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Implementing Health Reform: Senator Rebuffed In Challenge To Congressional Participation In ACA Exchanges


July 23rd, 2014

The Halbig and King cases released on July 22, 2014 dramatically overshadowed another court decision released the previous day. That case, Johnson v. U.S. Office of Personnel Management, was important in its own right, however, and is covered here.

On July 21, 2014, Judge William C. Griesbach of the United States District Court for the Eastern District of Wisconsin dismissed a case brought by Wisconsin Republican Senator Ron Johnson and one of his staff members. The plaintiffs claimed that the rule promulgated by the Office of Personnel Management that allows members of Congress and their official staff to purchase health insurance through the exchanges with federal subsidies violates the Affordable Care Act and is unconstitutional. Judge Griesbach held that the plaintiffs had not been injured by the rule and thus had no standing to challenge it. This decision not only disposes of one more ACA challenge, it also calls further into question Congressman John Boehner’s proposed lawsuit challenging other ACA implementation decisions.

The ACA provides that “the only health plans that the Federal Government may make available to Members of Congress and congressional staff” are qualified health plans and plans sold through the exchange. This provision was adopted as an amendment offered by Senator Charles Grassley (R-IA), apparently to challenge the Democrats’ willingness to participate in the same program they were creating for other Americans. This challenge was embraced by the Democrats, however, resulting in the current law.

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Health Policy Brief Updates


July 22nd, 2014

In the first half of 2014 Health Affairs has released seven new Health Policy Briefs and also has provided updates of five previously released briefs, in order to reflect continuously changing and evolving health policy issues and perspectives.

The following Health Policy Briefs were updated in 2014:

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Implementing Health Reform: Hobby Lobby Response, The ACA In The Territories, And More


July 18th, 2014

July 17, 2014 was a remarkably active day in an otherwise quiet week for Affordable Care Act implementation. First, the Departments of Labor, Treasury, and Health and Human Services issued their first response to the Supreme Court’s Hobby Lobby decision —a Frequently Asked Question (FAQ) guidance requiring ERISA plans to provide notice to their participants and beneficiaries if they do not intend to cover contraceptives. Second, the Department of Health and Human Services sent letters to the territories (the Virgin Islands, Northern Mariana Islands, Guam, American Samoa, and Puerto Rico) informing them that insurers that market individual insurance policies in the territories are no longer required to comply with the ACA’s insurance market reforms.

Third, HHS released an enrollment bulletin at its REGTAP website describing how insurers in the federally facilitated exchange should handle enrollment for 2015 for individuals whose coverage was terminated in 2014 for non-payment. This post describes these issuances, as well as the May Medicaid enrollment report released on July 11, 2014 by HHS

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The Medicaid Boom And State Budgets: How Federal Waivers Are Advancing State Flexibility


July 18th, 2014

Note: The authors would like to thank Erica Socker, Senior Research Associate, and Michelle Shaljian, Associate Director of Communications, for their review and editorial assistance.

According to data released by the Department of Health and Human Services, one in five Americans now receive their health insurance through a state Medicaid program. Despite this increase in enrollment, it is estimated that 6 million Americans will likely remain uninsured because 20 states have decided not to expand Medicaid as the Affordable Care Act (ACA) envisioned. There are at least four states that are considering expanding Medicaid but have yet to do so.

Medicaid expansion continues to be one of the most politically charged directives of the health care law, mainly because the Supreme Court decision left the choice to states. This decision has generated an ongoing debate about whether and how states should expand their Medicaid programs. For example, an intense debate has been underway in Virginia, over the decision to include Medicaid expansion in the state budget; putting Democratic Governor Terry McAuliffe at odds with the Republican State Legislature. Similar debates are occurring in states across the country, and are further complicated by states’ option to pursue alternative expansion approaches under a Medicaid waiver. For states that have not yet expanded the program, the success of these alternative expansion models may influence whether they can find a politically feasible path forward.

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ACAView: New Findings On The Effect Of Coverage Expansion Since January 2014


July 9th, 2014

Editor’s note: In addition to Josh Gray, Iyue Sung also coauthored this post. 

Together, athenahealth and the Robert Wood Johnson Foundation (RWJF) have undertaken a new joint venture called ACAView, as part of the foundation’s Reform by the Numbers project, a source for timely and unique data on the impact of health reform.

The goal of ACAView is to provide current, non-partisan measurement and analysis on how coverage expansion under the Affordable Care Act (ACA) is affecting the day-to-day practice of medicine. athenahealth provides a single-instance, cloud-based software platform to a national provider base.

Any information that our clients enter using our software is immediately aggregated into centrally hosted databases, providing us with timely visibility into patient characteristics, clinical activities, and practice economics at medical groups around the country.

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After Hobby Lobby: How Might Policymakers Mitigate The Decision’s Impact On Women And Families?


July 3rd, 2014

Editor’s note: In addition to Sara Rosenbaum, Adam Sonfield and Rachel Benson Gold also coauthored this post. 

On June 30, the U.S. Supreme Court handed down a ruling that has the potential to undermine an important provision of the Affordable Care Act (ACA) that establishes for women a federal guarantee of coverage for their full range of contraceptive methods, services, and counseling without any out-of-pocket costs. This guarantee is administered through private health plans, whether purchased in the individual market or made available through the insurers and plan administrators that provide group coverage.

The 5-4 ruling in Burrell v. Hobby Lobby Stores, written by Justice Samuel Alito on behalf of the Court’s conservative bloc, held that closely held for-profit corporations that assert a religious objection to some or all forms of contraception cannot be required to include such coverage in the health plans they sponsor for employees and their families. As emphasized by Justice Ruth Bader Ginsburg in her dissent (joined in whole by Justice Sotomayor and in part by Justices Kagan and Breyer), the Court’s decision could have serious and widespread consequences.

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The Supreme Court And The Contraception Mandate: A Temporary Setback For Contraception Coverage


June 30th, 2014

Editor’s note: See Health Affairs Blog for more coverage of the Supreme Court’s Hobby Lobby decision.

Today, the United States Supreme Court ruled that for-profit companies may avoid providing contraception coverage to employees if the companies sincerely object on religious grounds. At its narrowest interpretation, this decision is a significant but remediable setback for women’s reproductive health. At its broadest (but least likely interpretation), the decision has the potential to wreak havoc on public health regulation.

The legal challenges to the Affordable Care Act’s (ACA’s) contraception mandate have been well described in three previous Health Affairs Blog posts. To briefly recap, though, the ACA requires preventive services to be covered without copayments or other cost sharing in most employer-supported health plans. To implement this requirement, the Department of Health and Human Services (HHS) issued regulations that include all FDA-approved contraceptives, and a company that does not provide no-cost coverage of contraception is subject to substantial penalties.

Three groups of employers are exempt from the mandate: small businesses with less than 50 employees, purely religious employers, and “grandfathered” plans that have not changed meaningfully since the ACA was passed. Additionally, religiously affiliated non-profits (such as universities and hospitals) received a special accommodation from HHS by which women can receive contraception from third-party insurers at no extra cost to employees or the organization if the organization objects to covering contraception and identifies an alternate insurer.

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Implementing Health Reform: The Supreme Court Rules on Contraception Coverage (Updated)


June 30th, 2014

On June 40, 2014, the Supreme Court issued its opinion in Hobby Lobby v. Burwell and Conestoga Wood Products v. Burwell. The Court’s decision has very important ramifications for religious liberty in the United States, for women’s access to health care, for employers’ and employees’ rights, even for corporate law. Its importance justifies its being released on the final day of the term, an honor usually reserved for only the most notable cases. But unlike the Court’s decision in National Federation of Independent Business v. Sebelius on the last day of its term two years ago, Hobby Lobby does not pose a serious threat — indeed any threat at all — to the Affordable Care Act.

From the perspective of the ACA, the case involves only the application of one particular provision of a regulation to one particular group of employers. The Court’s decision does not invalidate any provision of the ACA. It does not even fully invalidate any regulatory requirement. It simply says that the Department of Health and Human Services must extend to one group of employers an accommodation HHS has already extended to another group.

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Do Insurance Marketplace Consumers Need More Doctor Choices In-Network, Or Just Better Information?


June 26th, 2014

Media outlets have focused extensively on consumer complaints about “limited networks” and not being able to find a doctor under qualified health plans (QHPs) offered through the Health Insurance Marketplaces (HIMs). In response, the Obama administration released new standards which will require all QHPs to contract with a larger proportion of essential community providers within its service area. This means that health plans will be forced to accept more health care providers within their network, which may potentially increase costs for consumers.

At the heart of the recent changes lies a fundamental question worth exploring: Is consumer satisfaction with, and perceptions of health plan “network adequacy” grounded in the number of choices for doctors within network, or is it something different?

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New Offices Of Minority Health At FDA And CMS: Will They Help Eliminate Disparities In Health?


June 19th, 2014

Given the rocky roll-out of healthcare.gov, the end of the open enrollment period brought surprising good news: over eight million Americans signed up for coverage through the new Health Insurance Marketplaces. Three million previously uninsured young adults are now covered through their parents’ policies and six million more are enrolled in Medicaid and the Children’s Health Insurance Program.

Minorities are disproportionately more likely to be uninsured, and continued expansions in coverage will help significantly to close gaps in care. However, the impact of the Affordable Care Act (ACA) will not be limited to coverage. A number of provisions to address disparities were included in the ACA, relating to community health, workforce, and data collection. In addition, the ACA authorized new offices of minority health to lead and coordinate federal and national efforts to improve health and reduce disparities.

Several operating divisions at the U.S. Department of Health and Human Services (HHS), including the Centers for Disease Control and Prevention and the Agency for Healthcare Research and Quality, had existing offices dedicated to improving the health of vulnerable populations. However, this was not the case for the Food and Drug Administration (FDA) or the Centers for Medicare & Medicaid Services (CMS).

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Implementing Health Reform: Premiums And Choice In The 2014 Health Insurance Marketplace (Updated)


June 18th, 2014

In the fall of 2013 the headlines were full of stories of individuals facing steep premium increases as the Affordable Care Act’s market reforms went into effect. The question was raised repeatedly whether Affordable Care Act premiums were really affordable. Commentators observed that major national commercial insurers were avoiding the exchanges and that in some states the ACA marketplace offered few choices and little competition.

On June 17, 2014, the Health and Human Services Assistant Secretary for Planning and Evaluation (ASPE) released a report surveying Premium Affordability, Competition, and Choice in the Health Insurance Marketplace, 2014. ASPE examined over 19,000 2014 marketplace plans within the four bronze, silver, gold, and platinum metal levels in each of the 501 geographic rating areas in the 50 states and the District of Columbia; the office analyzed premium levels, available choices, and market variables that might affect cost. It is always possible to find negative anecdotes (particularly if one is not too careful in checking their veracity), but when we look beyond anecdotes at the actual data, it is clear that the ACA was largely successful in achieving many of its goals for 2014.

One of the primary goals of the ACA is to make health insurance affordable to lower-income Americans. During the 2014 open enrollment period, 5.4 million individuals selected a plan in the 36 states served by the federal exchange (which are the states primarily covered by the report since state exchange data is still being assembled and analyzed). According to the report, 87 percent of these individuals qualified for a premium tax credit. They paid a premium that was, on average, 76 percent less than the full premium that they would have owed before the premium tax credit was applied.

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Cancelled Non-Group Plans: What We Know Now That We Did Not Know In October


June 17th, 2014

In October of 2013 President Obama faced a political firestorm over the cancellation of millions of individual insurance plans — plans not compliant with the requirements of the Affordable Care Act (ACA). The Associated Press (AP) estimated that 4.8 million persons with non-group coverage had their policies cancelled, and this estimate was widely quoted in the media and the Congress. In headline stories, the media also reported that policyholders of the canceled plans were now offered alternative plans, often at premiums more than double of their current plans.

When the controversy over cancelled policies broke, no surveys were available to estimate the number and the cost of cancelled policies. In October, HealthCare.gov and many state-based marketplace websites were virtually non-functional, so assessing comparative cost and benefits of cancelled and Marketplace plans largely was precluded. In this post I highlight information from subsequent surveys and analyses conducted in late 2013 and 2014 that measure the number of cancelled plans and the comparative cost of coverage in the pre-ACA and post ACA-Markets. The next two paragraphs summarize findings.

Recent survey data indicates the number of persons affected by cancelled policies was about 1.9 million persons, less than the often cited 4.8 million estimate. When persons with group health insurance are included in the denominator, these cancellations affected less than one percent of persons holding comprehensive private insurance. The number of people with non-group policies who became uninsured following last October’s cancellation of policies is similar to what occurs in the normal churn of the non-group market.

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Thoughts On The VA Scandal And The Future


June 13th, 2014

For eight years, until May 2013, I directed the Department of Veterans Affairs (VA) medical research program from its Central Office and became familiar with the operations of the Veterans Health Administration (VHA). It was my only VA job and I felt honored to be part of the VA’s vital mission, as did most VA employees I met. Based on this experience, I have some ground level observations on the state of the VA and its future planning in light of the present scandal.

VA’s Scope and Assets

VA has three components: a large health system (VHA), a benefit center (Veterans Benefits Administration, or VBA), and the highly regarded National Cemetery Administration. All report to the VA Secretary but have different missions, issues, and management requisites. For example VHA was a pioneer in the Electronic Health Record (EHR), while VBA has had a more recent painful conversion to information technology (IT). VHA is run by the Undersecretary for Health, on whom VA Secretaries almost totally rely given their general lack of experience in health care.

VHA is divided into 21 networks and has 8.9 million enrollees (out of the 22 million U.S. veterans). It cares for 6.4 million veterans annually at over 1,700 sites of care, including 152 hospitals, about 820 clinics, 130 long-term care facilities, 300 Vet Centers for readjustment problems, and a suicide hotline, as well as homelessness and other programs. It has partly trained two-thirds of U.S physicians and made groundbreaking medical research contributions. These assets create strong constituencies for VA both within and outside the veterans’ community.

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Repeal, And Replace, The Employer Mandate


June 4th, 2014

As it enters its fifth year, the Affordable Care Act has chalked up an impressive list of accomplishments. More than 8 million Americans have chosen a health plan through the ACA exchanges. At least another five million have likely enrolled in Medicaid. The minimum medical loss ratio requirement has saved privately insured Americans billions of dollars, while the closing of the doughnut hole has saved Medicare beneficiaries billions more. The percentage of Americans who are uninsured is dropping precipitously and is already at the lowest level it has been for years.

Recent polling, however, seems to show that Americans are not yet impressed — a majority still oppose the Affordable Care Act. Significantly, however, polling also consistently shows that Americans are not giving up on the law–a substantial majority of Americans are against repealing the ACA and would rather that problems with the ACA be fixed. Support for amending the law should create an opening for lawmakers who can identify real problems with the ACA and propose practical solutions.

One provision of the ACA that cries out for repair is the employer mandate. The Urban Institute has recently raised the question, “Why Not Just Eliminate the Employer Mandate?Conservative advocacy groups have called for its repeal for some time. Repeal of the employer mandate might, in fact, not be such a bad idea, as long as the current mandate was replaced with a better alternative.

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Reducing Barriers To Care For Patients With Parkinson’s And Other Chronic Diseases


May 29th, 2014

Editor’s note: For more on this topic, see the February issue of Health Affairs, which features a series of articles on connected health. 

It is one of the greatest ironies of our time that the United States is home to some of the highest-quality medical care in the world, yet millions of Americans cannot access it. This problem is all too familiar for Parkinson’s patients who could receive better clinical outcomes simply by being connected to a specialist outside of their immediate vicinity.

Every year, approximately 60,000 people in the U.S. are diagnosed with Parkinson’s disease, a chronic, progressive neurological disease for which there is no cure. But there is hope.

The TELE-MED Act

With the use of technology, there is an easy way to allow patients to integrate their complex disease management into their daily lives while eliminating frequent and disruptive travel. Unfortunately, this option – popularly known as telemedicine – is not properly regulated, and lawmakers need to update licensure regulations though common sense solutions such as the TELE-MED Act (HR 3077).

This bipartisan measure introduced by Congressmen Nunes (R-CA) and Pallone (D-NJ) would enable health care providers in the Medicare program to treat Medicare patients virtually across state lines without having to obtain additional state medical licenses.

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Halbig And King: A Simple Case Of IRS Overreach


May 22nd, 2014

On March 25, a three-judge panel of the D.C. Circuit heard oral arguments in Halbig v. Sebelius, one of four lawsuits challenging the legality of implementing certain ACA provisions in the 34 states with federally established health insurance Exchanges. On May 14, a panel of the Fourth Circuit heard arguments in a related case, King v. Sebelius. Rulings in these cases could come at any time.

Washington & Lee University law professor Timothy Jost recently provided commentary on Halbig, King, and two similar cases. Since our research helped to generate these lawsuits, Health Affairs Blog invited us to respond, as we have responded to Jost’s previous commentary on this issue.

The ACA Authorizes Certain Provisions Only in States that Establish Exchanges

The Halbig cases, as we will call them, are simple and straightforward.

Prof. Jost has written, and we agree, that the statutory eligibility rules for the ACA’s premium-assistance tax credits “clearly say” that eligibility “depends on the applicant being enrolled in a qualified health plan ‘through an Exchange established by the State.’” The rules employ that restrictive phrase nine times, without deviation. Since the Act explicitly ties its cost-sharing subsidies, employer-mandate penalties, and (in many cases) individual-mandate penalties to the availability of these tax credits, it therefore also authorizes those provisions only in states that establish Exchanges. Congress simply did not authorize those spending and revenue measures in the 34 states that opted for a federal Exchange.

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Immigration And The ACA: Will Differing State Systems Offer A Controlled Experiment In Extending Coverage To Immigrants?


May 7th, 2014

Immigration and health care reform remain controversial issues, and their intersection remains fraught with complexities. Immigration reform that would provide a pathway to legalization for the 11-12 million unauthorized immigrants in the country is stalled in Congress.  Some of the fundamental controversies surrounding the Affordable Care Act (ACA) have, however, been settled, and the law is well into implementation. Now is a good time to focus on how the ACA is affecting and might affect health coverage, costs, and outcomes for various populations, including immigrants.

In addition to federal support for health coverage, the ACA is also ushering in an era of increased state experimentation. The law allows states to open their own insurance marketplaces or participate in the federal marketplace, and with last year’s Supreme Court decision, to decide whether or not to expand Medicaid for low-income childless adults. The law may also open opportunities for states to experiment with coverage options for the one major group excluded from the ACA: unauthorized immigrants.

Unauthorized Immigrants and the Affordable Care Act

ACA excludes the unauthorized from the marketplaces and eligibility for federal subsidies to purchase health insurance. According to the Migration Policy institute, an estimated 7-8 million unauthorized immigrants are currently uninsured, due to low employer coverage and ineligibility for Medicaid and other public programs; the unauthorized represent between one-fifth and one-sixth of the total 40-45 million uninsured. Their uninsurance rate ranges widely from state to state, peaking at over 70 percent in a number of Southeastern and Southwestern states.

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Implementing Health Reform: A Summary Health Insurance Marketplace Enrollment Report


May 1st, 2014

On May 1, 2014, the Department of Health and Human Services, Office of the Assistant Secretary for Planning and Evaluation (ASPE) released a summary enrollment report for the federal and state marketplaces (exchanges) for the entire 2014 open enrollment period — from October 1, 2013 to March 31, 2014, including special enrollment (SEP) activity reported through April 19, 2014. The report was accompanied by a press release, an infographic, and an addendum reporting state level data, as well as the March Medicaid and CHIP enrollment report.

The headline of the report is old news by now: Over 8 million individuals selected a qualified health plan through the federally facilitated marketplace (FFM) and state-based marketplaces (SBM) during the covered period. The Medicaid report adds that as of March, 2014, Medicaid and CHIP enrollment has grown by 4.8 million, 8.2 percent, over baseline figures from the third quarter of 2013.

Both the marketplaces and Medicaid programs saw a dramatic surge in enrollment in March. Nearly 3.8 million people selected a marketplace plan during March and April, 47 percent of the total (including 910,495 who enrolled during the April SEP). Medicaid and CHIP enrollment in March increased by 1.8 million over that that reported in February.

Age distribution. As expected, enrollees trended younger as the open enrollment period ended. The number of young adults aged 18 to 34 who selected a marketplace plan doubled during the last month, accounting for 31 percent of March and April enrollment. This surge increased the total proportion of young adult enrolled only to 28 percent, compared to 66 percent of enrollees above age 35 and 25 percent between ages 55 and 64 (with 6 percent below age 18).

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The ACA After The First Open Enrollment: A Health Affairs Conversation With Paul Ginsburg, Sherry Glied, and Bill Hoagland


May 1st, 2014

The first open enrollment period for the Affordable Care Act’s health insurance exchanges recently closed. In the latest edition of our Health Affairs Conversations podcast series, Paul Ginsburg, Sherry Glied, and Bill Hoagland discuss what we can learn from that experience. They also look at other aspects of ACA implementation, such as Medicaid expansion and payment and delivery reforms.

Paul Ginsburg is the Norman Topping Chair in Medicine and Public Policy at the University of Southern California. From 1995 through the end of 2013 he was President of the Center for Studying Health System Change (HSC). He also served as the founding Executive Director of the Physician Payment Review Commission (now the Medicare Payment Advisory Commission.)

Sherry Glied is Dean of New York University’s Robert F. Wagner Graduate School of Public Service. Glied served as Assistant Secretary for Planning and Evaluation at the Department of Health and Human Services from July 2010 through August 2012. Before that she chaired the Department of Health Policy and Management at Columbia University’s Mailman School of Public Health.

G. William Hoagland is a senior vice president at the Bipartisan Policy Center (BPC). Previously he served as vice president of public policy at CIGNA Corporation. He came to CIGNA after a distinguished Capitol Hill career culminating in service as the director of budget and appropriations in the office of Senate Majority Leader Bill Frist.

You can access the podcast recording here.

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The Subsidy Cliff: Incentives For Increasing Projected Income To Qualify For Exchange Subsidies


April 29th, 2014

Editor’s note: This post is also coauthored by Jacob Wallace.

During the first round of open enrollment under the ACA, millions of Americans learned whether they qualify for subsidized health insurance coverage through the law’s exchanges. At that time, one significant feature of the law became especially apparent: the dramatic cutoff of premium assistance for individuals who do not qualify for Medicaid in their state, but also earn too little to qualify for subsidies through the exchanges.

For example, if, during enrollment, a sixty year-old Miami man projected that he would earn $11,500 in 2014, he could purchase a bronze plan using a full subsidy so there would be no cost to him in premiums.  But if the same man projected earning just $500 less, $11,000, he would no longer qualify for any subsidy at all and the same coverage would require him to pay the full $6,573 premium.

Here is how the coverage gap works: Under the ACA, people earning below the key threshold of 100 percent of the federal poverty level (FPL) do not qualify for any premium subsidies through the exchanges; the law was written to provide them with Medicaid coverage instead. In reality, however, Florida and 23 other states chose not to expand Medicaid under the ACA, creating a gap into which roughly five million people with annual incomes less than 100 percent FPL ($11,490 for an individual or $23,550 for a family of four) will likely fall.

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