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Implementing Health Reform: The Latest Affordable Care Act Coverage Numbers (Updated)


April 18th, 2014

On February 17, 2014, the White House announced that 8 million Americans have signed up for private health insurance coverage through the health insurance marketplaces, or exchanges. This significantly exceeds the White House’s original goal of 7 million enrollees. It is far more than the Congressional Budget Office’s recent projections of 6 million.

The number of actual enrollees will be smaller than this number. The CBO’s projections are for the average number of those actually enrolled in coverage over the course of a calendar year. To calculate the average number of enrollees, one must subtract from the 8 million the number of individuals who fail to pay their premiums and thus are never actually enrolled in coverage, as well as those who will drop coverage at some later point during the year. To that reduced number, then, must be added back the number who become newly covered through special enrollment periods during the remainder of the year. In the end, 6 to 7 million average enrollees is probably a reasonable estimate.

This does not, however, exhaust the number of Americans who are now covered under the Affordable Care Act. The fact sheet states that 3 million young adults are covered under their parents’ plans because of the ACA. This number is probably high, but it is clear that the ACA has dramatically increased coverage of Americans between the age of 19 and 25 — the age group most likely to lack health insurance prior to the ACA (and still).

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Mental Illness In America’s Jails And Prisons: Toward A Public Safety/Public Health Model


April 1st, 2014

Editor’s note: This post is published in conjunction with the March issue of Health Affairs, which features a cluster of articles on jails and health. 

Mental Illness in America’s Jails and Prisons

The United States continues to have one of the highest incarceration rates in the world, with 5 percent of the world population, but nearly 25 percent of the world’s prisoners.  Inmates are spending more time behind bars as states adopt “truth in sentencing laws,” which requires inmates to serve 85 percent of their sentence behind bars.

In 2012, about 1 in every 35 adults in the United States, or 2.9 percent of adult residents, was on probation or parole or incarcerated in prison or jail, the same rate observed in 1997.  If recent incarceration rates remain unchanged, an estimated 1 out of every 20 persons will spend time behind bars during their lifetime; and many of those caught in the net that is cast to catch the criminal offender will be suffering with mental illness.

Nearly a decade ago, I wrote an article with Patrick Brown titled “Crisis in Corrections: The Mentally Ill in America’s Prisons.”  It was about the alarming growth in the number of mentally ill individuals behind bars.  Since then, it has been shown that about 20 percent of prison inmates have a serious mental illness, 30 to 60 percent have substance abuse problems and, when including broad-based mental illnesses, the percentages increase significantly. For example, 50 percent of males and 75 percent of female inmates in state prisons, and 75 percent of females and 63 percent of male inmates in jails, will experience a mental health problem requiring mental health services in any given year.

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Incarceration And Release From Jail: Improving Re-integration Into Society Using A Health Information Exchange


March 17th, 2014

Editor’s note: This post is coauthored by Mary Darby, vice president for health policy at Burness Communications, working on issues related to health care and jails.

In the Narrative Matters essay, “To Improve Public Health And Safety, One Sheriff Looks Beyond The Jail Walls,” published in the March issue of Health Affairs, Michael Ashe, sheriff of Hampden County in Massachusetts, describes the county’s efforts to help break the cycle of reincarceration by ensuring inmates get quality health care in and out of jail. Here, Jeffrey Brenner reflects on efforts to bring jails in Camden, N.J., into a health information exchange.   

Camden, N.J., is one of the nation’s poorest cities, with 38.6 percent of the population below the poverty line in 2010, according to Census Data.  With profound poverty comes a host of other problems, including high levels of crime, violence, pollution, and illness.  People here struggle to maintain decent health, and often it is a losing battle.

One day in 2002, at the family medicine practice in Camden where I worked, I opened an envelope from the Camden County jail.  It contained a letter from a patient, “James,” who told me he’d wound up in jail, a result of some bad choices on his part.  I knew James and his family quite well.  I’d seen his wife for prenatal care when she was pregnant and given his kids their routine well-child checkups.  James himself was a poorly controlled asthmatic with seizure disorder, so I had seen him pretty regularly in the clinic.

James’ letter distressed me.  He said that his asthma and allergies, already severe, were getting worse.  In addition to being sick, he felt overwhelmed, depressed, and afraid.  After reading his letter, I called the jail to find out what was happening.

Although the staff people with whom I spoke were very nice, I found it difficult to get the information I needed – and to share the important information I had concerning James’ medical history with the appropriate personnel.  After all, James had two potentially serious chronic conditions, and he took several medications.  The health care providers in the jail didn’t know James’ medical history and they didn’t know what medications he was taking.  They also had no connection to the primary care provider who knew him best: me.

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Implementing Health Reform: Ryan White Third-Party Payments, 2015 Letter To Issuers, And Other ACA Developments


March 15th, 2014

On March 14, 2014, the Department of Health and Human Services released a flood of regulations, proposed regulations, and guidance addressing a host of Affordable Care Act implementation issues. From all indications, HHS has cleared the decks of all the regulatory issuances it had under consideration– nothing involving ACA implementation remains pending at the Office of Management and Budget. Perhaps someone made a promise that all would be completed by the end of the winter (or by Saint Patrick’s Day). More likely the necessity of having the ground rules for 2015 in place so that insurers could proceed with their 2015 forms and rates, and states with approving them, drove the deluge. In any event, it will take several posts to cover it all.

Yesterday’s post covered a notice on extending the federal preexisting condition high risk pool and a frequently asked questions document on coverage of same-sex spouses. The Internal Revenue Service also released a set of general Tax Tips for Same-Sex Couples (which covers general tax information and will not be discussed here), while HHS issued a blog post summarizing its frequently asked questions document.

This post will cover several other issuances released late in the day on March 14, 2014. These include an interim final rule (with comment period) dealing with third party payments for qualified health plans (QHPs) and stand-alone dental plans (SADPs); the 2015 final annual letter to issuers in the federally facilitated marketplace; a set of frequently asked questions on retroactive coverage, and a set of frequently asked questions on the use of exchange grants and no-cost extensions.

A final post will examine a proposed rule on exchange and insurance standards for 2015 and beyond and an accompanying bulletin on product discontinuance.

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New Health Affairs: ACA’s Impact On Americans With HIV/AIDS And Jail-Involved Individuals


March 3rd, 2014

Health Affairs’ March issue, released today, explores how the Affordable Care Act (ACA) could affect two key sectors of the population with unique public health needs—those living with HIV/AIDS and people who have recently cycled through local jails.

When it comes to HIV treatment, timing is everything. Dana Goldman of the University of Southern California and coauthors modeled HIV transmission and prevention based on when HIV-positive individuals started combination antiretroviral treatment (cART). They estimate that from 1996-2009, early treatment initiation in the US prevented 188,700 HIV cases and avoided $128 billion in life expectancy losses.

The authors highlight treatment at “very early” stages (when CD4 white blood cell counts are greater than 500, consistent with current treatment guidelines in the US) as responsible for four-fifths of prevented cases. Early treatment both reduces morbidity and mortality in people living with HIV/AIDS, and decreases the transmission of the disease to the uninfected. Goldman and coauthors conclude that early treatment has clear value for both HIV-positive and HIV-negative populations in the US.

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Broadening the ACA Story: A Totally Accountable Care Organization


January 23rd, 2014

Note: This post is coauthored by Stephen Somers and Tricia McGinnis of the Center for Health Care Strategies.

Amid the bumpiness of Obamacare’s widely publicized technical launch, some in the media started taking the opportunity to laud the Affordable Care Act’s (ACA) largely untold story in reforming our “overpriced, underperforming health care system.”  The New York Times’ Bill Keller and Harvard health economist David Cutler, writing in the Washington Post, reported that progress was being made on multiple fronts in re-orienting the system to pay “for the value, not the volume, of medical care.” They pointed to penalties for hospital readmissions; the use of bundled payments; the development of Medicare and commercial accountable care organizations (ACOs); and a slowdown in health care cost growth at least partially attributable to these changes.

Within state-run Medicaid programs, a parallel phenomenon has been taking shape—the creation of ACOs tailored to the care needs of Medicaid’s beneficiaries, many of whom have multiple chronic health and social challenges. While ACOs for the broad range of Medicaid beneficiaries will be similar to the ACOs that already exist in the Medicare and commercial insurance sector, a new breed of Totally Accountable Care OrganizationsTACOs – offer the potential to push accountability for Medicaid populations, including those with complex needs, to a new level. “Totally” refers to the expectation that these organizations will be responsible for services beyond just medical care (for example, mental health, substance abuse treatment and other social supports), as well as the aspiration that these organizations will assume accountability for all associated costs of care, ultimately, through global payment mechanisms.

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Implementing Health Reform: New Affordable Care Act Guidance; Church Plans And Contraceptive Coverage


January 10th, 2014

The pace of Affordable Care Act regulatory activity has slowed dramatically with the new year, particularly in comparison with the frenetic pace late in 2013 leading up to the January 1, 2014 implementation date for major ACA reforms. On January 9, 2014, however, the Departments of Labor, Treasury, and Health and Human Services issued a series of Frequently Asked Questions (FAQs) regarding implementation of the ACA, as well as the Mental Health Parity and Addiction Equity Act of 2008 (MHPAEA). This post discusses these FAQs and summarizes other recent regulatory and legal developments.

Coverage of breast cancer risk-reducing drugs. The first FAQ provides that, pursuant to a September, 2013 recommendation from the United States Preventive Services Task Force, non-grandfathered group health plans and health insurers must cover without cost sharing breast cancer risk-reducing medications, such as tamoxifen or raloxifene, for women who are prescribed such medications by their clinicians because they are at increased risk for breast cancer and are at low-risk for adverse medication effects.

Cost-sharing guidance. FAQs two through five address issues that have arisen with respect to ACA limits on cost sharing for essential health benefits (EHB). An earlier guidance provided that group health plans and insurers that use more than one service provider to administer EHBs would be permitted for 2014 to apply out-of-pocket maximums up to the statutory limit ($6350 for self-only and $12,700 for family coverage for 2014) for each form of coverage they offered (for example pediatric dental or prescription drug coverage), as long as the out-of-pocket limit for major medical coverage (including mental health coverage) or for any other single form of coverage did not individually exceed the statutory out-of-pocket limit. FAQ two clarifies that this exception only applies for 2014, and plans and insurers will be expected to be in full compliance with the out-of-pocket limits requirement by 2014.

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Slowed ACO Growth Leads Health Affairs Blog November Top Ten


December 24th, 2013

With the success or failure of Accountable Care Organizations (ACOs) having significant implications for the U.S. health care system, David Muhlestein‘s post on the slowed growth of ACOs was the most-read post on Health Affairs Blog in November. Next on the list is James Rickert‘s discussion of patient-centered care, followed by two posts by Timothy Jost on health insurance policy terminations and events in the individual market, including mental health and substance abuse parity.

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Implementing Health Reform: Affordable Care Act Round-Up


December 23rd, 2013

As we reach the end of what has been a very long, exhausting, year for health care reform, one would have hoped that the pace of implementation might slow a little for the holidays. No such luck. December 20 ended the week before Christmas with a number of Affordable Care Act developments.

First, President Obama held a press conference that focused in part on health reform issues. The President announced that:

more than half a million Americans have enrolled through healthcare.gov in the first three weeks of December alone. In California, for example, a state operating its own marketplace, more than 15,000 Americans are enrolling every single day. And in the federal website, tens of thousands are enrolling every single day. Since October 1st, more than 1 million Americans have selected new health insurance plans through the federal and state marketplaces.

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New Health Affairs Issue Focuses On Emergency Medicine


December 3rd, 2013

The December issue of Health Affairs, released today, examines the state of emergency care in the United States. As Founding Editor John Iglehart describes in the issue: “Emergency departments seem like orphans in the US health care system, with few strong allies among policy makers; as an afterthought in the Affordable Care Act…long popularized by television dramas but less recognized for the expanding array of activities in which its practitioners are engaged.”

This theme issue, titled “The Future of Emergency Medicine: Challenges & Opportunities,” explores and explodes these myths. It received support from the Hospital Corporation of America; the American Hospital Association; the American College of Surgeons; the Emergency Medicine Action Fund, a consortium sponsored by the American College of Emergency Physicians; the American College of Emergency Physicians; the Jewish Healthcare Foundation; the Society for Academic Emergency Medicine; and MEP.

Several articles in the issue will be discussed at a December 4 Health Affairs briefing in Washington, D.C.

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Implementing Health Reform: The Individual Market; Mental Health And Substance Abuse Parity


November 9th, 2013

The first week of November, 2013, was a very bad week for the health care reform project. Healthcare.gov continues to stumble. Although the Department of Health and Human Services continues to insist in daily briefings that the performance of the website is improving, and that it will be fully operational by the end of November, improvement is frankly not yet visible. Full functionality in time for millions of Americans to enroll in coverage in time for the premium tax credits becoming available on January 1, 2104, looks increasingly unrealistic.

The news of the week, however, focused not only on the website woes, but also on millions of Americans in the individual and small group markets who have received notices that their current coverage is not going to be available in 2014 and that the policies that are available are going to cost them more, and in some instances impose higher cost-sharing obligations. The media have characterized these notices as “cancellation” notices, but in fact in most instances they are not terminating coverage as such, but rather changing the form of coverage that is available. In any event, enrollees receiving these notices are understandably upset and are complaining loudly to the media and to their congressional representatives.

Both HHS Secretary Sebelius and Center for Medicare and Medicaid Services Administrator Tavenner testified before Congressional committees, facing hostile questions (indeed demands for resignation in the case of Sebelius) from Republicans, who have long fought against the legislation, and anxious pleas from Democrats, who have long stood by it. At the end of the week, President Obama, apologized to those whose premiums were increasing, saying, “I’ve assigned my team to see what we can do to close some of the holes and gaps in the law,” and suggesting that there might be some sort of “administrative fix” that could help those whose costs were increasing but who would not be eligible for the premium tax credits.

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Provider Opportunities for Population Health Improvement


November 5th, 2013

Significant changes in the health care sector have been set in motion or accelerated by the Affordable Care Act.  For health care providers, much of this activity has focused on improving patient care and lowering costs.  There are also numerous opportunities through the Affordable Care Act for health care providers to improve population health, either […]

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New Health Affairs: Issues Facing The Health Care Workforce


November 4th, 2013

The November issue of Health Affairs, released today, discusses how the US health care workforce can respond to the Affordable Care Act’s expanded coverage and new models of care, as well as to an aging population. Some notable studies in the issue are described below, and the issue will be discussed at a Washington DC briefing on Thursday, November 14.

The aging population’s implications for specialty care and primary care.A study by Timothy Dall of IHS Inc. and coauthors forecasts future demand for health care services and providers based on projected demographics and other predictive changes, including the expected effects of expanded health insurance coverage under the Affordable Care Act. The authors project that demand for adult primary care services will grow by roughly 14 percent between 2013 and 2015, and demand for certain specialty care services will grow even faster at a high of 31 percent growth for vascular surgery. Cardiology (20 percent) and neurological surgery, radiology, and general surgery (each 18 percent) round out the list of the top five.

Dall and coauthors caution that failure to address the inadequate number and inappropriate mix of specialty care providers will further contribute to long wait times, reduce access to care, and decrease patients’ quality of life.

Diabetes patients in patient-centered medical homes are well served by nonphysicians and physicians alike. In this first study to compare the effectiveness of physician assistants (PA) and nurse practitioners (NP) roles to physician-only care for patients with chronic disease, Christine Everett of Duke University and coauthors found that patient outcomes were generally the same in thirteen comparisons. In four comparisons, PA and NP care was found to be superior; in three, the physician-only outcomes were higher.

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We Need To Know More About Wellness Incentives


August 22nd, 2013

Recently, the federal government published Final Rules on wellness incentives. What’s in it for you? From next year, your employer may increase your insurance premiums by up to 50 percent of the cost of coverage if you smoke. If you’re overweight, you may look at a 30 percent surcharge. But employers may also reduce premiums by up to 30 percent for normal weight.

Will such incentives be effective health promotion tools, or merely means to shift cost to the unhealthy? Regrettably, we may never really know. This is why we need reporting of key features of all wellness programs.

Wellness incentives typically come as ‘carrots’ or ‘sticks’. In the ‘carrot’ format, they reduce net insurance costs by a certain amount, provided you engage in healthy behaviors. ‘Sticks’ impose a net-increase if you don’t.

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Workplace Wellness Programs: Continuing The Discussion With Dinardo, Horwitz, And Kelly


August 21st, 2013

This is a response to the DiNardo, Horwitz, and Kelly Health Affairs Blog post in which the authors replied to my previous commentary, “Structuring Legal, Ethical, and Practical Workplace Health Incentives: A Reply to Horwitz, Kelly, And DiNardo.” In my prior post, I highlighted my disagreements with many of the points made by Horwitz et al. in their Health Affairs article entitled “Wellness Incentives in the Workplace: Cost Savings through Cost Shifting to Unhealthy Workers.” This post continues that dialogue.

I begin this commentary with some hesitation. I want to be clear that my intent in posting these blogs is not to “dig in my heels.” In fact, I fully understand, appreciate, and empathize with DiNardo et al.’s positions. They are rightfully concerned about protecting poor, minority, and disenfranchised workers whose rights may be threatened by unscrupulous employers who wish to place the onus on employees to “become healthy” or “else” — the “else” meaning paying a higher health insurance premium than their “healthy” counterparts. I appreciate that DiNardo et al. are protecting the interests of workers who, through no fault of their own, have become ill and are now faced with the prospect of paying more for health care coverage because of their illness.

Let me unequivocally state that paying more for health insurance because you are ill or have certain health risk factors is not the goal of workplace health promotion (wellness) advocates. Quite the opposite is true. Our intent is to keep workers healthy for as long as possible so that they can be spared the human and financial burden of paying for health care services that might otherwise have been avoided. The point of workplace wellness programs is to inspire people to improve their health behaviors and biometric measures so that they do not suffer from illnesses that are to a large degree attributable to lifestyle practices — e.g., lung cancer, type-2 diabetes, chronic obstructive pulmonary disease (COPD), and coronary heart disease (CHD).

In my previous post, I highlighted ways to structure incentive programs so that they are fair and contain provisions to guard against abuse. Here, I address additional challenges to workplace health promotion programs posed by DiNardo et al.

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Lessons From Early Medicaid Expansions Under The Affordable Care Act


June 14th, 2013

The Affordable Care Act (ACA) will dramatically expand Medicaid in a number of states starting in January 2014. In this month’s issue of Health Affairs, new research from DeLeire and colleagues on Wisconsin’s 2009 BadgerCare expansion and from Price and Eibner on predicted cost and coverage impacts of the Medicaid expansion provides insights on the implications of state decision-making about whether to expand the program.

Since 2010, six states have already expanded Medicaid to cover some or all of the low-income adults targeted for coverage under health reform. To provide additional information on the impacts of such expansions, we undertook an in-depth exploration of the experiences of these states – California, Connecticut, the District of Columbia, Minnesota, New Jersey, and Washington – through qualitative interviews with 11 high-ranking Medicaid officials across all six states. In analyzing these interviews, we identified several key policy lessons that help elucidate the opportunities and challenges of expanding Medicaid under the ACA. Below are some of our preliminary findings.

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A Tribute To Surgeon General C. Everett Koop


March 1st, 2013

A frequent statement of mine is, “We need public health leadership that cares enough, knows enough, is willing to do enough, and will be persistent.” Surgeon General C. Everett Koop was just such a leader, for he was caring; he was competent; he was courageous; and he was passionately persistent.

Before he was a Surgeon General, he was a pediatric surgeon. This was before the field was well-established. But he cared about children and their health. He gave conjoined twins the chance to live independent lives by performing surgery to separate them before the art was well developed. He cared about the education of medical students and residents, and spent time educating and counseling them. His former students still tell stories of their interactions with him.

The Office of the Surgeon General is not political. The American people look to the Surgeon General for reliable information based on the best available public health science, not politics, religion, or personal opinion. A combination of presidential nomination, Senate confirmation, and science-based expertise all have resulted in the Surgeon General maintaining, in the minds of the American people, a place of authority. As Surgeon General, Koop spoke and wrote with authority.

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From The Health Affairs Archives: An Interview With C. Everett Koop


February 27th, 2013

In 2004, Health Affairs’ Fitzhugh Mullan interviewed C. Everett Koop, who passed away on Monday. The full interview is freely available to all readers, as is a 1998 Health Affairs article coauthored by Dr. Koop evaluating health education programs designed to reduce health risks and costs. Health Affairs Blog will carry more about Dr. Koop’s life and work in the coming days.

Koop is probably best-known for his pioneering work as Surgeon General under President Ronald Reagan, but his interview with Mullan begins with a discussion of children’s health, reflecting Koop’s role in helping to found the discipline of pediatric surgery. Koop sounds a warning about the nation’s treatment of its children. “We always talk about children being our future,” he notes,

but I’m afraid we don’t always deliver … the older I get, the more I understand the relationship of poverty in a child and poor outcomes in everything else. I’m not beating a socialist kind of drum here. I think as we look to the future, unless we take into account what a severe role poverty plays in the lives of many children, we will never be able to achieve good child health in the United States.

Since children can’t vote or lobby as seniors do, “In the long run, child health is about advocacy,” says Koop, who also highlights the challenge of pediatric obesity.

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Implementing Health Reform: The Final Market Reform Rule


February 23rd, 2013

The time is quickly approaching when health insurers must file the rates and forms they will need to put in place for 2014. The Department of Health and Human Services is rapidly releasing the final rules that insurers will need to determine the coverage and price of those plans, and that the states and exchanges will need to approve or disapprove them. On February 22, 2013, HHS released the final market reform regulations, which establish the ground rules under which insurers will market their products in the reformed health insurance market. (The fact sheet is here.)

Whereas health insurance underwriting in the individual and small group market is currently based heavily on health status and gender, health insurers in the reformed market will only be able to consider age, tobacco use, geographic area, and family unit size in setting premiums. Insurers will also have to guarantee the availability and renewability of coverage. Proposed rules implementing these reforms were published on November 26, 2012 and were covered by this blog. This post discusses the final version of these rules.

On February 22, 2014, the Department of Labor also issued interim final regulations on procedures for addressing complaints by employees that they have suffered retaliation from their employers because they reported violations of the ACA’s consumer protections, or because they have received advance premium tax credits. (See the press release here.)

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The Complex Economics Of Disease Prevention And Longevity


January 22nd, 2013

In August, the Center for Sustainable Health Spending (CSHS) was awarded a grant from the Robert Wood Johnson Foundation to, among other things, examine the relationship between disease prevention and health care costs. This project heightened my interest in the wonderfully-researched report from the Congressional Budget Office (CBO) entitled Raising the Excise Tax on Cigarettes: Effects on Health and the Federal Budget, and its excellent summary in the New England Journal of Medicine (NEJM).

The report was years in the making and is noteworthy for its original research and its thorough and insightful literature review. As the title suggests, its economic focus is on the federal budget. In some ways this is a very broad perspective as it brings into play smoking’s impact on employment and earnings (hence tax payments), as well as health care costs and Social Security payments. But in other ways it is quite narrow, being limited to federal revenues and costs. Before discussing this CBO report, and the complex economics of disease prevention and longevity it underscores, I’d like to create some context.

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