KHN On Call: Answers To Questions On Tax Credits, Penalties And Age Ratings

Published: Monday, March 20, 2017 @ 2:36 PM

For years, Republicans in Congress have promised to repeal and replace the Affordable Care Act, claiming that its requirement for nearly everyone to buy insurance or pay a fine is burdensome and costly, and that it doesn’t give people enough flexibility to get the coverage they need.

Now that they’re in charge, the bill they’ve released as an alternative (the American Health Care Act) would effectively eliminate the requirement to buy coverage and might open up more health care choices. It’s also under fire because it may cause millions of people to lose their coverage. According to the nonpartisan Congressional Budget Office, up to 24 million more people could be without insurance by 2026 if it passes.

So what are the differences between the ACA and the GOP alternative, and what does it all mean to you and your health care? We put some of your questions from our Twitter chat (#ACAchat) earlier this month to Alison Kodjak, NPR health policy correspondent, and Julie Rovner, chief Washington correspondent for Kaiser Health News.

Many questions came in about the elimination of the requirement to buy insurance, known as “the mandate,” and how the lack of one might affect the health insurance market.

Is the mandate in the GOP bill? It won’t work if people sign up only when they are sick.

.@sjp3121 I read mandate still there, just no fine. Is this accurate? #ACACHAT Won't work without mandate if only sign up when sick.

— ILPoliticalPug (@BarbinIL52) March 9, 2017

Kodjak: The mandate is technically still written into the law, but since no one will enforce it under this new bill, it’s unlikely to have any impact. In fact, the Internal Revenue Service has already issued some guidance that suggests it may not enforce the mandate very actively even now, before this bill becomes law. The result? People who think insurance is too expensive and don’t expect to need it are unlikely to sign up for a health plan.

Rovner: It’s true that the GOP bill technically preserves the mandate, but it eliminates the penalties. Instead, the bill would require those with a lapse in insurance of more than 63 days to pay an insurance premium that’s 30 percent higher for one year. Analysts say that could actually serve as a disincentive for healthy people to purchase insurance if they’ve had a break.

Can someone wait until they are sick to buy insurance, knowing that they would have to pay a 30 percent fine?

Thanks for doing #ACAchat. Can someone wait till they are sick to get insurance under cont cov rule even if they pay 30% more?

— AtoZ (@InOneFortyRLess) March 9, 2017

Rovner: Not exactly. There will still be standardized open enrollment periods once a year, and you will only be able to buy insurance outside of those windows if you have a life change, like moving or losing a job. But if you’re willing to wait as long as 11 months, then, yes, you can wait and buy insurance after you get sick.

Kodjak: It’s not without risk. The Department of Health and Human Services has already proposed regulations that would reduce that open enrollment period to six weeks from the current three months. So a patient may incur some health care costs while awaiting the open enrollment, and then face the 30 percent penalty when they do buy a health plan. However, if the individual has a health issue where treatment can wait, then they certainly can enroll at the correct time and then seek medical care.

We also got a lot of questions about the GOP bill’s new tax credits to help people buy insurance, and how different they would be from the structure of purchasing help in the ACA.

Explain the difference between tax credits and subsidies, and will tax credits be distributed quarterly or at the end of the year?

@NPRHealth Please explain the difference between tax credits and subsidies. Will there be quarterly tax credits or just year end? #ACACHAT

— songbirder74 (@songbirder74) March 9, 2017

Kodjak: Both the ACA and the AHCA use advanceable, refundable tax credits. That means the government each month sends the tax credit amount to your insurance company.

We refer to the Obamacare financial assistance as a “subsidy” in part because the amount fluctuates and is based on your income — the idea is to limit your health costs to a specific percentage of your income. In addition, under the ACA, there are payments to insurers to help cover the copayments and deductibles of lower-income people.

Rovner: The tax credits differ in how large they are and how they are calculated. The ACA tax credits are based on income and how much insurance costs in a given area. The GOP credits, by contrast, are based primarily on age and do not vary according to the cost of insurance in an area, so in low-cost parts of the country they will go further than in very high-cost areas.

In addition, the ACA has a series of subsidies that help those with low incomes (under 250 percent of poverty; about $50,000 for a family of three) pay their deductibles and other out-of-pocket expenses in addition to the tax credits to help pay for premiums.

Why does the GOP bill provide age-based tax credits instead of income-based ones?

#ACAchat @NPRHealth what's the policy behind providing age-based tax credits as opposed to income-based?

— molliegel (@molliegel) March 9, 2017

Kodjak: The basis for age-based tax credits is that people who are younger tend to have fewer health costs, so insurance policies are likely to be lower-priced for them than for older people.

Republicans prefer the fixed credits in part because they are cheaper, and more predictable, than the income-based credits under the Affordable Care Act. That’s because those ACA credits rise as premiums rise, giving insurers little incentive to keep their premiums low. Republicans hope that by restraining the government’s financial help to patients, insurance companies will offer cheaper policies that better match the cost of the tax credits.

Rovner: Younger adults, on average, need less health care than older adults. The ACA limited the differential in premiums for older adults to three times more than the amount charged to younger adults. The GOP bill would change that so older adults could be charged five times more. The change would make insurance less expensive for younger people, likely enticing more of them to enroll, and lowering premiums for all, at least marginally, according to the Congressional Budget Office. But it would dramatically increase premiums for older adults, particularly those aged 55-64, just under the age to qualify for Medicare.

Which brings us to this question, which represents several we received about how the AHCA appears to disproportionately penalize people ages 55-64.

Do I face a penalty for waiting to buy health insurance until I’m eligible for Medicare in three years? I’m concerned that I’ll be stuck with an expensive plan.

@SabrinaCorlette If I'm 62 and I decide 5:1 health insurance is too expensive and I wait for Medicare, no penalty for me, right? #ACAchat

— Anne Paulson (@KrampusSnail) March 9, 2017

Kodjak: No 30 percent penalty if you wait for Medicare, but remember, if you get sick while you’re waiting, you could be in financial trouble.

Rovner: That is correct. Also, remember, if you fail to sign up for Medicare when you first become eligible at age 65, you would also pay a premium penalty. It’s 10 percent per year, forever.

Got more questions? We’ll keep answering them as the GOP bill moves through Congress. Send them to us via Twitter at #ACAchat or via email at

Kaiser Health News (KHN) is a national health policy news service. It is an editorially independent program of the Henry J. Kaiser Family Foundation.

WATCH: Girls perform adorable ditty to sell Girl Scout cookies

Published: Saturday, January 20, 2018 @ 3:20 PM

The History of Girl Scouts

Two young girls from New Hampshire are using their musical talents to sell Girl Scout cookies.

Lyla and Avery Holzapfel are 8 and 6 years-old. With the help of their parents, Brynne and Doug, they wrote a little ditty to make some sales, Boston25News reported.

>> Read more trending news 

And it's taken off.

The video has several thousand views since it was posted on Tuesday. 

Doug Holzapfel, a composer and producer, tells Boston 25 his family of seven recently moved back to New Hampshire after spending some time in Los Angeles, Boston25News reported.

It appears creativity and talent runs in the family.

Flu virus spread by breathing, study finds

Published: Friday, January 19, 2018 @ 1:06 PM

Joe Raedle/Getty Images
(Joe Raedle/Getty Images)

Most people believe that the influenza virus is spread through the coughs and sneezes of infected people, but new research published Thursday suggests that the flu virus is spread more easily than previously thought.

>> Read more trending news

Medical professionals believe that the virus is spread most often by “droplets made when people with flu cough, sneeze or talk,” according to the Centers for Disease Control and Prevention. But researchers studying how the virus spreads recently found large amounts of the virus in the breath of people suffering from the flu, according to the University of Maryland’s School of Public Health.

>> Related: Influenza surveillance map: Where is the flu in my state? 

The researchers -- from the University of Maryland, San Jose State University, Missouri Western State University and the University of California, Berkeley -- published their findings Thursday in the Proceedings of the National Academy of Sciences.

“We found that flu cases contaminated the air around them with infectious virus just by breathing, without coughing or sneezing,” said Donald Milton, professor of environmental health in the University of Maryland School of Public Health and lead researcher for the study.

Milton and his team examined the virus content in the breath of 142 people who were diagnosed with flu as they were breathing normally, speaking, coughing and sneezing. Researchers found that a majority of those who participated in the study had enough of the infectious virus in just their regular, exhaled breath to possibly infect another person.

A review of the data collected from the coughs and sneezes of infected participants showed that neither action appeared to have a large impact on whether or not the virus was spread.

>> Related: 11 things parents need to know about the flu, the vaccine, how long kids need to stay out of school  

“People with flu generate infectious aerosols (tiny droplets that stay suspended in the air for a long time), even when they are not coughing and especially during the first days of illness,” Milton said.

The study’s authors said the results highlighted how necessary it is for people who have the flu to stay at home.

>> Related: What is the H3N2 flu and how bad is flu season this year? 

“The study findings suggest that keeping surfaces clean, washing our hands all the time, and avoiding people who are coughing does not provide complete protection from getting the flu,” said Sheryl Ehrman, the dean of the Charles W. Davidson College of Engineering at San Jose State University. “Staying home and out of public spaces could make a difference in the spread of the influenza virus.”

<p>5 Reasons to get a Flu Shot</p>(Bryan Erdy/News | WHBQ)

This local woman dropped 243 pounds. But she said real beauty didn’t come until her life crumbled.

Published: Friday, January 19, 2018 @ 6:00 AM

Kelley Gunter (the author of "You Have Such a Pretty Face") she didn't learn the real meaning of beauty until she lost nearly everything. Video by Amelia Robinson.

Based on what she’s done in this life, Kelley Gunter guesses she probably barked and walked on all fours in the last one. 

“I must have been a dog in a past life because I am so loyal,” the Troy resident joked during our meeting at Ghostlight Coffee in Dayton’s South Park neighborhood. 

In flawless makeup and straightened hair, Kelley sat across from me with a big mug of hot chocolate. 

>> 10 things to look forward to when the weather warms up

She’d later email me the hot chocolate recipe her spunky grandmother used to make. 

Striking at 5-feet, 9-inches tall, Kelley and her visual beauty are hard to miss. 

But her face and body were frequent topics of conversation when she weighed 391 pounds, too. 

“People would constantly say to me, ‘Kelley, it is a shame; you have such a pretty face’,” Kelley said. “My entire existence was a shame because I was packed into a body that was unacceptable (to them). People think that is a compliment, but it is so not a compliment.”


Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

Kelley outlines the emotional journey that took her through bariatric surgery, loose skin removal, losing almost everything, and finally recognizing true beauty in her new self-published book, “You Have Such a Pretty Face.” 

>> Best way to lose weight with the most minimal effort

The paperback book is $16.99 and available for purchase on kelleygunter.comAmazon and other online booksellers. 

Even after her weight loss surgery 16 years ago and losing and keeping off 243 pounds, Kelley said she felt like true happiness eluded her.  

“I always looked to feel pretty for someone else,” she told me. “My whole life I was fighting for people who didn’t have a voice. I didn’t realize in all of it, I was losing my own voice because I couldn’t fight for myself.” 

It took a fast crash and a hard fall for her to achieve that self-awareness. 


Kelley, a Pleasant Hill native, said she was an achiever even before her days as a cheerleader and member of the Newton High School homecoming court. 

Kelley, a prom princess, continued achieving in college. 

She earned a bachelor’s degree in sociology from Wright State University and a master’s in clinical, counseling and applied psychology from the University of Dayton. 

She founded and led Isaiah’s Place, a Christian-based foster care agency launched in 2003 and based at 1100 Wayne St. in Troy. 

She lived in a four bedroom house last valued at $340,600 by the Miami County Auditor’s Office. 

Though called “Tree Truck Legs” and “Richter” in high school by bullies who said she shook the Earth when she jumped, Kelley said she actually started packing on the weight during her college days. 

Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

Miserable and labeled morbidly obese, she had weight loss surgery in August 2002 at age 37. 

Life wasn’t a fairy tale.  

After the skin surgeries that removed 11 pounds of skin from her stomach alone, Kelley said she continued to hide and suppress truth about her traumatic childhood. Self-destruction was always around the corner. 

In November of 2016, Kelley was forced to resign from Isaiah’s Place on the heels of a public scandal involving what authorities said was more than $100,000 in missing funds. Her nice big house is now in foreclosure, according to Miami County court records. 

>> PREVIOUS COVERAGE: Foster care agency funds may have been used for gambling, vacations 

Kelley and her 22-year-old son, Alec, now live with their three rottweilers in a two-bedroom home she had once rented out. 

“I lost everything and everyone except my son,” she told me. 

It was a hard pill, but Kelley says it is one she had to shallow. 

“God had to break me. I would not have broke if people were cushioning my fall,” she told me. “I didn’t take care of what God blessed me with, which is why God took it away. I was just out of control. You run from yourself, but it is not a race you can win.”


Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

What followed was intense treatment in Sedona, Ariz., where Kelley says she addressed the sexual abuse she faced between ages 5 and 12 and had buried deep in her soul.

Through therapy, she said she learned that ignored pain contributed to a life of poor decision-making (she says she takes responsibility for the financial mismanagement of Isaiah’s Place) and bad relationships. 

“I was just destroying myself, really. I never had a grasp of the destructive factors in my life. If I wasn’t dating the wrong man, I was dating a worse man,” she said. 

There were liars, womanizers and a long line of general users, Kelley says. When she wasn’t focused on them, she says she was shopping. 

In her book, she writes: 

“I shopped more than anyone should ever shop. I couldn’t overeat anymore, but I could shop. It felt good to be able to buy anything I wanted.... I would buy more than I needed and then not even wear half of it. I would charge my credit cards until the were maxed and then stress out over how I was going to pay them off. I would shop for gifts for people who didn’t deserve gifts from me. I would give and give and give. I suppose I thought that if I gave enough, those people would love me. I never for one second thought that just giving myself was plenty.” 


Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

Kelley said she didn’t tell anyone — not even her best friend — about the sexual abuse. After coming forward, she’s heard from others with similar stories. 

“It’s a beautiful thing to stand in the light of the truth,” she said. “Why did I have to carry shame?” 

>> Oregon District fixture fighting back following devastating illness

Kelley says she now recognizes that even her social work efforts were a mask of sorts. 

“I am that much healthier for allowing that out of my soul. My soul was just screaming, ‘I want to be heard’,” she said. “I knew kids and I knew hurting kids. It meant the world to me. I knew how they felt, and I knew how to work for those kids.” 

Kelley has always had a passion for writing, and has in the past penned words published by the Troy Daily News and the Dayton Daily News, where she was a freelance writer. 

Now, Kelley says she hopes to help people by telling her stories. 

“I was willing to do all the work I needed to do to come out a better me,” she said. “Every one of us is so much more than what’s been done to us.” 

She is penning her second book, “The Homecoming Queen of Crazy Town,” and plans to write “Any Color as Long as it is Red,” a book based on the outlandish and wise sayings her grandmother made up.

Before her life changed forever 15 months ago, Kelley said she was loyal to everyone but herself. 

“I feel very beautiful now,” she said. “What I know is who I am created to be, and no one else can define that for me.”

>>  Troy man on Steve Austin’s show: “It was intense, but we knew it was going to be intense”

Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

Troy resident Kelley Gunter, the author of the new book "You Have Such a Pretty Face," loss 243 with the help of weight loss surgery in 2002. She says true transformation came when he sought help for her destructive behavior. She lives with her son Alec and three Rottweilers.

5 questions every woman in her 40s should ask her doctor

Published: Friday, January 19, 2018 @ 10:36 AM

Women are waiting longer on average to have babies. Now there’s a push for women in their 20s and 30s to spend thousands of dollars to have their eggs stored. So they can improve their chances for pregnancy later in life. Freezing tiny embryos is also an option. At Reproductive Biology Associates, a fertility clinic in Atlanta, lab workers fertilize patients’ eggs, one by one, with sperm. This lab worker uses a tube and the suction of her breath to hold the material in place for the delicate pro

Women who are in their 40s are in many cases reaching a new stage in their lives. Your children may be more independent, and you might have a well-established career. It can also be a time of change, when it's easier to gain weight, and you may start to see the first signs of menopause.

»RELATED: 4 questions every woman in her 30s should ask her doctor

Being informed about the changes you may face during your 40s is an important way to protect your health for many years to come. It pays to have regular checkups and discuss any potential issues or concerns with your doctor. In addition, you may want to undergo some health screenings to confirm or rule out problems that may be more common after age 40.

The following are five questions every woman in her 40s should ask her doctor:

What supplements should I take?

It's common for women in their 40s to be deficient in nutrients such as vitamin D, according to, so it's important to ask your doctor if you should be taking any supplements. This vitamin helps your body absorb calcium, which protects against osteoporosis-related bone loss – a particular concern as you get older.

A blood test can check your vitamin D levels, and if they're low, you may be advised stop smoking, start resistance training and add a supplement to your daily routine.

Should I be tested for diabetes?

Your risk of developing type 2 diabetes increases with age, especially after you're 45, according to Healthline. A blood test can determine whether your body is using insulin efficiently enough to help your body maintain consistent blood glucose levels.

You're at particular risk of developing type 2 diabetes if you're overweight, have a family history of the disease or have a history of gestational diabetes. If you have this disease, you're at an increased risk of developing heart disease, blindness and depression.

How can I control my weight?

Women's metabolism slows after age 40, and as a result, you'll need to eat less and exercise in order to maintain the same weight, according to You may also have hypothyroidism – an underactive thyroid gland that can result in weight gain. If you're gaining weight, it's worth asking your doctor about, especially if you have dry skin, feel tired and are less able to tolerate cold temperatures.

Your doctor can treat hypothyroidism and also suggest an appropriate fitness plan that takes into account your age, weight and health history.

Should I keep taking birth control pills?

If you're in your 40s, you may think you've left your child-bearing years behind, but that's not necessarily true. Unless you've been menopausal for more than a year, you'll still need to take birth control. The second highest rate of unintended pregnancy is for sexually active women who are age 40 to 50, JoAnn Pinkerton, executive director of The North American Menopause Society, told the Chicago Tribune.

Doctors have differing opinions on whether you should keep taking birth control pills after age 40, so talk to your doctor to find out what form of contraception he or she recommends for you.

What about menopause?

You may not be thinking about menopause yet, but it's normal for this process to occur at any age from 40 to 59, according to For an indication about when this might happen, look to when the older women in your family reached menopause. Although this can influence when you enter menopause, it's not guaranteed.

After menopause, your body produces less estrogen, and this may increase your risk of heart disease, the American Heart Association says. Heart disease is the number-one threat to women's health. Talk to your doctor about symptoms that could indicate your may be headed toward menopause and whether hormone replacement therapy is recommended.