mental health – R&R – Reachout and Rebuild

We Got to Work Together

David Posnett — Tue, 05 May 2020 14:49:41 +0000

“Being different is cool” – a lesson from kids in Germantown, PA.

A truly powerful video relevant to our current times (click on the image to see the musical video):

Recognized by the United Nations for Extraordinary Public Service

“On the Other Side of the Fence” is a touching documentary about a musical (by the same name) that was created to foster empathy and partnership between children from two Philadelphia schools for over 30 years.

Holocaust Seen Through the Eyes of a Child

David Posnett — Thu, 19 Oct 2017 19:11:21 +0000

Letter published in the Newburyport News, Massachusetts, by Steve Ludsin of R&R

Very moving’ article about local author’s book, Oct 12, 2017

To the editor:

The article “Local author writes about Holocaust through her father’s eyes” by Dyke Hendrickson, [Daily News, Oct. 10] was very moving. It is true that for many Jews with a European background, the past is never the past.

Margaret A. McQuillan’s recent book, “An Orange in Winter: The Beginning of the Holocaust as Seen Through the Eyes of a Child“, written about a child who was her father was an emotional challenge. I am also a child of a Holocaust survivor and I know the additional stress that can create. I have begun to explore the studies about the possible inheritance of post-traumatic stress syndrome through the DNA from the traumatized parent.

The need to remember the evil of the Holocaust is self-evident, particularly when there is a tendency to forget and in the face of the heated rhetoric from the alt-right movement. I think the author’s goal to portray oppression eight decades ago to young people today will help to rebut the threatening words of people who exclaim you will not replace us with chants of “Blood and soil”. The flame of remembrance should not be extinguished.

Steven A. Ludsin, East Hampton, N.Y. The writer was a member of the President’s Commission on the Holocaust and the first U.S. Holocaust Memorial Council that built the U.S. Holocaust Memorial Museum in Washington, D.C.

Comment from D. Posnett MD:

The medical and psychology literature is replete with studies on the epigenetic effects of post-traumatic stress syndrome, which can be inherited. In lay language: DNA (inheritance of specific genes) is the Christmas tree, while “epigenetics” is the decorations we put on the tree. Curiously, there is mounting evidence that sometimes these decorations become part of the tree itself and subsequent generations of the trees grow with the decorations!!!

A PubMed search for “epigenetics post-traumatic stress syndrome” came up with 48 articles, 27 of them were reviews.

Examples:

The epigenetic impacts of social stress: how does social adversity become biologically embedded? Cunliffe VT. Epigenomics. 2016 Dec;8(12):1653-1669. Epub 2016 Nov 21.
Epigenetic Alterations Associated with War Trauma and Childhood Maltreatment. Ramo-Fernández L, Schneider A, Wilker S, Kolassa IT. Behav Sci Law. 2015 Oct;33(5):701-21.

The new Senate health care bill — and the return of preexisting conditions — explained

David Posnett — Fri, 14 Jul 2017 13:14:09 +0000

Posted on Vox.com

Updated by Sarah Kliff sarah@vox.com Jul 13, 2017, 1:18pm EDT

Senate Republicans introduced a revised version of their bill to repeal and replace the Affordable Care Act on Thursday, one that would allow insurers to once again deny coverage based on preexisting conditions, and to charge higher rates to sick people.

The bill would keep most of the Affordable Care Act’s tax increases but repeal one aimed specifically at medical device manufacturers. It would deeply cut the Medicaid program, making few changes to the bill’s first draft.

Even with these new changes, the general structure of the bill stays the same from its original draft, which was itself largely similar to the bill that passed the House in the spring.

Healthier and higher-income Americans would benefit from the changes in the new Republican plan, while low-income and sick Americans would be disadvantaged. It would create a two-track system for health coverage on the individual market. One would offer cheaper, deregulated health plans, which healthy people would likely flock to. The other would include comprehensive plans governed by Obamacare’s regulations, which would cost more and mostly be used by less healthy people and those with preexisting conditions — a system experts expect would function like a poorly funded high-risk pool.

Deductibles would almost certainly rise under the Republican plan, as would overall costs for low- and middle-income Americans. Individual market participants would have more options to purchase catastrophic coverage, an option likely to appeal to those with few health care costs.

Experts expect the changes will do little to change the Congressional Budget Office’s estimates that 22 million Americans would lose coverage under the proposal.

You can see a full explainer on the Senate bill here, which will be updated shortly with the latest information. This post focuses on the changes made in the July 13 revision.

Health insurers could bring back preexisting conditions, offer skimpy health plans

Perhaps the biggest policy change in this revision is an amendment to allow health insurers to deny coverage based on preexisting conditions and cover few benefits, so long as they offer a comprehensive plan that covers the Affordable Care Act’s mandated benefits.

These deregulated health plans would be allowed to charge sick people higher premiums or simply deny them coverage. They would not have to pay by the rules of the preexisting condition ban that the Affordable Care Act sets up (Phil Klein at the Washington Examiner has a summary of the rules they’d be exempted from here). Instead, they would operate much like health plans in the pre-Affordable Care Act market, offering cheap rates to consumers they believe would have low medical bills.

Health policy experts know exactly how this would play out: Healthy people would pick the skimpier plan, while the comprehensive plan would essentially become a high-risk pool for sicker Americans.

Individual market enrollees would likely game the system too. A couple expecting a baby, for example, would be expected to upgrade to the plan that covers maternity care for one year before returning to the cheaper plan they had before.

“Someone with chronic illness, they’re going to end up wanting to buy the more comprehensive coverage,” says Joe Antos, a health policy expert with the conservative American Enterprise Institute. “This means that people with those kinds of illnesses will end up paying more. Even if they receive a federal subsidy, they will likely see higher cost sharing.”

As Antos notes, individuals who want to buy the comprehensive plan would receive federal tax credits to do so. They could not use the tax credits for the deregulated plans.

But even after that financial help, these people would still face significant out-of-pocket costs, including high deductibles and premiums. The Congressional Budget Office estimates, for example, that a 64-year-old individual earning $11,500 and receiving tax credits would still need to pay $4,800 to purchase that plan.

The updated Senate bill also allows individuals to use tax credits to purchase catastrophic coverage

There is a quieter way the Senate bill lets people buy skimpier plans: by using their tax credits to purchase catastrophic plans.

This is a practice the Affordable Care Act barred, as the law’s drafters wanted to encourage enrollment in more generous options. But the Senate bill would allow the tax credits to be used for these high-deductible plans. These plans would only include three primary care visits before individuals hit their deductibles and have to pay their medical bills out of pocket. The plans could cover a wide array of health benefits, including maternity and mental health, but, again, coverage would only kick in after paying a large deductible.

The updated bill would let individuals use pre-tax dollars to pay for their premiums

An estimated 29 percent of American workers are enrolled in tax-advantaged health savings accounts (HSA), that allow them to use pre-tax dollars to cover things like copayments and coinsurance.

The Senate bill would allow HSA dollars to go toward premiums as well, meaning someone in the individual market could use pre-tax dollars to pay their monthly bill. This practice was not allowed under the Affordable Care Act.

Liberals have typically opposed this provision, which they argue would mainly benefit wealthy Americans who have the money to contribute to an HSA in the first place. This provision would have fewer benefits for low-income Americans, who rely on tax credits to finance the lion’s share of their premium.

The Senate bill gets rid of most Obamacare tax cuts — but keeps two on high earners in place

The Senate’s revised health care bill still includes an estimated $657 billion in tax cuts by eliminating the health law’s taxes on the medical industry and its individual mandate penalty for not carrying coverage, among other changes.

It does continue two taxes aimed at wealthy Americans: a 0.9 percent investment tax and a 3.8 percent Medicare payroll surtax. Keeping these two taxes in place would net the government an estimated $231 billion in revenue over the next decade, and eliminate some of the benefits high-income Americans would have received under the first draft.

These new taxes, however, do not seem to be fully spent on enhancing the law’s benefits. The new bill includes a $45 billion program to combat opioid abuse as well as $70 billion to offset the costs of expensive patients (this is in addition to the $112 billion already appropriated for that purpose in the first version of the bill). The inclusion of these taxes does not appear to lead to any additional funding of the Medicaid program or offset any of the cuts to the tax credits in the individual market.

The Senate bill still makes very deep cuts to Medicaid

The Senate bill is notable in what it doesn’t change: namely, significant cuts to the Medicaid program. While moderate senators have protested these cuts (particularly those who represent Medicaid expansion states), these provisions of the Senate bill remain largely intact.

One of the main ways Obamacare increased insurance coverage was by expanding the Medicaid program to cover millions more low-income Americans. Prior to the health law, the entitlement was restricted to specific groups of low-income Americans (pregnant women, for example, and the blind and disabled).

Obamacare opened up the program to anyone below 138 percent of the poverty line (about $15,000 for an individual) in the 31 states (plus the District of Columbia) that opted to participate.

The Medicaid expansion gave states generous funding to cover this particular population. Typically, the federal government picks up about half the cost of the Medicaid program and states cover the rest.

For Medicaid expansion, however, the federal government currently pays 95 percent of the costs — an especially good deal for states meant to assuage their budget concerns during the original Obamacare debate.

The Senate bill would begin ratcheting down that Medicaid expansion funding in 2021. By 2024, states would get that same match rate they typically get to cover other populations. In 2021, for example, the match rate would fall to 90 percent, then decline in steps to 75 percent by 2023.

The Congressional Budget Office has projected in a separate analysis that this policy change would mean no additional states expand Medicaid — and that some current expansion states would drop out of the program, resulting in millions losing coverage.

“CBO anticipates some states that have already expanded their Medicaid programs would no longer offer that coverage,” the agency wrote in its analysis of the House bill, which makes a similar change.

The Senate bill would cut the rest of the Medicaid program too

There are significant changes to Medicaid in the Senate bill outside of the expansion too. This bill would convert Medicaid to a “per capita cap” system, where states would get a lump sum from the federal government for each enrollee. Or states would have the opportunity of a block grant — a sum of money untethered from the number of people involved.

This is very different from current Medicaid funding. Right now the federal government has an open-ended commitment to paying all of a Medicaid enrollee’s bills, regardless of how high they go.

The Senate bill would set different amounts for different groups of people. It envisions, for example, higher payments to cover Medicaid enrollees who are disabled (and tend to have higher costs) than for Medicaid enrollees who are kids (generally healthy with lower costs).

The rate at which these payments grow is also important. The Senate bill would have the funding growth tethered to the Medical Consumer Price Index plus 1 percentage point through 2025, and then switch to the urban Consumer Price Index. Analysis of this type of proposal suggests this change would amount to funding cuts for Medicaid, as the program’s spending typically goes up faster than these growth rates.

Summary of CBO Report on Better Care Reconciliation Act of 2017 (Senate Bill)

David Posnett — Tue, 27 Jun 2017 01:20:04 +0000

June 26, 2017

Cost Estimate

CBO and JCT estimate that enacting the Better Care Reconciliation Act of 2017 would reduce federal deficits by $321 billion over the coming decade and increase the number of people who are uninsured by 22 million in 2026 relative to current law.

52849-hr1628senate.pdf

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1.37 MB

Summary

An Amendment in the Nature of a Substitute [LYN17343] as Posted on the Website of the Senate Committee on the Budget on June 26, 2017

The Congressional Budget Office and the staff of the Joint Committee on Taxation (JCT) have completed an estimate of the direct spending and revenue effects of the Better Care Reconciliation Act of 2017, a Senate amendment in the nature of a substitute to H.R. 1628. CBO and JCT estimate that enacting this legislation would reduce the cumulative federal deficit over the 2017-2026 period by $321 billion. That amount is $202 billion more than the estimated net savings for the version of H.R. 1628 that was passed by the House of Representatives.

The Senate bill would increase the number of people who are uninsured by 22 million in 2026 relative to the number under current law, slightly fewer than the increase in the number of uninsured estimated for the House-passed legislation. By 2026, an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

Following the overview, this document provides details about the major provisions of this legislation, the estimated costs to the federal government, the basis for the estimate, and other related information, including a comparison with CBO’s estimate for the House-passed act.

Effects on the Federal Budget

CBO and JCT estimate that, over the 2017-2026 period, enacting this legislation would reduce direct spending by $1,022 billion and reduce revenues by $701 billion, for a net reduction of $321 billion in the deficit over that period (see Table 1, at the end of this document):

The largest savings would come from reductions in outlays for Medicaid—spending on the program would decline in 2026 by 26 percent in comparison with what CBO projects under current law—and from changes to the Affordable Care Act’s (ACA’s) subsidies for nongroup health insurance (see Figure 1). Those savings would be partially offset by the effects of other changes to the ACA’s provisions dealing with insurance coverage: additional spending designed to reduce premiums and a reduction in revenues from repealing penalties on employers who do not offer insurance and on people who do not purchase insurance.
The largest increases in deficits would come from repealing or modifying tax provisions in the ACA that are not directly related to health insurance coverage, including repealing a surtax on net investment income and repealing annual fees imposed on health insurers.

Pay-as-you-go procedures apply because enacting this legislation would affect direct spending and revenues. CBO and JCT estimate that enactment would not increase net direct spending or on-budget deficits in any of the four consecutive 10-year periods beginning in 2027. The agencies expect that savings, particularly from Medicaid, would continue to grow, while the costs would be smaller because a rescinded tax on employees’ health insurance premiums and health plan benefits would be reinstated in 2026. CBO has not completed an estimate of the potential impact of this legislation on discretionary spending, which would be subject to future appropriation action.

Effects on Health Insurance Coverage

CBO and JCT estimate that, in 2018, 15 million more people would be uninsured under this legislation than under current law—primarily because the penalty for not having insurance would be eliminated. The increase in the number of uninsured people relative to the number projected under current law would reach 19 million in 2020 and 22 million in 2026. In later years, other changes in the legislation—lower spending on Medicaid and substantially smaller average subsidies for coverage in the nongroup market—would also lead to increases in the number of people without health insurance. By 2026, among people under age 65, enrollment in Medicaid would fall by about 16 percent and an estimated 49 million people would be uninsured, compared with 28 million who would lack insurance that year under current law.

Stability of the Health Insurance Market

Decisions about offering and purchasing health insurance depend on the stability of the health insurance market—that is, on the proportion of people living in areas with participating insurers and on the likelihood of premiums’ not rising in an unsustainable spiral. The market for insurance purchased individually with premiums not based on one’s health status would be unstable if, for example, the people who wanted to buy coverage at any offered price would have average health care expenditures so high that offering the insurance would be unprofitable.

Under Current Law. Although premiums have been rising under current law, most subsidized enrollees purchasing health insurance coverage in the nongroup market are largely insulated from increases in premiums because their out-of-pocket payments for premiums are based on a percentage of their income; the government pays the difference between that percentage and the premiums for a reference plan (which is the second-lowest-cost plan in their area providing specified benefits). The subsidies to purchase coverage, combined with the effects of the individual mandate, which requires most individuals to obtain insurance or pay a penalty, are anticipated to cause sufficient demand for insurance by enough people, including people with low health care expenditures, for the market to be stable in most areas.

Nevertheless, a small number of people live in areas of the country that have limited participation by insurers in the nongroup market under current law. Several factors may lead insurers to withdraw from the market—including lack of profitability and substantial uncertainty about enforcement of the individual mandate and about future payments of the cost-sharing subsidies to reduce out-of-pocket payments for people who enroll in nongroup coverage through the marketplaces established by the ACA.

Under This Legislation. CBO and JCT anticipate that, under this legislation, nongroup insurance markets would continue to be stable in most parts of the country. Although substantial uncertainty about the effects of the new law could lead some insurers to withdraw from or not enter the nongroup market in some states, several factors would bring about market stability in most states before 2020. In the agencies’ view, those key factors include the following: subsidies to purchase insurance, which would maintain sufficient demand for insurance by people with low health care expenditures; the appropriation of funds for cost-sharing subsidies, which would provide certainty about the availability of those funds; and additional federal funding provided to states and insurers, which would lower premiums by reducing the costs to insurers of people with high health care expenditures.

The agencies expect that the nongroup market in most areas of the country would continue to be stable in 2020 and later years as well, including in some states that obtain waivers that would not have otherwise done so. (Under current law and this legislation, states can apply for Section 1332 waivers to change the structure of subsidies for nongroup coverage; the specifications for essential health benefits [EHBs], which set the minimum standards for the benefits that insurance in the nongroup and small-group markets must cover; and other related provisions of law.) Substantial federal funding to directly reduce premiums would be available through 2021. Premium tax credits would continue to provide insulation from changes in premiums through 2021 and in later years. Those factors would help attract enough relatively healthy people for the market in most areas of the country to be stable, CBO and JCT anticipate. That stability in most areas would occur even though the premium tax credits would be smaller in most cases than under current law and subsidies to reduce cost sharing—the amount that consumers are required to pay out of pocket when they use health care services—would be eliminated starting in 2020.

In the agencies’ assessment, a small fraction of the population resides in areas in which—because of this legislation, at least for some of the years after 2019—no insurers would participate in the nongroup market or insurance would be offered only with very high premiums. Some sparsely populated areas might have no nongroup insurance offered because the reductions in subsidies would lead fewer people to decide to purchase insurance—and markets with few purchasers are less profitable for insurers. Insurance covering certain services would become more expensive—in some cases, extremely expensive—in some areas because the scope of the EHBs would be narrowed through waivers affecting close to half the population, CBO and JCT expect. In addition, the agencies anticipate that all insurance in the nongroup market would become very expensive for at least a short period of time for a small fraction of the population residing in areas in which states’ implementation of waivers with major changes caused market disruption.

Effects on Premiums and Out-of-Pocket Payments

The legislation would increase average premiums in the nongroup market prior to 2020 and lower average premiums thereafter, relative to projections under current law, CBO and JCT estimate. To arrive at those estimates, the agencies examined how the legislation would affect the premiums charged if people purchased a benchmark plan in the nongroup market.

In 2018 and 2019, under current law and under the legislation, the benchmark plan has an actuarial value of 70 percent—that is, the insurance pays about 70 percent of the total cost of covered benefits, on average. In the marketplaces, such coverage is known as a silver plan.

Under the Senate bill, average premiums for benchmark plans for single individuals would be about 20 percent higher in 2018 than under current law, mainly because the penalty for not having insurance would be eliminated, inducing fewer comparatively healthy people to sign up. Those premiums would be about 10 percent higher than under current law in 2019—less than in 2018 in part because funding provided by the bill to reduce premiums would affect pricing and because changes in the limits on how premiums can vary by age would result in a larger number of younger people paying lower premiums to purchase policies.

In 2020, average premiums for benchmark plans for single individuals would be about 30 percent lower than under current law. A combination of factors would lead to that decrease—most important, the smaller share of benefits paid for by the benchmark plans and federal funds provided to directly reduce premiums.

That share of services covered by insurance would be smaller because the benchmark plan under this legislation would have an actuarial value of 58 percent beginning in 2020. That value is slightly below the actuarial value of 60 percent for “bronze” plans currently offered in the marketplaces. Because of the ACA’s limits on out-of-pocket spending and prohibitions on annual and lifetime limits on payments for services within the EHBs, all plans must pay for most of the cost of high-cost services. To design a plan with an actuarial value of 60 percent or less and pay for those high-cost services, insurers must set high deductibles—that is, the amounts that people pay out of pocket for most types of health care services before insurance makes any contribution. Under current law for a single policyholder in 2017, the average deductible (for medical and drug expenses combined) is about $6,000 for a bronze plan and $3,600 for a silver plan. CBO and JCT expect that the benchmark plans under this legislation would have high deductibles similar to those for the bronze plans offered under current law. Premiums for a plan with an actuarial value of 58 percent are lower than they are for a plan with an actuarial value of 70 percent (the value for the reference plan under current law) largely because the insurance pays for a smaller average share of health care costs.

Although the average benchmark premium directly affects the amount of premium tax credits and is a key element in CBO’s analysis of the budgetary effects of the bill, it does not represent the effect of this legislation on the average premiums for all plans purchased. The differences in the actuarial value of plans purchased under this legislation and under current law would be greater starting in 2020—when, for example, under this bill, some people would pay more than the benchmark premium to purchase a silver plan, whereas, under current law, others would pay less than the benchmark premium to purchase a bronze plan.

Under this legislation, starting in 2020, the premium for a silver plan would typically be a relatively high percentage of income for low-income people. The deductible for a plan with an actuarial value of 58 percent would be a significantly higher percentage of income—also making such a plan unattractive, but for a different reason. As a result, despite being eligible for premium tax credits, few low-income people would purchase any plan, CBO and JCT estimate.

By 2026, average premiums for benchmark plans for single individuals in most of the country under this legislation would be about 20 percent lower than under current law, CBO and JCT estimate—a smaller decrease than in 2020 largely because federal funding to reduce premiums would have lessened. The estimates for both of those years encompass effects in different areas of the country that would be substantially higher and substantially lower than the average effect nationally, in part because of the effects of state waivers. Some small fraction of the population is not included in those estimates. CBO and JCT expect that those people would be in states using waivers in such a way that no benchmark plan would be defined. Hence, a comparison of benchmark premiums is not possible in such areas.

Some people enrolled in nongroup insurance would experience substantial increases in what they would spend on health care even though benchmark premiums would decline, on average, in 2020 and later years. Because nongroup insurance would pay for a smaller average share of benefits under this legislation, most people purchasing it would have higher out-of-pocket spending on health care than under current law. Out-of-pocket spending would also be affected for the people—close to half the population, CBO and JCT expect—living in states modifying the EHBs using waivers. People who used services or benefits no longer included in the EHBs would experience substantial increases in supplemental premiums or out-of-pocket spending on health care, or would choose to forgo the services. Moreover, the ACA’s ban on annual and lifetime limits on covered benefits would no longer apply to health benefits not defined as essential in a state. As a result, for some benefits that might be removed from a state’s definition of EHBs but that might not be excluded from insurance coverage altogether, some enrollees could see large increases in out-of-pocket spending because annual or lifetime limits would be allowed.

Uncertainty Surrounding the Estimates

CBO and JCT have endeavored to develop budgetary estimates that are in the middle of the distribution of potential outcomes. Such estimates are inherently inexact because the ways in which federal agencies, states, insurers, employers, individuals, doctors, hospitals, and other affected parties would respond to the changes made by this legislation are all difficult to predict. In particular, predicting the overall effects of the myriad ways that states could implement waivers is especially difficult.

CBO and JCT’s projections under current law itself are also uncertain. For example, enrollment in the marketplaces under current law will probably be lower than was projected under the March 2016 baseline used in this analysis, which would tend to decrease the budgetary savings from this legislation. However, the average subsidy per enrollee under current law will probably be higher than was projected in March 2016, which would tend to increase the budgetary savings from this legislation. (For a related discussion, see the section on “Use of the March 2016 Baseline” on page 15.)

Despite the uncertainty, the direction of certain effects of this legislation is clear. For example, the amount of federal revenues collected and the amount of spending on Medicaid would almost surely both be lower than under current law. And the number of uninsured people under this legislation would almost surely be greater than under current law.

Intergovernmental and Private-Sector Mandates

CBO has reviewed the nontax provisions of the legislation and determined that they would impose intergovernmental mandates as defined in the Unfunded Mandates Reform Act (UMRA) by preempting state laws. Although the preemptions would limit the application of state laws, they would impose no duty on states that would result in additional spending or a loss of revenues. JCT has determined that the tax provisions of the legislation contain no intergovernmental mandates.

JCT and CBO have determined that the legislation would impose private-sector mandates as defined in UMRA. On the basis of information from JCT, CBO estimates that the aggregate cost of the mandates would exceed the annual threshold established in UMRA for private-sector mandates ($156 million in 2017, adjusted annually for inflation).

Winners And Losers: 40 Is Old In Senate GOP Health Plan’s Subsidy Structure

David Posnett — Fri, 23 Jun 2017 19:47:14 +0000

KAISER HEALTH NEWS — REPEAL & REPLACE WATCH

By Julie Appleby June 22, 2017

People getting subsidies to help buy health insurance would see at least three sharp changes — tied to both age and income — that could dramatically affect how much they pay for coverage if the Senate Republican health plan becomes law.

The Senate bill released Thursday would reduce the income thresholds that determine eligibility, change the amount people who receive help pay toward their insurance premiums and peg subsidies to less generous coverage.

About 85 percent of the nearly 10 million consumers who enrolled in coverage last year through federal and state marketplaces received tax credit subsidies and other types of financial assistance. Under the Senate plan, some could pay less in premium costs, but many, particularly older Americans, could see their share of payments go up. And let’s be clear — you’re old at about 40.

Incomes Eligible For Help Fall To 350 Percent Of Poverty

The Affordable Care Act provides tax credit subsidies on a sliding scale for people earning up to 400 percent of the federal poverty level — an amount that equals about $47,520 this year for individuals. Starting in 2020, the Senate bill would drop that to 350 percent, which is now an annual income of about $41,580. As a result, fewer people would qualify. To be sure, some enrollees who exceed that new income limit might lose only a small subsidy because of the way the current law is structured, but older enrollees could lose substantial amounts. The Center on Budget and Policy Priorities estimated Thursday that a 60-year-old earning just above the cutoff would lose at least $3,000 annually in subsidies.

Age Matters

Tax credits are just one part of the picture. Under the ACA, subsidy-eligible enrollees must pay a percentage of their annual household income toward premiums, ranging from about 2 percent to just over 9.5 percent for those with higher incomes. Those amounts go up over time. The Senate bill would adjust those percentages based on age, keeping the lower limit at around 2 percent, but exceeding 16.2 percent at the highest income and age group. So if you are 39 or younger, you generally would pay smaller percentages of your income when compared with what you pay under the ACA, ranging from about 2 percent to 8.9 percent.

But once you hit 40, things change. Let’s say you earn $41,580 — 350 percent of poverty — you would pay more than 12.5 percent of your income, or $5,197, under the Senate plan. That compares with $4,029, or 9.69 percent currently under the ACA. At that same income level, percentages rise to 15.8 for those ages 50 to 59 and up to 16.2 percent of income for those 60 and up.

Aiming For Bronze: Subsidies Tied To Less Generous Coverage

The Senate would link the subsidies to plans with less generous coverage than the ACA. Subsidies under current law are pegged to a benchmark “silver” plan, which covers an average of about 70 percent of medical expenses. The Senate would peg the subsidy to the median price of a policy that covers about 58 percent of health costs, roughly equivalent to today’s “bronze” plans. Consumers pay the rest of the cost, usually through deductibles and copayments. This year, average deductibles for bronze plans were more than $6,000, while silver plans averaged $3,500, according to consumer website HealthPocket. People could still use subsidies to buy more generous plans, but the premiums would be higher.

Christopher Condeluci, who served as tax and benefit counsel to the Senate Finance Committee when the ACA was drafted, said the changes might prompt more people to buy insurance, noting that subsidies will be available to those who are under the federal poverty level, which they aren’t under current law. Younger people also might benefit by paying less toward coverage, helping boost their enrollment.

To make that happen, however, he said, the formula had to be adjusted so older people at the higher-income end of subsidy eligibility pay more.

“The current ACA discourages younger people from getting in,” said Condeluci, who expects “the older-age lobby will continue to criticize this type of proposal.”

While getting people under the poverty level covered by insurance would be a good thing, it should be done by expanding Medicaid, said Sabrina Corlette, who studies the individual insurance market as research professor at Georgetown University’s Health Policy Institute.

“It’s much more expensive for the federal government to subsidize private insurance than provide a Medicaid benefit,” said Corlette, who also doubts that many people earning less than $12,000 a year have enough saved to cover the cost of a deductible in the types of plans the Senate proposal would subsidize.

In total, the changes proposed in the Senate bill mean, Corlette said, “the subsidy buys you less and the older you are, the more you will be asked to pay.”

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

New polling numbers are out for ‘Trumpcare’, and they’re a disaster for Republicans

David Posnett — Thu, 22 Jun 2017 16:54:01 +0000

But when is this going to affect voters’ behavior?

POSTED ON DAILY KOS

By Hunter

Wednesday Jun 21, 2017 · 2:15 PM EDT

Which is exactly why they’re trying to ram a Senate bill through without letting the public know what’s in it.

Take Action

Send a letter to Republican senators and stop Mitch McConnell from forcing Trumpcare!

As Republicans continue to barrel towards repealing the nation’s healthcare reform efforts regardless of the suffering it will cause, their efforts continue to get even more wildly unpopular among voters.

As the GOP-led Senate prepares to take up the measure, only 35 percent of voters surveyed approve of the bill passed by the House last month. Nearly half of voters, 49 percent, disapprove of the bill. The other 16 percent don’t know or don’t have an opinion, the poll shows.POLITICO/Morning Consult polling indicates the bill has become less popular since the House advanced it in early May. Immediately after the bill passed, slightly more voters approved of the bill, 38 percent. Opposition to the bill was lower, too, immediately after the House passed it: 44 percent.

Which is the one and only reason Senate Republicans are keeping their version of the bill a closely-held secret until the last possible moment: They know the public is going to hate it. It’s going to look very much like the House bill, it’s going to uninsure millions of American citizens for no other reason than to pass the House-style tax cuts, people are going to die as a direct result and nearly everybody in America knows all of that.

Many in the Republican base are still fine with it, because they would agree to saw off their own legs and glue live chickens to the stumps if they thought Barack Obama would be against them doing that, but anyone with a preexisting condition, anyone who has health insurance now that didn’t have it before, anyone on Medicaid who couldn’t get it before and anyone who has a basic sense of decency isn’t a fan. And Republican disapproval, too, is rapidly rising:

Among Republican voters, 30 percent disapprove of the GOP health care bill. That is up from 15 percent of Republicans disapproving in early May.

That’s a trend that Republicans can’t afford to see continue, hence both the secrecy and the speed. There won’t be hearings because the Republican leadership simply can’t afford to have their own base continue to hear about this thing—and given that only a third of all American voters like it, total, that shows you just how despised it is among voters who aren’t a part of their base.

[I]ndependent voters disapprove of the bill by a 2-to-1 margin: 26 percent approve, versus 53 percent who disapprove.

That’s abysmal. You could get higher approval ratings by promising to give everyone in America free herpes.

[F]ew voters are cheering for the legislation’s passage. Only 27 percent think it will make the U.S. health care system better, compared to 41 percent who think it will make the system worse. Just 17 percent think it will decrease costs for them and their families, while 46 percent think costs will increase.

Voters are making a dramatic statement here: All but a handful detest this “reform” effort and oppose Republicans following through on it. And nearly everyone is clear on the effects, saying this bill will hurt both the overall U.S. healthcare system and them, personally.

The bad news is that the Republican lawmakers installed by those voters simply do not seem to care. At all. Rather than listening to voters warning them about how disastrous the bill will be they’ve decided to hunker down and simply not tell anyone what will be in it from now on, rushing to pass a final version within days of public release so that the public won’t have a chance to either review it or complain.

Why? What’s in this for Republican lawmakers? It’s going to cost them votes even among their own base, it’s going to open them up to endless future campaign commercials each featuring individual Americans from their own states and districts who lost insurance, or care, or even loved ones due to the Republican effort, and in return they get—what?

What’s being promised to them that outweighs all that?

No One in Zeldin’s Office Could Care Less

David Posnett — Fri, 16 Jun 2017 20:22:48 +0000

By Steven Lupo

I called Senators Schumer and Gillibrand’s office yesterday. I spoke to Jason at Schumer’s office and Saj (her nickname) at Gillibrand’s office.

I stated I heard that 13 Republican men were hiding behind closed doors, trying to come up with a bill that was abominable enough for the Republican caucus to support. That bill would destroy the ACA, gut Medicaid and give huge tax cuts to the rich.

I asked them both to urge the senators to do everything in their power — procedurally — to stall this legislation at least until the summer recess. This way the Republican senators will get an ear full from their constituents when they return home to their states.

I told them my personal story, of my autistic brother. I informed them that my brother is not a lazy person looking for “free stuff”. My brother is disabled. My family has relied on Medicaid for his care most of his life. My family would’ve been devastated without Medicaid. And now the Republicans are trying to take that away — to give tax cuts to their rich donor class?!?

This is where I found a stark contrast.

Both staffers seemed genuinely concerned. They asked me questions about my brother.

You can pay a staffer to take down comments from a constituent but you cannot make a staffer compassionate or empathetic. Those traits come from the person. When I called Zeldin’s office and repeated the same story, I just get an unemotional, “I’ll pass that on to the congressman” line. No one in Zeldin’s office could care less about my brothers situation. No one!

Both tried to ease my anxiety by stating the senators are going to do everything in their power to prevent the Republicans from destroying the ACA.

Jason tried to ease my anxiety by stating he personally did not believe the Senate would find consensus to destroy the ACA. I politely reminded him that many of my friends kept telling me not to worry, that Donald Trump would not win. I simply cannot find comfort in hopeful thinking. I informed him that although I believe Republicans destroying the ACA will be a political disaster for them, I do not want to see Americans suffer in order to have another reason to bash the Republican Party.

Zeldin on Opiods

David Posnett — Thu, 15 Jun 2017 21:50:20 +0000

Posted in Smithtown Matters, June 14

To The Editor:

I read Mr. Zeldin’s op-ed concerning the opioid epidemic in wonderment. It is hard to disagree with his view that the opiod epidemic is a crisis America needs to confront. But, to see Mr. Zeldin pound his chest over his so-called achievements is an insult to all of us.

He has already broken his promise to “continue working to advance legislation that helps those coping with drug addiction, by increasing treatment and recovery services to stop the tragic loss of life, family, and community as a result of addiction.” House Republican just approved a health care bill (of which Mr. Zeldin is still an outspoken champion) that, in the view of experts, make the epidemic even worse — by repealing Obamacare protections for access to drug addiction treatment.

The Affordable Care Act (also known as Obamacare) required insurers to cover ten essential health benefits, one of which is mental health services and addiction treatment.

In contrast, the American Healthcare Act (AHCA), the Republican health care bill, allows states to get waivers to this requirement that would allow state insurers to exclude mental health services and addiction treatment from the coverage available.

Before Obamacare, it was fairly common for insurers to leave out addiction treatment in their plans. If someone with a drug use disorder wanted coverage, she would need to find a more expensive plan that did include addiction treatment — and perhaps she wouldn’t be able to find a plan, particularly an affordable one, at all. Obamacare solved that problem.

An analysis of Obamacare concluded that it helped 2.8 million Americans with drug use disorders and nearly 1.3 million with serious mental disorders. Under Mr. Zeldin’s AHCA, these people would stand to lose addiction and mental health coverage if essential health benefits were repealed.

The AHCA’s waiver provision is not the only hurdle to obtaining addiction coverage. Several other aspects of the AHCA threaten to reduce health coverage, particularly to people who rely on coverage to get drug treatment.

Over the next few years, the AHCA would phase out the Medicaid expansion. It would pull back Obamacare’s tax credits, as well as regulations that shield older people from high premiums, effectively making coverage more expensive for older, low- income Americans. It also cuts Medicaid by transitioning its benefits to a “per capita cap” system or a block grant system that gives states less money for the program, on top of imposing a work requirement for Medicaid eligibility.

Obviously, losing access to Medicaid and other insurance would hurt a lot of people in general, removing access to any health care. But one of the forms of health care that is most affected here would be coverage for drug treatment. And those most affected will low-income people, for whom the cost of insurance will not be offset by the proposed tax credit plan under the AHCA. This group simply will not be able to afford addiction-related care. So millions of Americans with drug use disorders stand to suffer under the bill — in the middle of the deadliest drug crisis in US history.

For Mr. Zeldin to brag about his efforts to fight the opiod endemic in the face of championing a healthcare bill that will eviscerate coverage borders on outrage. This is just a continuation of his penchant for deceiving his constituency over his actions in Congress.

Bruce Colbath

R&R has published several other posts on Zeldin and the drug crisis:

Lee Zeldin’s Drug Crisis: Billions, or Millions ?

Posted on April 19, 2017 by D. Posnett MD.

Regarding the drug epidemic, the CDC (Center for Disease Control) has pointed out 2 trends: A 15-year increase in overdose deaths involving prescription opioid pain relievers and a recent surge in illicit opioid overdose deaths, driven largely by heroin. Prescription …

Zeldin’s “War on drugs” ineffective

Posted on March 2, 2017 by D. Posnett MD

This letter appeared today March 1st in the East Hampton Press on page A7 Rep. Lee Zeldin writes about his health care goals in the Riverhead Local: “… here in Suffolk County, our communities and families have been severely impacted …

Trump Budget Would Slash Funds for Office Fighting Opioid Epidemic

Posted on May 9, 2017 by bcolbath42

Published by Mother Jones The Office of National Drug Control Policy is facing a 95 percent budget cut. JULIA LURIE MAY 5, 2017 12:45 PM The White House is calling for a 95 percent funding cut for the Office of National …

GOP Rep [Zeldin] brushes off town hall mom pleading for help for her heroin-addicted son

Posted on April 29, 2017 by bcolbath42

Published by ShareBlue Media By Oliver Willis |APRIL 28, 2017 Rep. Lee Zeldin (R-NY) refused to answer a mother after she pleaded with him to stop Donald Trump from gutting coverage for substance abuse treatment for her heroin-addicted son. Rep. Lee …

‘My Life Is Very Full’: People With Disabilities Worry About GOP Medicaid Cuts

David Posnett — Wed, 07 Jun 2017 22:27:46 +0000

Kaiser Health News

By Elly Yu, WABE June 7, 2017

Evan Nodvin, seen here in his Atlanta-area apartment, uses services

that are covered by Medicaid. (Elly Yu/WABE)

Several decades ago, Evan Nodvin’s life probably would have looked quite different.

Nodvin has his own apartment just outside Atlanta, in Sandy Springs, Ga., and a job at a local community fitness center. He also has Down syndrome.

“I give out towels, and put weights away, and make sure people are safe,” the 38-year-old said.

To get to and from work, Nodvin relies on rides from people who are hired to help him. He also has a counselor to help him do daily chores like grocery shopping, cleaning and cooking.

“My favorite thing to cook on Wednesdays — I like to cook turkey patties once a week,” he said. “And on Thursdays, I make fish, and other days, I make other good stuff like spaghetti.”

Nodvin can live independently because of these services that are covered in Georgia under Medicaid, the government health insurance for people with disabilities and the poor. According to the Georgia Department of Community Health, the state spends about 6 percent of its Medicaid budget on services for people with developmental disabilities.

When Congress started to talk about making big changes to Medicaid in the health care bill in March, Nodvin went to Washington, D.C., with a group of advocates to lobby. He read a speech there, which he recited in his living room.

“As you can see, my life is very full. I work, live and play in the community. My dream is to continue this healthy and useful life. Thank you,” he read.

But that dream is uncertain. The Congressional Budget Office estimates the proposed cuts to Medicaid in the Obamacare repeal bill that passed the House of Representatives amounts to $834 billion over 10 years. In Georgia, more than half of the state’s Medicaid dollars go to the elderly or people with disabilities, according to the Georgia Department of Community Health.

Instead of matching state funds, under the new plan the federal government would give states a fixed amount of money based on what they’ve been spending, said Bill Custer, a professor of health administration at Georgia State University.

“In a state like Georgia, the impact would be immediate and fairly severe over time,” he said.

According to the Kaiser Family Foundation, Georgia ranked the second lowest in Medicaid spending per enrollee in fiscal year 2011. (Kaiser Health News is an editorially independent program of the foundation.) Georgia currently gets about two federal dollars for every one dollar the state puts in, but the new plan would give states a capped amount of funding for Medicaid.

Custer said Medicaid in Georgia might be OK in the beginning, but as health care costs rise, states will increasingly have to shoulder the burden.

“That means states are going to have to either find the money to maintain the program or shrink the program either by covering fewer services, or covering fewer people, or both,” he said.

That worries Eric Jacobson, executive director of the Georgia Council on Developmental Disabilities, a state advocacy group.

“Medicaid is the lifeline for people with disabilities,” he said.

Jacobson said the community support services like Nodvin gets under Medicaid are considered optional by states.

“Those are the kinds of services that we hope won’t get cut, but because of the reduction in funds, [they] might be the first on the chopping block,” he said.

He said services are already limited. According to the state Department of Community Health, nearly 9,000 people with intellectual or developmental disabilities are on a waiting list to get help in order to live on their own or in their communities.

Jacobson worries more people might be forced into institutions if there are budget cuts.

“The way I look at it, institutionalization for people with developmental disabilities — it’s kind of like sending you to jail for no crime,” he said. “You can’t go out. I remember talking to somebody, and he said, ‘I want to take my girlfriend to the movies. I can’t take my girlfriend to the movies because I’m not allowed to go off campus.’”

Jacobson said there’s been a movement over the past several decades to allow people with disabilities to live in their communities. He said it’s about quality of life and can save the state a lot of money.

In his Sandy Springs apartment, Evan Nodvin tabs through his CD collection. He has a Beatles poster hanging up near his room.

“I have Michael Jackson, Beatles, whatever … I got more of them here,” he said.

He’s lived on his own for the past 16 years, not long after graduating from high school. He has a job, a girlfriend and an apartment and, as he said in his speech in D.C.: “I am able to be independent because I get help from my Medicaid waiver in my state of Georgia.”

That’s why Nodvin and his family will be watching what happens next in Washington, D.C.

This story is part of a partnership that includes WABE, NPR and Kaiser Health News.

Kaiser Health News, a nonprofit health newsroom whose stories appear in news outlets nationwide, is an editorially independent part of the Kaiser Family Foundation.

New amendment to GOP health bill effectively allows full elimination of community rating, exposing sick to higher premiums

David Posnett — Sun, 30 Apr 2017 13:16:12 +0000

Brookings Institute

Matthew FiedlerThursday, April 27, 2017

In recent weeks, the Trump Administration and House Republicans have been engaged in negotiations aimed at resurrecting the American Health Care Act (AHCA). Last night, the House Rules Committee posted an amendment to the AHCA emerging from those negotiations. The amendment would allow states to waive certain insurance market regulations that exist under current law, including the “community rating” requirements that bar insurers from setting premiums based on health status.

At first glance, it might appear that the community rating waivers allowed under this amendment would only allow insurers to charge premiums based on health status to people with a recent gap in coverage. Even that approach would significantly weaken community rating since coverage gaps are common, including for people with pre-existing conditions. In fact, however, the framework created by the waiver would allow states to effectively eliminate community rating protections for all people seeking individual market coverage, including people who had maintained continuous coverage.
In brief, healthy people would have a strong incentive to “opt out” of the community-rated pool and instead pay a premium based on health status. With healthy enrollees opting out of the community-rated pool, community-rated premiums would need to be extremely high, forcing sicker individuals—including those with continuous coverage—to choose between paying the extremely high community-rated premium or being underwritten themselves. Either way, people with serious health conditions would face prohibitively high premiums. As a result, community rating would be eviscerated—and with it any meaningful guarantee that seriously ill people can access coverage.

The remainder of this blog post describes the amendment and its effects in greater detail.

DESCRIPTION OF THE COMMUNITY RATING WAIVER ALLOWED UNDER THE NEW AMENDMENT

The new amendment, which is sponsored by Representative MacArthur, would allow interested states to waive certain insurance market regulations that exist under current law. Most relevant for this blog post, states would be permitted to partially waive the “community rating” requirements that exist under current law, which forbid insurers from varying premiums based on enrollees’ health status. In particular, insurers would be permitted to vary premiums based on health status for people who “cannot demonstrate” that they had coverage for all but 63 days of the prior twelve months. Health status rating would replace the 30 percent premium surcharge that would otherwise be imposed on people without continuous coverage under the AHCA.

States would technically be required to satisfy certain criteria to receive a waiver, but as noted by Tim Jost, those criteria would be trivial to meet. The state would have to agree to operate a high risk pool, reinsurance program, or related program under other provisions of the AHCA. But that would often happen automatically, and the waiver process would not require the state to ensure that the program is adequately funded (or otherwise effective). Waiver applications would also be required to explain how the waiver would improve the state’s health insurance market along at least one of five dimensions. Those criteria would also be easy to meet. Indeed, one is “reducing average premiums” in the state, which almost any waiver of this type would achieve by driving many sick individuals from the market.

HEALTHY PEOPLE WOULD OPT OUT OF THE COMMUNITY-RATED POOL, CAUSING IT TO UNRAVEL

Implementing a waiver like the one permitted by the MacArthur amendment would have the effect of completely unraveling community rating. Under the waiver, insurers would set two premium schedules: (1) a community-rated premium schedule for people who demonstrate continuous coverage; and (2) a medically underwritten premium schedule for people who do not demonstrate continuous coverage.

Health people would always prefer to pay an underwritten premium since it would allow them to avoid being pooled together with sicker people who have higher health care costs. Indeed, a healthy person opting into the underwritten pool could realize savings of hundreds or thousands of dollars per year. As discussed in detail in the next section, there would likely be no barrier to a healthy person opting to enroll in the underwritten pool. Moreover, it would also be in an insurer’s interest to not only allow prospective healthy enrollees to purchase underwritten policies, but to actively guide enrollees in that direction. If one insurer was unwilling to offer underwritten policies in these cases or failed to make enrollees aware of the option, another insurer could do so and thereby steal the healthy enrollees.

The ultimate outcome would be that premiums in the community-rated pool would have to be set at a prohibitively high level, leaving people with serious illnesses with no affordable options.

As a result, the community-rated pool would attract only people with significant health needs, requiring premiums to be set at a very high level. This would drive still more people into the underwritten pool, driving the community-rated premium still higher. The ultimate outcome would be that premiums in the community-rated pool would have to be set at a prohibitively high level, leaving people with serious illnesses with no affordable options, whether or not they had maintained continuous coverage. Many of these people would likely be driven from the individual market entirely.[1]

COULD HEALTHY PEOPLE OPT OUT OF THE UNDERWRITTEN POOL IN PRACTICE?

In light of the discussion above, an important question is whether healthy people who maintained continuous coverage would, in fact, be able to opt for the underwritten pool. As the amendment is drafted, they almost certainly would. As noted above, under the amendment, the underwritten premium schedule would apply to anyone who “cannot demonstrate” that they maintained continuous coverage. There is nothing to keep a prospective enrollee from simply declining to provide the needed documentation. For the reasons described above, an insurer would not be motivated to obtain the relevant documentation, so there would be no evident barrier to this strategy.

The federal government could theoretically try to require individuals enrolling in the underwritten pool to prove that they had a coverage gap. It is far from clear that the Trump Administration would actually be interested in doing this, as the administration has reportedly broached allowing state waivers that would fully eliminate community rating in the course of negotiations. But even if the administration were interested in going down this road, it would face an array of practical barriers.

Requiring individuals to affirmatively prove that they lack continuous coverage to enroll in the underwritten pool is not obviously consistent with the statute and would, in any case, be challenging to administer and enforce. Moreover, even if such a documentation requirement could be effectively enforced, it would likely be some combination of ineffective and actively destructive. Healthy people could still access the underwritten pool by dropping coverage for 63 days and then seeking coverage, simultaneously undermining the requirement’s effectiveness and creating unnecessary coverage disruptions. Moreover, people who could not document their continuous coverage status one way or another—including people who had continuous coverage—would be left with literally no way of obtaining individual market coverage. Many other potential enrollees would likely be scared off by the hassle of providing additional documentation, something CBO suggested would occur even under the AHCA’s existing continuous coverage requirement.

HOW MIGHT STATES USE THESE WAIVERS?

Predicting exactly how many states would take up an option to fully eliminate community rating is challenging, but it is plausible that many states would be interested in such a waiver in light of the fact that only a small minority of states had community rating regulations in place prior to enactment of the Affordable Care Act. This likely reflected the political and economic challenges of implementing community rating without adequate subsidies and an individual mandate, policies that undergird the existing individual market but which the AHCA would weaken or remove entirely. The market disruption caused by the AHCA’s other provisions might also make states receptive to steps they might otherwise decline to consider, particularly steps that lowered some residents’ premiums, even if those premium reductions came at the direct expense of other, vulnerable state residents.

Of course, it is also possible for states to use the waivers allowed by this amendment to weaken community rating in a more contained way. For example, a state could require that the underwritten premiums offered to people without continuous coverage be strictly higher than the community-rated premiums offered to people with continuous coverage. This approach, if strictly enforced, would eliminate the incentive for healthy people to shift into the underwritten pool and thereby keep the community-rated pool from unraveling. It is important to note that, since coverage gaps are common, even this approach would meaningfully weaken the scope of community rating protections and thereby threaten financial security and access to care for people who become seriously ill.

CONCLUSION

Contrary to appearances, the new MacArthur amendment would, in effect, allow states to completely eliminate community rating. In so doing, the amendment could seriously jeopardize both financial security and access to care for people with serious illnesses. Notably, this is not the only way in which the effects of the MacArthur amendment would be larger than they first appear. For example, the amendment’s provision allowing states to set their own definition of essential health benefits would not only seriously disrupt the individual market, but could also undermine the Affordable Care Act’s ban on annual and lifetime limits and its requirement that plans cap annual out-of-pocket spending for people in employer coverage. In its totality, then, the amendment would almost entirely satisfy House conservatives’ main demand in recent negotiations: eliminating the Affordable Care Act’s major insurance market reforms.

[1] In states that also obtain a waiver of the essential health benefits requirements, sicker individuals might not be driven from the insurance market altogether. Instead, insurers might offer these individuals very stingy coverage (such as coverage with a low annual limit), and these individuals might conclude that coverage was worth taking, particularly in light of the tax credit available under the AHCA. In either case, sicker individuals would be left without access to coverage that provides meaningful financial protection and access to care.