senator Kelly Ayotte is already up with an ad attacking Governor Maggie Hassan, one of the most watched Senate races in the country, over Governor Hassan’s support for the Affordable Care Act.

What’s notable, though, is that the amount of advertising specifically around the Affordable Care Act is actually down significantly from earlier years. It’s almost as if public opinion on this matter has been baked in for the last five years — or six years really since it’s been debated. And there aren’t that many people who are willing to change their minds.

JUDY WOODRUFF: So, just because I know it’s complicated, Mary Agnes, but why has this happened?

MARY AGNES CAREY: Well, it’s happened for a variety of reasons.

Insurers may have gotten in early and underpriced their products to try to get more market share. And now they are going to have to even that out. We may have had — likely have had a lot of sicker people get in first. Everyone sort of knew that when they did the Affordable Care Act. The sickest people come first. They are the most expensive people.

You also have an ability of some plans manage costs better than other plans. And so now we’re going to hear more about these things called narrow networks and other tightening of costs. And also some federal programs to help insurers balance out the cost of these really sick people, two of them are going away next year, and the other hasn’t necessarily worked as intended, so it’s sort of a combined effect.

And different factors have a different effect depending on where you live.

JUDY WOODRUFF: So we talked to several people around the country affected by these rate increases.

Let’s begin with a woman named Beth Plein. She lives in Maryland.

BETH PLEIN: My name is Beth Plein. I’m 64. And I live in Cockeysville, Maryland.

I am one of the small number of people who self-insures and doesn’t qualify for a subsidy, so my insurance premiums are very high, bordering on the unaffordable. I have actually tracked my insurance even in the years before the Affordable Care Act, and they were rising gradually, but after 2014, they were spiking dramatically.

I started with a $548 premium. So I changed the plan, went down to a $411 premium with a higher deductible. And then next year, I don’t know what it will be. I can’t change it again, because this is the least expensive plan.

I don’t know what can be done because it’s such a complex issue. At this point, you have to depend on the government to iron it out. So, hopefully, that’s what they will do.

JUDY WOODRUFF: Mary Agnes, how typical is she?

MARY AGNES CAREY: Well, we’re hearing more and more from these people who don’t qualify for a subsidy. It’s roughly in the ballpark of five to seven million people who are buying on the individual market or in the exchanges. They don’t qualify for a subsidy.

And it’s really difficult, because while many people, something like 85 percent, of individuals on the exchange can get that subsidy that can help lower the premium, there are folks that don’t have that.

And I received an e-mail this week from a small business person who said he felt like he had absolutely no hope for the Affordable Care Act for him to be able to afford the premiums. And, of course, we have this requirement for coverage.

JUDY WOODRUFF: And, Reid, we just heard her say, she said, I wish — she says it’s now up to the federal government to fix it. But what’s the likelihood that that can happen?

REID WILSON: Well, the question really depends on what happens in November, two weeks from now, on Election Day.

If Hillary Clinton wins the presidency, Democrats win the Senate, and Democrats win the House, well, there’s a real good shot that the Democrats will do something to repair the Affordable Care Act on a wholesale basis.

But taking back the House is a really steep hurdle for Democrats, and we have seen Republicans in control of the House vote to repeal the Affordable Care Act 50-plus times. This is — the Republicans in the House have been unwilling to even make technical corrections to the bill.

So, unless there is some massive sea change within the Republican Party, which I don’t see happening, it’s going to be very difficult for even the smallest corrections to be made.

JUDY WOODRUFF: So, we also talked to a single mother with two children in Greensboro, North Carolina. This is one of the states where so many insurers have pulled out.

NATALIE CUNNINGHAM: My name is Natalie Cunningham. I’m 30 years old. And I live in Greensboro, North Carolina.

I have Coventry health insurance, where I pay just $9 a month. And the subsidy on it is $237. I recently found out that my insurer, Coventry, was not going to be part of the marketplace, Obamacare, anymore. And so now I’m at the point of, you know, OK, now I’m going to be switching to Blue Cross/Blue Shield, but whether I will be able to afford it, because I don’t know how much the plans are going to go up, and they had already just about doubled at the end of 2015.

Just going by what I can handle, because when you want to pick between buying school shoes or, you know, paying extra money into the health insurance plan, as a mother, sometimes, you have got to make those decisions and cut out the health insurance.

JUDY WOODRUFF: Mary Agnes, why are so many insurers pulling out?

MARY AGNES CAREY: Well, sometimes, they just didn’t make the money that they wanted to make or they have had a hard time managing the sicker folks who have come in initially, and trying balance out the risk pool.

But what’s really interesting I think about this example is that it illustrates states where insurers are leaving the market causing some problems. She’s from North Carolina. In about — about 230,000 people in North Carolina are going to have a change with their plan because two or three insurers are dropping out.

Alabama and South Carolina, there’s one insurer statewide. But one word of encouragement, if I could offer, is that her subsidy is going to increase as the plans increase in price. You mentioned this in your introduction.


MARY AGNES CAREY: For that benchmark plan, that will also increase. So, she may find it not as unmanageable as she thinks.

And, of course, for all of these consumers, getting on, or your state-based exchange to shop, you might be able to go to a plan in that same category, whether it’s a silver or a bronze or gold or a platinum, and you might find something at a lower price that still works for you.

JUDY WOODRUFF: And that’s just going to take some time for them to figure it out.


JUDY WOODRUFF: So, finally, let’s hear — this is a young woman who lives in Brooklyn. She happens to be healthy. She’s looking for an affordable policy.

LAURA BRICKMAN: I’m Laura Brickman. I’m a 27-year-old who lives in Brooklyn, New York. I’m working as a freelance journalist doing video and print work.

But, because it’s freelance, I don’t have an insurance plan through my employer. So, I’m currently uninsured. To me to buy a plan is a little bit frustrating, because I feel that I don’t use it personally, and the amount of money I would be spending on insurance is things that I could divert to non-health care issues, because I honestly don’t have many health care expenses.

And so the chances of me really taking advantage of the plan are very low, I think. I don’t have any chronic health issues. The only thing I would use medical care for at this point is like a major medical emergency, which has not happened, fortunately.

JUDY WOODRUFF: So, Mary Agnes, this reminds us these tough choices for young people like her who know they do have to pay a fine if they’re not in the system.


That’s really important to remember. For next year, it’s $695, or 2.5 percent of income, whichever is greater. And you have got to remember, even if you think, I can afford to pay that, you still don’t have health insurance, and you’re going to be on the hook if something happens to you.

So there are some things that she can consider. There’s a catastrophic plan for people under 30. There are some other options. Again, you should really go to the marketplace and check it out to see if something works.

JUDY WOODRUFF: So, Reid, just finally, before we wrap this up, talk about what it is that Hillary Clinton and Donald Trump have said they want to do to either fix or adjust the Affordable Care Act.

REID WILSON: Well, neither have offered a lot of specifics on the matter. Donald Trump has talked about allowing insurance plans to be purchased across state lines, which has been a staple of the Republican policy for quite a long time.

Hillary Clinton, on the other hand, has talked about the positive aspects of the Affordable Care Act, being able to stay on your parents’ insurance plan until you’re 26, some of the other positives that are broadly favorable, broadly popular across the country.

But what’s clear is that the next president is going to have to deal with some kind of fix for the Affordable Care Act. The question is what will they be able to get through what is likely to be a divided Congress.

JUDY WOODRUFF: But the idea of unwinding it completely, which is what Donald Trump talks about, how practical?

REID WILSON: That — just like Republicans going along with changes to the Affordable Care Act is unlikely for a Democratic president, unwinding the Affordable Care Act is going to be very unlikely for a Republican president, whether it Donald Trump or whoever comes next, because there is a significant Democratic presence in the Senate, and they’re able to block that.

JUDY WOODRUFF: Well, this is a subject we have been talking about from the beginning of this campaign until right down to the end.

Reid Wilson, Mary Agnes Carey, thank you both.


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