Instruction: create a high quality summary of the given input

Input:
Client details stolen in Deloitte cyber attack
 One of the world’s “big four” accountancy firms has been targeted by a sophisticated hack that compromised the confidential emails and plans of some of its blue-chip clients, the Guardian can reveal.

Deloitte, which is registered in London and has its global headquarters in New York, was the victim of a cybersecurity attack that went unnoticed for months.

One of the largest private firms in the US, which reported a record $37bn (£27.3bn) revenue last year, Deloitte provides auditing, tax consultancy and high-end cybersecurity advice to some of the world’s biggest banks, multinational companies, media enterprises, pharmaceutical firms and government agencies.

The Guardian understands Deloitte clients across all of these sectors had material in the company email system that was breached. The companies include household names as well as US government departments.

So far, six of Deloitte’s clients have been told their information was “impacted” by the hack. Deloitte’s internal review into the incident is ongoing.

The Guardian understands Deloitte discovered the hack in March this year, but it is believed the attackers may have had access to its systems since October or November 2016.

The hacker compromised the firm’s global email server through an “administrator’s account” that, in theory, gave them privileged, unrestricted “access to all areas”.

The account required only a single password and did not have “two-step“ verification, sources said.

Emails to and from Deloitte’s 244,000 staff were stored in the Azure cloud service, which was provided by Microsoft. This is Microsoft’s equivalent to Amazon Web Service and Google’s Cloud Platform.

Microsoft’s Azure cloud service. Photograph: Microsoft

In addition to emails, the Guardian understands the hackers had potential access to usernames, passwords, IP addresses, architectural diagrams for businesses and health information. Some emails had attachments with sensitive security and design details.

The breach is believed to have been US-focused and was regarded as so sensitive that only a handful of Deloitte’s most senior partners and lawyers were informed.

The Guardian has been told the internal inquiry into how this happened has been codenamed “Windham”. It has involved specialists trying to map out exactly where the hackers went by analysing the electronic trail of the searches that were made.

The team investigating the hack is understood to have been working out of the firm’s offices in Rosslyn, Virginia, where analysts have been reviewing potentially compromised documents for six months.

It has yet to establish whether a lone wolf, business rivals or state-sponsored hackers were responsible.

Sources said if the hackers had been unable to cover their tracks, it should be possible to see where they went and what they compromised by regenerating their queries. This kind of reverse-engineering is not foolproof, however.

A measure of Deloitte’s concern came on 27 April when it hired the US law firm Hogan Lovells on “special assignment” to review what it called “a possible cybersecurity incident”.

The Washington-based firm has been retained to provide “legal advice and assistance to Deloitte LLP, the Deloitte Central Entities and other Deloitte Entities” about the potential fallout from the hack.

Responding to questions from the Guardian, Deloitte confirmed it had been the victim of a hack but insisted only a small number of its clients had been “impacted”. It would not be drawn on how many of its clients had data made potentially vulnerable by the breach.

The Guardian was told an estimated 5m emails were in the ”cloud” and could have been been accessed by the hackers. Deloitte said the number of emails that were at risk was a fraction of this number but declined to elaborate.

“In response to a cyber incident, Deloitte implemented its comprehensive security protocol and began an intensive and thorough review including mobilising a team of cybersecurity and confidentiality experts inside and outside of Deloitte,” a spokesman said.

“As part of the review, Deloitte has been in contact with the very few clients impacted and notified governmental authorities and regulators.

“The review has enabled us to understand what information was at risk and what the hacker actually did, and demonstrated that no disruption has occurred to client businesses, to Deloitte’s ability to continue to serve clients, or to consumers.

“We remain deeply committed to ensuring that our cybersecurity defences are best in class, to investing heavily in protecting confidential information and to continually reviewing and enhancing cybersecurity. We will continue to evaluate this matter and take additional steps as required.

“Our review enabled us to determine what the hacker did and what information was at risk as a result. That amount is a very small fraction of the amount that has been suggested.”

Deloitte declined to say which government authorities and regulators it had informed, or when, or whether it had contacted law enforcement agencies.

Though all major companies are targeted by hackers, the breach is a deep embarrassment for Deloitte, which offers potential clients advice on how to manage the risks posed by sophisticated cybersecurity attacks.

“Cyber risk is more than a technology or security issue, it is a business risk,” Deloitte tells potential customers on its website.

“While today’s fast-paced innovation enables strategic advantage, it also exposes businesses to potential cyber-attack. Embedding best practice cyber behaviours help our clients to minimise the impact on business.”

Deloitte has a “CyberIntelligence Centre” to provide clients with “round-the-clock business focussed operational security”.

“We monitor and assess the threats specific to your organisation, enabling you to swiftly and effectively mitigate risk and strengthen your cyber resilience,” its website says. “Going beyond the technical feeds, our professionals are able to contextualise the relevant threats, helping determine the risk to your business, your customers and your stakeholders.”

In 2012, Deloitte, which has offices all over the world, was ranked the best cybersecurity consultant in the world.

Earlier this month, Equifax, the US credit monitoring agency, admitted the personal data of 143 million US customers had been accessed or stolen in a massive hack in May. It has also revealed it was also the victim of an earlier breach in March.

About 400,000 people in the UK may have had their information stolen following the cybersecurity breach. The US company said an investigation had revealed that a file containing UK consumer information “may potentially have been accessed”.

The data includes names, dates of birth, email addresses and telephone numbers, but does not contain postal addresses, passwords or financial information. Equifax, which is based in Atlanta, discovered the hack in July but only informed consumers last week.

Output: Global accountancy firm Deloitte has lost confidential client details in a cyber attack that went undetected for months. Six major clients have been informed that their information was “impacted”. An internal review is being conducted into the loss, which saw IP addresses, passwords, medical records and architectural diagrams compromised. The hack was discovered in March, but may have been in progress since November of last year. “In response to a cyber incident, Deloitte implemented its comprehensive security protocol and began an intensive and thorough review”, said a spokesman for the company.


Instruction: create a high quality summary of the given input

Input:
20% of Dutch businesses hit by cyber attacks in 2016
 More than 20% of Dutch companies employing more than 10 people were hit by cyber attacks by third parties in 2016, the national statistics office CBS said on Monday. Companies operating in the financial and energy sectors were hardest hit.

Some 43% of companies also had to cope with internet breakdowns and other IT failures last year, the CBS said.

The CBS also looked into people’s willingness to report cyber crimes such as online bullying, hacking and sales fraud to the authorities.

It found around a quarter of incidents are reported to the police or other authorities but only 7.6% of people affected by cyber crime went on to make a formal report to police.

Output: Over 20% of businesses in the Netherlands with 10 or more employees were targeted by cyber attacks last year, according to the country's national statistics office. Financial and energy firms were the most common victims. In addition, 43% of all Dutch companies reported internet breakdowns and other IT failures in the last year. Despite the large number of attacks, only a quarter of breaches were reported to the police or other relevant authorities.


Instruction: create a high quality summary of the given input

Input:
Gatorade pays $300,000 to settle complaint over Usain Bolt game
 Dive Brief:

Gatorade, owned by PepsiCo, agreed to pay $300,000 to settle the California attorney general’s complaint filed over Gatorade’s “Bolt” game, featuring track star Usain Bolt getting faster when he touched a Gatorade icon,and slowing down when he touched a water droplet, according to the San Francisco Chronicle and a statement from the attorney general's office.

California’s AG Xavier Becerra cited studies that found this type of game can negatively affect a child’s desire for healthy food. The game was played 87 million times between 2012 and 2013, and roughly 70% of the players were aged 13-24.

“Making misleading statements is a violation of California law,” Becerra said in a press release. “But making misleading statements aimed at our children is beyond unlawful, it’s morally wrong and a betrayal of trust. It’s what causes consumers to lose faith in the products they buy.”

Dive Insight:

Gatorade is paying the price for misleading advertising, but the entire food and beverage industry can learn a couple of lessons from it. The first is simply to not lie about a competing product in an ad campaign. And lastly, don’t lie about healthy products in a format that is geared toward children. It won’t end well, as Gatorade can attest.

It’s understandable that Gatorade wants to differentiate itself in the increasingly crowded sports drink market. The beverage is already a giant in the space, dividing about a 70% share with Coca-Cola’s Powerade. But that doesn’t mean the company isn't angling for a larger take of the $8.5 billion consumers spend annually on sports drinks. However, going after water is no way to win over consumers of other energy drinks. Bottled water is the nation's most popular drink category, with 12.8 billion gallons sold to consumers last year. And that doesn't count water that people drink from their own taps.

PepsiCo could take a note other manufacturers outside of the sports drink category which have discovered ways to stand out from the crowd — without getting sued under consumer protection laws.

In January 2016, Campbell was the first major company to tell consumers which of its products contained genetically modified ingredients by printing it on the label. It also plans to comply with the Food and Drug Administration's new Nutrition Facts panel by the original July 2018 deadline, even though the timetable was recently delayed by the agency. Campbell's actions aren't targeting competitors, but are instead making its own brand look more transparent.

Dollar General stores has made its mark by offering exclusive branded products. This past summer, the store has offered Oreo Mississippi Mud Pie cookies, a 16-ounce Coca-Cola can series honoring military veterans, Regal Cinemas brand popcorn and an exclusive six-pack of Mott's mango juice. These exclusives appeal to shoppers from a variety of demographics and bring them into the store.

Output: PepsiCo-owned soft drinks giant Gatorade has agreed to pay $300,000 to settle a lawsuit brought by California's attorney general, Xavier Becerra. He filed the complaint, claiming Gatorade's Bolt game was misleading and could discourage children from eating and drinking healthily. In the game, track and field star Usain Bolt sped up when he touched a Gatorade droplet, but slowed down when he touched water. Between 2012 and 2013, Bolt was played 87 million times, with around 70% of players aged between 13 and 24.


Instruction: create a high quality summary of the given input

Input:
US hurricanes leave smaller businesses at higher risk of failure
 Assistant Professor of Risk Management and Insurance in the Fox School of Business at Temple University and a Research Fellow at the Wharton School's Risk Management and Decision Processes Center

Photo: Brendan Smialowski/AFP/Getty Images

An interview with Ben Collier, Professor of Risk Management, Temple University and Fellow at Wharton Risk Center

Damage estimates from Hurricanes Harvey and Irma are still pouring in and recovery efforts are underway. Historically, small and medium enterprises (SMEs) are particularly hard hit, have less insurance and in the aftermath, face credit restraints when trying to secure the funds to rebuild.

BRINK spoke with Ben Collier, professor of risk management at Temple University and a fellow at the Wharton Risk Center about the effects on SMEs in the aftermath of such disasters, based on his study of those businesses in the aftermath of Superstorm Sandy. Mr. Collier provides insights on why such firms are so dramatically affected and some of the psychology behind why those that pour their life’s savings into a business often fail to insure it fully.

BRINK: What has the history of disasters told us about the impact on small and medium enterprises?

Ben Collier: A consistent theme has been that firms are often unprepared when disaster strikes. Many don’t have disaster plans or insurance in place at that time. Another piece that comes up in the history that we’ve seen commonly is that disasters destroy the property of small and medium enterprises, at least natural disasters do, and those property losses do tend to be big ticket items. These are some of the businesses that lose the most.

More commonly, disasters can create business interruptions due to customer disruption or power outages. Those can be especially challenging. Insuring against those business interruptions is difficult, and often the flood-related interruptions, such as we’ve seen with Hurricane Harvey, and that we saw with Superstorm Sandy, [can] be especially challenging because there are so few [insurance] products that cover those risks.

Some research indicates, too, that SMEs fail at higher rates in the years following disasters due to the challenges of fully recovering. There are some businesses that close their doors when a disaster strikes and never reopen and others that make it a few more years, but they never are fully recovered.

BRINK: How are the effects of a disaster different for SMEs than they are for larger firms?

Mr. Collier: There are a couple different ways I think we could think about this issue, but let me focus on one or two points here. Disasters may be especially challenging for younger firms than for smaller firms.

Entrepreneurs face many risks when they’re starting out. They’re trying to seek out their place in the market. Many can’t operate sustainably before their startup capital runs out. There are a lot of entrepreneurs that may have good ideas, then something gets in the way and they’re not able to make the business viable. New businesses face so many risks that it seems like they may be especially unlikely to worry about rare events, such as hurricanes, because there are so many more probable, likely dangers that will cause them to fail.

As businesses mature the nature of a company’s risk falls. The ones that survive the first years have established themselves in the market by demonstrating their viability. For these firms, disaster risks may become more prominent. You start to worry more about a disaster causing you to fail than the younger firm that’s worried about many different risks that might cause it to fail.

Maybe for these reasons we’ve found that older and larger firms are more likely to buy insurance. So, for example, my colleagues and I studied whether New York area businesses had insurance in place at the time of Superstorm Sandy, and we found that younger firms and smaller firms were especially unlikely to be insured.

Maybe the more fundamental point that you’re asking about is vulnerability, too. Smaller firms tend to be more spatially concentrated. If you think about the local retailer with a single office or a few offices, in Houston, Hurricane Harvey may have affected all of those offices; [at] a bigger firm, not all of their locations would be affected by such an event. The same thing with business lines. Larger firms tend to have a variety of business lines of revenue. We see more specialization with smaller firms.

BRINK: In general, how does thinking about risk impact smaller firms?

Mr. Collier: Thinking about risks can be challenging for all of us. So let me put on the small-firm hat for a minute. Many small business owners went into business because they have some specific type of work that they really like to do and are good at doing. For a lot of these businesses it can be tempting to consider risk management a distraction from that work, from what they got into business to do. If you’re coming at it from that perspective, it would be quite natural for an owner to have this internal narrative that every minute I’m thinking about this [risk management] stuff is a minute that I could be working with my customers.

For a lot of businesses it can be tempting to consider risk management as just a distraction from work.

What we’ve learned from psychology is that we can make very different decisions when we’re going with our gut. When we’re trying to think quickly and intuitively about something we make very different decisions than when we’re planning deliberately for something, especially when it’s a complex topic or it’s [a] really challenging area like risk management.

What we like to see are businesses challenging this natural tendency that’s pushing them to avoid thinking about disasters and instead think about such things more deliberately and plan better.

BRINK: Based on the research that you did in the aftermath of the Superstorm Sandy, for example, how are SMEs likely to respond to Hurricanes Harvey and Irma?

Mr. Collier: What we saw with Sandy was that SMEs frequently weren’t insured. About 30 percent of SMEs that were negatively affected by Sandy had no insurance of any kind. Those numbers were much higher for the young firms. More than 50 percent, close to 60 percent of firms that were five years and younger didn’t have any insurance at all. Even among insured firms, only a portion of their losses were covered.

We found that negatively affected firms were about twice as likely to apply for credit than unaffected firms following Sandy to finance recovery. And these businesses often faced credit constraints. Negatively affected firms were more likely to report that access to financing had decreased and that interest rates had increased or that they were required to use collateral more often than unaffected firms.

This was especially true for younger firms. So we had this picture that the younger firms and smaller firms were least likely to be insured and they’re most likely to face credit constraints after these events. The prognosis is really dire for those firms moving forward.

BRINK: If someone has poured their heart and soul into a business, why then do they fail to insure it against such disasters?

Mr. Collier: This is really a great and tricky question, a challenging question. One reason is the psychology behind it, as we talked about earlier. We are geared to not think about rare events, or want to avoid thinking about them, and just hope for the best. I think that’s part of the challenge. A lot of businesses are credit constrained to begin with. They’re trying to get credit to invest in the business and so there’s this competition between buying insurance and investing more in the business.

One of the potential solutions that we might see related to credit constraints, is that to the extent that lenders or supply chain partners or other firms connected to those small businesses recognize the value of insuring, they may help smaller business overcome those financing constraints. If I’m a lender and I recognize a business really should be insured from certain risks if they’re not right now, maybe I can offer better interest rates or maybe I can help supply some additional credit to make sure they have the right insurance in place.

This interview has been edited and condensed for clarity.

Output: Smaller businesses in the US have a higher risk of failing because of natural disasters such as hurricanes and are more likely to be without insurance, according to an expert in risk management. Professor Ben Collier of Temple University in Philadelphia warned that small and medium-sized enterprises (SMEs), particularly those in their early years of trading, are more vulnerable to business interruption or failure caused by hurricane damage than larger enterprises. Many do not see insurance as a priority and, of the SMEs affected by Hurricane Sandy in 2012, nearly 60% of those that were less than five years old had no insurance.


Instruction: create a high quality summary of the given input

Input:
MIT researchers create framework for predicting extreme events
 Credit: CC0 Public Domain

Many extreme events—from a rogue wave that rises up from calm waters, to an instability inside a gas turbine, to the sudden extinction of a previously hardy wildlife species—seem to occur without warning. It's often impossible to predict when such bursts of instability will strike, particularly in systems with a complex and ever-changing mix of players and pieces.

Now engineers at MIT have devised a framework for identifying key patterns that precede an extreme event. The framework can be applied to a wide range of complicated, multidimensional systems to pick out the warning signs that are most likely to occur in the real world.

"Currently there is no method to explain when these extreme events occur," says Themistoklis Sapsis, associate professor of mechanical and ocean engineering at MIT. "We have applied this framework to turbulent fluid flows, which are the Holy Grail of extreme events. They're encountered in climate dynamics in the form of extreme rainfall, in engineering fluid flows such as stresses around an airfoil, and acoustic instabilities inside gas turbines. If we can predict the occurrence of these extreme events, hopefully we can apply some control strategies to avoid them."

Sapsis and MIT postdoc Mohammad Farazmand have published their results today in the journal Science Advances.

Looking past exotic warnings

In predicting extreme events in complex systems, scientists have typically attempted to solve sets of dynamical equations—incredibly complex mathematical formulas that, once solved, can predict the state of a complex system over time.

Researchers can plug into such equations a set of initial conditions, or values for certain variables, and solve the equations under those conditions. If the result yields a state that is considered an extreme event in the system, scientists can conclude that those initial conditions must be a precursor, or warning sign.

Dynamical equations are formulated based on a system's underlying physics. But Sapsis says that the physics governing many complex systems are often not well-understood and they contain important model errors. Relying on these equations to predict the state of such systems would therefore be unrealistic.

Even in systems where the physics are well-characterized, he says there is a huge number of initial conditions one could plug into associated equations, to yield an equally huge number of possible outcomes. What's more, the equations, based on theory, might successfully identify an enormous number of precursors for extreme events, but those precursors, or initial states, might not all occur in the real world.

"If we just blindly take the equations and start looking for initial states that evolve to extreme events, there is a high probability we will end up with initial states that are very exotic, meaning they will never ever occur for any practical situation," Sapsis says. "So equations contain more information than we really need."

Aside from equations, scientists have also looked through available data on real-world systems to pick out characteristic warning patterns. But by their nature, extreme events occur only rarely, and Sapsis says if one were to rely solely on data, they would need an enormous amount of data, over a long period of time, to be able to identify precursors with any certainty.

Searching for hotspots

The researchers instead developed a general framework, in the form of a computer algorithm, that combines both equations and available data to identify the precursors of extreme events that are most likely to occur in the real world.

"We are looking at the equations for possible states that have very high growth rates and become extreme events, but they are also consistent with data, telling us whether this state has any likelihood of occurring, or if it's something so exotic that, yes, it will lead to an extreme event, but the probability of it occurring is basically zero," Sapsis says.

In this way, the framework acts as a sort of sieve, capturing only those precursors that one would actually see in a real-world system.

Sapsis and Farazmand tested their approach on a model of turbulent fluid flow—a prototype system of fluid dynamics that describes a chaotic fluid, such as a plume of cigarette smoke, the airflow around a jet engine, ocean and atmospheric circulation, and even the flow of blood through heart valves and arteries.

"We used the equations describing the system, as well as some basic properties of the system, expressed through data obtained from a small number of numerical simulations, and we came up with precursors which are characteristic signals, telling us before the extreme event starts to develop, that there is something coming up," Sapsis explains.

They then performed a simulation of a turbulent fluid flow and looked for the precursors that their method predicted. They found the precursors developed into extreme events between 75 and 99 percent of the time, depending on the complexity of the fluid flow they were simulating.

Sapsis says the framework is generalizable enough to apply to a wide range of systems in which extreme events may occur. He plans to apply the technique to scenarios in which fluid flows against a boundary or wall. Examples, he says, are air flows around jet planes, and ocean currents against oil risers.

"This happens in random places around the world, and the question is being able to predict where these vortices or hotspots of extreme events will occur," Sapsis says. "If you can predict where these things occur, maybe you can develop some control techniques to suppress them."

More information: "A variational approach to probing extreme events in turbulent dynamical systems" Science Advances (2017). advances.sciencemag.org/content/3/9/e1701533 Journal information: Science Advances

Output: Researchers at MIT in the US have created a system for predicting previously unexpected extreme events. The method takes existing equation models for predicting outcomes and uses real-world data to identify only those initial scenarios most likely to occur. They tested the general framework on a simulation of a turbulent fluid flow, looking for the precursor conditions predicted by their model, and found these led to extreme events in between 75% and 99% of cases. The scientists say the model could have applications predicting extreme events in ocean currents around oil installations and air flows around aeroplanes.


Instruction: create a high quality summary of the given input

Input:
West Health opposes Graham-Cassidy; says disastrous bill fails to protect the critical healthcare needs of older, most vulnerable citizens
 West Health opposes Graham-Cassidy; says disastrous bill fails to protect the critical healthcare needs of older, most vulnerable citizens

SAN DIEGO and WASHINGTON, D.C. – September 23, 2017– Dedicated to enabling seniors to successfully age in place with access to high-quality, affordable health and support services, West Health, a nonprofit based in San Diego, issued the following statement from its president and CEO, Shelley Lyford, in opposition to the U.S. Senate’s Graham-Cassidy legislation:

“The Graham-Cassidy bill would deliver a devastating blow to Medicaid, which provides critical services and assistance to nearly 75 million poor, elderly and disabled Americans. Further, the bill fails to address the fundamental fact that America’s healthcare costs too much, and does virtually nothing to create a sustainable and high-performing healthcare system. For these reasons, more than anything else, all Americans should strongly oppose this bill and urge policy makers to put politics aside and put people first. We must only support legislation that offers strategies to address the unsustainable trajectory of healthcare expenses so we protect access and choice for everyone, especially our older and most vulnerable citizens, and eliminate the prevalence of disparities in care as well as the unnecessary tests and procedures caused by fee-for-service medicine. Our healthcare system is broken, and now is the time to fix it instead of making it worse.”

###

Output: Dedicated to enabling seniors to successfully age in place with access to high-quality, affordable health and support services, West Health, a nonprofit based in San Diego, issued the following statement from its president and CEO, Shelley Lyford, in opposition to the U.S. Senate’s Graham-Cassidy legislation


Instruction: create a high quality summary of the given input

Input:
Everyone Wants to Reduce Drug Prices. So Why Can’t We Do It?
 Of all the promises President Trump made for the early part of his term, controlling stinging drug prices might have seemed the easiest to achieve.

An angry public overwhelmingly wants change in an easily vilified industry. The pharmaceutical industry’s recent publicity nightmare included 1,000 percent price increases and a smirking chief executive who said, “I liken myself to the robber barons.” Even powerful members of Congress from both parties have said that drug prices are too high.

But any momentum to curtail prescription drug costs — a problem that a large number of Americans now believe government should solve — has been lost amid rancorous debates over replacing Obamacare and stalled amid roadblocks erected via lobbying and industry cash.

“There is a very aggressive lobby that is finding any and all means to thwart any reform to a system that has produced very lucrative profits,” said Ameet Sarpatwari, an epidemiologist and lawyer at Harvard Medical School who follows drug legislation. “Everything that’s coming out is being hit and hit hard — even stuff that’s common-sensical.”

Output: Of all the promises President Trump made for the early part of his term, controlling stinging drug prices might have seemed the easiest to achieve.


Instruction: create a high quality summary of the given input

Input:
How will the Graham-Cassidy proposal affect the number of people with health insurance coverage?
 This analysis is part of the USC-Brookings Schaeffer Initiative for Health Policy , which is a partnership between the Center for Health Policy at Brookings and the University of Southern California Schaeffer Center for Health Policy & Economics. The Initiative aims to inform the national health care debate with rigorous, evidence-based analysis leading to practical recommendations using the collaborative strengths of USC and Brookings.

On September 13, Senators Graham and Cassidy, together with two other Republican colleagues, introduced legislation that would repeal major portions of the Affordable Care Act (ACA). Press reports indicate that the legislation has gained considerable support among Senate Republicans, and Senate Majority Leader McConnell’s office announced on Wednesday that the Senate would hold a vote on this legislation sometime during the week of September 25.

This legislation has not yet been analyzed by the Congressional Budget Office (CBO), and CBO has indicated that it will not be able to provide a complete analysis of the legislation before the Senate vote. Notably, CBO stated that its analysis would not include “point estimates of [the Graham-Cassidy legislation’s] effects on the deficit, health insurance coverage, or premiums.” To help fill the gap left by the Senate’s decision to hold a vote in the absence of a complete CBO analysis, this analysis draws upon CBO’s estimates for prior legislation to evaluate how the Graham-Cassidy legislation might affect the number of people with health insurance coverage.

For years prior to 2020, this new legislation broadly tracks prior Republican bills, most importantly by immediately repealing the individual mandate. CBO’s analyses of these prior bills imply that the Graham-Cassidy legislation would reduce insurance coverage by around 15 million in 2018 and 2019. The reduction would be larger if uncertainty about the effects of the more radical changes implemented by the legislation in 2020 caused some insurers to pre-emptively withdraw from the individual market.

Starting in 2020, the Graham-Cassidy proposal would eliminate the ACA’s Medicaid expansion and Marketplace subsidies. Also in that year, the legislation would begin providing block grant funding to states, as well as allowing states to seek waivers from ACA regulations that bar insurers from varying premiums based on health status and require insurers to cover certain health care services.

To estimate the effects on insurance coverage during these years, we consider the various ways in which states might respond to the options provided by the legislation, using prior CBO analyses to evaluate the likely coverage outcomes for each of four broad categories of states. We then make assumptions about how many states will take each broad policy approach.

Based on this analysis, we estimate that the Graham-Cassidy legislation would reduce the number of people with insurance coverage by around 21 million each year during the 2020 through 2026 period. This estimate likely understates the reductions in insurance coverage that would actually occur under the Graham-Cassidy legislation, particularly toward the beginning and end of the seven-year period, because it does not account for the challenges states will face in setting up new programs on the bill’s proposed timeline, the possibility that uncertainty about the program’s future will cause market turmoil toward the end of the seven-year period, or the bill’s Medicaid per capita cap and other non-expansion-related Medicaid provisions. These estimates are, of course, subject to considerable uncertainty, most importantly because predicting how states would respond to the dramatic changes in the policy environment under the Graham-Cassidy proposal is very challenging. What is clear, however, is that the legislation would result in very large reductions in insurance coverage.

Based on this analysis, we estimate that the Graham-Cassidy legislation would reduce the number of people with insurance coverage by around 21 million each year during the 2020 through 2026 period.

The Graham-Cassidy legislation’s adverse effects on insurance coverage are likely to increase after its block grant funding expires at the end of 2026. After that time, the legislation is similar to the “repeal and delay” proposal that the Senate considered in July, which CBO estimated would reduce the number of people with insurance coverage by 32 million people in the long run. Reductions in insurance coverage would likely be somewhat larger under the Graham-Cassidy proposal because of the legislation’s non-expansion related Medicaid provisions, which would further reduce insurance coverage.

Table 1 summarizes our conclusions. The remainder of this analysis discusses the effects of the Graham-Cassidy legislation in more detail.

Overview of the Graham-Cassidy Legislation

Under the Graham-Cassidy proposal, policy changes would take effect in three phases:

Policy changes prior to 2020 :The legislation would repeal the individual and employer mandates retroactive to 2016. The legislation would also provide temporary funding that states could use to operate reinsurance or similar programs in their individual markets during 2018 and 2019.

:The legislation would repeal the individual and employer mandates retroactive to 2016. The legislation would also provide temporary funding that states could use to operate reinsurance or similar programs in their individual markets during 2018 and 2019. Policy changes in 2020 through 2026 : Starting in 2020, the legislation would also eliminate the ACA’s premium tax credits and cost-sharing reductions for people purchasing individual market coverage, as well as the state option to expand Medicaid to cover low-income adults with incomes under 138 percent of the federal poverty level. Those programs would be replaced with a block grant to states, which states could use for a variety of different purposes and which would, in the aggregate, provide less federal funding than would have been provided through individual market subsidies and the Medicaid expansion under current law. States would be permitted to waive a range of individual and small group market insurance regulations, including regulations that bar insurers from varying premiums for based on health status and that require insurers to provide certain benefits. 1 The proposal would also impose a per capita cap on federal funding to state Medicaid programs, which would drive further reductions in federal funding.

: Starting in 2020, the legislation would also eliminate the ACA’s premium tax credits and cost-sharing reductions for people purchasing individual market coverage, as well as the state option to expand Medicaid to cover low-income adults with incomes under 138 percent of the federal poverty level. Those programs would be replaced with a block grant to states, which states could use for a variety of different purposes and which would, in the aggregate, provide less federal funding than would have been provided through individual market subsidies and the Medicaid expansion under current law. States would be permitted to waive a range of individual and small group market insurance regulations, including regulations that bar insurers from varying premiums for based on health status and that require insurers to provide certain benefits. The proposal would also impose a per capita cap on federal funding to state Medicaid programs, which would drive further reductions in federal funding. Policy changes in 2027 and beyond : Starting in 2027, the block grant funding available for 2020 through 2026 would disappear, as would the authority to waive insurance regulations. The other policy changes implemented by the Graham-Cassidy proposal would remain in effect.

The effects of the legislation on insurance coverage would differ markedly across these three different time periods, so we consider each period separately below.

Effects on Insurance Coverage in 2018 and 2019

Prior to 2020, the major policy changes made by the Graham-Cassidy proposal are similar to those in the House-passed American Health Care Act (AHCA) and the Better Care Reconciliation Act (BCRA) that was considered by the Senate in July. CBO concluded that both bills would have reduced the number of people with coverage by around 15 million in 2018 and 2019, primarily due to repeal of the individual mandate.2

While these estimates are a reasonable starting point for assessing the near-term effects of the Graham-Cassidy proposal, both private insurers and state governments may take actions in anticipation of the broader changes that take effect in 2020 that would drive additional reductions in insurance coverage. Notably, as discussed in greater detail below, it is uncertain how states will make use of the block grant funding and waiver authority provided under Graham-Cassidy, and thus how the individual market will function in 2020 and beyond. This uncertainty, together with the fact that 2018 and 2019 would be unsettled years in the individual market due to repeal of the individual mandate and ongoing uncertainty around cost-sharing reduction payments, could cause some insurers to delay investments required to maintain (or expand) their individual market presence. The resulting reduction in insurer participation could lead to higher premiums and leave some parts of the country with no insurers participating in the individual market. Similarly, some states might elect to begin the process of winding down their Medicaid expansion prior to 2020, which could also add to coverage losses during this period.

When CBO analyzed the “repeal and delay” legislation the Senate considered in July—which would have repealed the individual and employer mandates immediately and repealed individual market subsidies and Medicaid expansion after a two-year delay—it concluded that these anticipatory effects could be important. CBO estimated that insurance coverage would fall by 17 million people in 2018 and 18 million in 2019, with about 10 percent of the population living in areas with no individual market insurers.

Effects on Insurance Coverage from 2020 through 2026

Forecasting how the Graham-Cassidy legislation would affect insurance coverage is more difficult for the years 2020 through 2026. In these years, the bill’s effects would depend in significant part on how states allocate the block grant funding the legislation makes available and how they use the option to waive various insurance market regulations. This section discusses three key questions about the nature of state decision-making and then provides a quantitative assessment of how the Graham-Cassidy legislation would likely affect insurance coverage during these years.

Would states direct block grant funds to unrelated purposes?

In considering how the bill’s block grant funding would affect health insurance coverage, the first question is to what extent states would use block grant funds to achieve objectives unrelated to increasing insurance coverage, like cutting taxes or increasing spending on unrelated programs.

There are no apparent legal barriers to diverting funds to unrelated uses. All states would need to do is identify existing state health care programs that qualify for block grant funding, thereby freeing up the state dollars currently devoted to those program to be used in whatever way the state wishes. If this were a state’s goal, the legislation makes it easy to achieve. Total block grant funding under the Graham-Cassidy proposal is $200 billion in 2026.3 States could almost certainly use block grant funds to support programs that provide substance abuse and mental health services; non-Medicaid state and local government spending on such services is likely to be on the order of $50 billion in 2026.4 As another example, states could likely use block grant funding to finance health benefits for state and local employees; state costs in this area are likely to be on the order of $200 billion in 2026.5 Thus, these expenditures alone are more than sufficient to absorb the block grant funding that the Graham-Cassidy legislation would make available in 2026.

States would likely identify many other categories of existing programs that could be funded with block grant dollars, such as programs that compensate medical providers for uncompensated care or spending on health care for prison inmates.6 In other instances, states might be able to direct money into their general funds by funneling them through public hospitals. While it is likely that some of these uses are not intended by the legislation’s authors, many of them may be difficult to disallow while still providing states with the broad discretion over the use of the block grant funds that the authors clearly do intend.

Whether block grant funds will be diverted in practice would thus depend on the objectives of state policymakers, specifically how they value investments in coverage programs relative to alternative uses of funds. How state policymakers would evaluate this tradeoff would likely vary from state to state.

At one end of the spectrum are the 19 states—accounting for 39 percent of the U.S. population—that have not expanded their Medicaid programs under the ACA. These states have demonstrated that they place a low value on coverage programs since, for each dollar a state devoted to its Medicaid expansion, it had to forgo at most 10 cents of other state spending. Investments in coverage programs would be far less attractive under the Graham-Cassidy legislation because devoting an additional dollar of the block grant funding to coverage programs requires forgoing a full dollar that could otherwise be devoted to other state programs.7 While it is conceivable that some of these states could respond differently to Graham-Cassidy because it was enacted by Republicans or because states are willing to pay more to avoid reductions in insurance coverage than to increase insurance coverage, these states seem particularly likely to find it attractive to divert block grant funds to uses other than new coverage programs.

Other states, by contrast, may see mitigating the reductions in insurance coverage that would occur under the Graham-Cassidy proposal as a high priority and therefore devote a relatively large fraction of the block grant dollars to setting up new coverage programs. The 17 states that set up their own Marketplaces under the ACA—accounting for 35 percent of the U.S. population—are the most likely candidates for this type of approach, although, as noted above, the fiscal rewards to making investments in coverage programs would be considerably smaller than under current law.

Even in states that do use block grant funding to set up new coverage programs initially, it seems likely that the share of block grant funding devoted to other uses would rise over time. Inevitably, most states will face periods of fiscal stress, whether due to recessions or other unexpected developments. Such periods might well drive states to redirect block grant funds to other purposes, and there is no guarantee those funds would be returned to their original purposes afterward.

As a final note, a long literature in economics has examined how state and local governments adjust their spending in response to the availability of targeted federal block grant funding. That literature has found that states often do divert a large fraction of block grant funding to unrelated uses, although the extent of diversion varies widely from setting to setting, from near complete diversion in some settings to virtually no diversion in other settings.8 The possibility that the Graham-Cassidy funding will be diverted to unrelated purposes thus has ample precedent in prior experience.

How effective would the insurance coverage programs states create be?

A separate question is how effective the block grant dollars that states do devote to insurance coverage programs would be in increasing insurance coverage. For a variety of reasons, we expect that the programs states would create in response to the Graham-Cassidy legislation would generally have a lower “bang for the buck” than the coverage programs that exist under current law.

Notably, state policymakers will face greater operational challenges than their federal counterparts, particularly with respect to policy toward the individual market. Federal policymakers benefited from significant economies of scale; for example, they were able to build a single enrollment website, a single income verification system, and a single system for handling financial transactions with insurers, and then deploy those systems across many states. By contrast, under the Graham-Cassidy proposal, each state will need to build its own system to do these things, increasing administrative costs. The federal government also had certain capabilities that would likely be completely unavailable to state policymakers. For example, federal policymakers relied upon existing federal databases to verify income and citizenship status when individuals applied for Marketplace subsidies. Lacking access to such systems, states may either need to target subsidies less precisely than the ACA or build suitable systems from scratch.

As a process matter, the ACA also benefited from explicit choices by both legislative and executive branch policymakers to make designing, enacting, and implementing major health care legislation a priority, and then allocate staff and other resources accordingly. A policy process foisted on governors and state legislatures, each of whom have their own policy priorities and objectives, is unlikely to operate as smoothly, particularly given the short implementation timeline states will be operating under. (On the plus side, the policy process in some states could benefit from lower levels of partisan conflict between the executive and the legislature than was the case during federal implementation of the ACA.) The ACA also benefited from the ample analytic resources available to federal policymakers, including CBO and the large analytic teams at federal agencies. While many state governments have similar entities that do high-quality work, many are not as well-resourced as their federal counterparts.

A final consideration is that the ACA, while not perfect, is reasonably well designed to deliver coverage in a cost-effective fashion. For both substantive and political reasons, the drafters of the ACA were highly motivated to achieve as large an increase in insurance coverage as possible given the budgetary resources available and certain other constraints, at least as assessed by CBO. Holding outlays fixed, deviations from the ACA’s design are thus likely to generally result in reduced insurance coverage. There will, of course, be exceptions to that general rule. States that are willing to use Medicaid-like programs to provide coverage to individuals further up the income spectrum may be able to provide coverage somewhat more cost-effectively than is the case under current law since Medicaid coverage is generally less expensive than private coverage on a per enrollee basis. States may also have a greater ability to tailor the design of coverage programs to local conditions, although because states already have the ability to customize their programs through the section 1332 waiver process and other avenues, the extent of those advantages are likely to be limited.

What would states do with the Graham-Cassidy waiver authority?

A final question is whether and how states will use the option to waive certain insurance market regulations. These include the “community rating” regulations that bar insurers from varying premiums for individual and small group market plans based on health status, as well as “essential health benefit” regulations that govern what types of health care services individual and small group market plans must cover.

We believe that some states will likely allow insurers to vary individual market premiums based on health status and substantially pare back essential health benefit requirements, similar to the conclusion CBO reached in analyzing the AHCA. Indeed, relatively few states had these regulations prior to the ACA, likely reflecting the challenges of barring insurers from varying premiums based on health status without having an individual mandate and robust subsidies to ensure a broad risk pool. States taking this approach are likely to disproportionately be those who are unwilling to devote a significant fraction of the block grant funds to subsidizing individual market coverage, in part because maintaining these regulations without providing sufficient subsidies to individual market plans is likely to result in the market’s collapse.

Other states, however, will likely maintain protections more like those that exist under current law. Both community rating and essential health benefit requirements are popular with the public, which may discourage some state policymakers from making changes in this area. The fact that the default if state policymakers take no action is for these regulations to remain in place may also influence the outcome.

Quantifying the insurance coverage effects of the Graham-Cassidy legislation

Building on the discussion above, we estimate the overall reduction in insurance coverage that would occur under the Graham-Cassidy legislation using the following two-step process. First, we assume that states would fall into four broad categories and identify prior CBO estimates that reflect the nationwide effect on insurance coverage if all states nationwide adopted the relevant approach. Obviously, there would be variation across states that is not captured by our categories, but we believe that these categories capture the most important dimensions of variation.9 Second, we make our best estimate of what share of the U.S population would fall in each category of state, recognizing that there is considerable uncertainty about what states would actually choose to do.

The four categories we consider are as follows:

Category #1: States that devote a small share of block grant funds to effective insurance coverage programs and make large changes to market regulations: These states would place a low priority on using block grant funds to increase insurance coverage and would therefore devote the large majority of these funds to other uses or to programs that are relatively ineffective in increasing insurance coverage. To keep their individual markets from unraveling in the absence of adequate subsidies, these states would also largely eliminate both community rating and essential health benefit requirements. If every state adopted this approach, the national effect of the Graham-Cassidy legislation would be similar to fully repealing the coverage provisions of the ACA (including its insurance market regulations), which CBO has estimated would reduce insurance coverage by 24 million people by 2026. We assume that states accounting for 30 percent of the U.S. population would take this approach, somewhat smaller than the share of people currently living in Medicaid non-expansion states.

These states would place a low priority on using block grant funds to increase insurance coverage and would therefore devote the large majority of these funds to other uses or to programs that are relatively ineffective in increasing insurance coverage. To keep their individual markets from unraveling in the absence of adequate subsidies, these states would also largely eliminate both community rating and essential health benefit requirements. If every state adopted this approach, the national effect of the Graham-Cassidy legislation would be similar to fully repealing the coverage provisions of the ACA (including its insurance market regulations), which CBO has estimated would reduce insurance coverage by 24 million people by 2026. We assume that states accounting for 30 percent of the U.S. population would take this approach, somewhat smaller than the share of people currently living in Medicaid non-expansion states. Category #2: States that devote a small share of block grant funds to effective insurance coverage programs and make few changes to market regulations: These states would place a low priority on using block grant funds to increase insurance coverage and would therefore devote most of these funds to other uses or to programs that are relatively ineffective in increasing insurance coverage. However, political barriers or other constraints would keep them from making significant changes to market regulations. If every state adopted this approach, the national effect of the Graham-Cassidy legislation would be similar to the “repeal and delay” legislation analyzed by CBO last month, which CBO estimated would reduce insurance coverage by 32 million people by 2026, reflecting in part the near collapse of the individual health insurance market. Because of the dire negative consequences of this approach, we assume that such states would account for only around 5 percent of the U.S. population.

These states would place a low priority on using block grant funds to increase insurance coverage and would therefore devote most of these funds to other uses or to programs that are relatively ineffective in increasing insurance coverage. However, political barriers or other constraints would keep them from making significant changes to market regulations. If every state adopted this approach, the national effect of the Graham-Cassidy legislation would be similar to the “repeal and delay” legislation analyzed by CBO last month, which CBO estimated would reduce insurance coverage by 32 million people by 2026, reflecting in part the near collapse of the individual health insurance market. Because of the dire negative consequences of this approach, we assume that such states would account for only around 5 percent of the U.S. population. Category #3: States that devote almost all block grant funds to effective insurance coverage programs and make few changes to market regulations: These states would place a high priority on using block grant funds to increase insurance coverage and would therefore devote most of these funds to coverage programs. Because of the comparatively significant subsidies provided to the individual market in these states, they would not be compelled to make significant changes to market regulations. The total amount of block grant funding available under the Graham-Cassidy legislation roughly matches the federal spending on Medicaid expansion and Marketplace subsidies that would occur after the significant reductions in insurance coverage attributable to repeal of the individual and employer mandates. 10 Thus, if every state adopted this approach, the national effect of the Graham-Cassidy legislation on insurance coverage would be similar to the effect of “skinny repeal” bill the Senate considered this summer, which CBO estimated would reduce insurance coverage by 16 million people by 2026. We assume that states accounting for 40 percent of the U.S. population will take this approach, somewhat more than the share of people living in states that currently operate their own Marketplaces under the ACA.

These states would place a high priority on using block grant funds to increase insurance coverage and would therefore devote most of these funds to coverage programs. Because of the comparatively significant subsidies provided to the individual market in these states, they would not be compelled to make significant changes to market regulations. The total amount of block grant funding available under the Graham-Cassidy legislation roughly matches the federal spending on Medicaid expansion and Marketplace subsidies that would occur after the significant reductions in insurance coverage attributable to repeal of the individual and employer mandates. Thus, if every state adopted this approach, the national effect of the Graham-Cassidy legislation on insurance coverage would be similar to the effect of “skinny repeal” bill the Senate considered this summer, which CBO estimated would reduce insurance coverage by 16 million people by 2026. We assume that states accounting for 40 percent of the U.S. population will take this approach, somewhat more than the share of people living in states that currently operate their own Marketplaces under the ACA. Category #4: States that devote around half of block grant funds to effective insurance coverage programs and make few changes to market regulations: These states would place a moderate priority on using block grant funds to increase insurance coverage and would therefore devote about half of the block grant funds to coverage programs. They would not make significant changes to market regulations. We assume that the insurance coverage outcomes for these states would be exactly intermediate between category #2 and category #3 described above. Thus, if every state adopted this approach, the national effect of the Graham-Cassidy legislation would be to reduce insurance coverage by 24 million people by 2026. We assume that the remaining 25 percent of the U.S. population would live in states that adopt this approach.

Averaging across the four categories as described above, we estimate that the Graham-Cassidy legislation would reduce the number of people with insurance coverage by approximately 21 million during the 2020 through 2026 period. Table 2 summarizes the assumptions we have made for each category of states.

For a few reasons, this estimate likely understates the reduction in insurance coverage that would actually occur under the Graham-Cassidy legislation. First, these estimates completely ignore the challenges associated with transitioning to the entirely new system envisioned under Graham-Cassidy. Transitions are difficult even under the best of circumstances. Government agencies need to gain experience administering their states’ new regulatory regimes and subsidy programs. Private insurers need to learn to set premiums for a new market, while individuals need to learn how to access new coverage arrangements. That type of learning inevitably takes time and involves some amount of trial and error, which would likely cause insurance coverage to remain meaningfully below its long run “steady state” for at least some time after 2020.

In this case, transitional challenges would be greatly exacerbated by the tight timeline that states would be operating under. States would have only around 15 months to get new policies in place to do so before insurers would need to begin developing products for 2020 and only about 27 months before the new rules would have to be in effect. For comparison, the process of drafting and implementing the ACA began close to five years before the new rules would be in effect. It seems likely that many states would simply fail to meet this timeline or meet the timeline only by deploying ineffective policies.

Second, these estimates ignore the potential for market turmoil toward the end of the 2020-2026 period as insurers anticipate the disappearance of the block grant funding and waiver authority. As with the years leading up to 2020, uncertainty about what rules will govern the individual market in the future may put downward pressure on individual market participation, increasing premiums and reducing coverage.

Third, because suitable CBO estimates are not available, the reductions in insurance coverage assigned to each of the scenarios described above do not account for the effects of the legislation’s per capita cap on Medicaid spending, which would drive additional reductions in insurance coverage, particularly toward the end of the 2020 through 2026 period. These estimates also ignore the bill’s various other Medicaid provisions, including the introduction of state options to impose work requirements and disallow retroactive eligibility, which would drive further reductions in insurance coverage.

For these reasons, we believe our estimates are more likely to understate than overstate reductions in insurance coverage under the Graham-Cassidy legislation. However, there is also significant uncertainty around these estimates, particularly because they depend so heavily on predictions about states’ decisions. For example, it is possible that significantly more or significantly fewer states would choose to devote a large share of their block grants to effective insurance coverage programs, in which case actual reduction in insurance coverage could be smaller or larger than we estimate here.

Effects on Insurance Coverage in 2027 and Beyond

The effects of the Graham-Cassidy legislation on insurance coverage become clearer after the block grant and state waiver authority expire at the end of 2026. Once those aspects of the legislation expire, the bill’s effects would likely to be similar to legislation that would fully repeal the individual and employer mandates, Medicaid expansion, and Marketplace subsidies without any replacement.

As noted above, CBO estimated that legislation of this type would reduce insurance coverage by 32 million people in the long run, reflecting in part the near complete unraveling of the individual market. In fact, the long run outcomes would be somewhat worse under the Graham-Cassidy legislation because of the additional changes to the Medicaid program under this legislation. Most important in this regard is the legislation’s Medicaid per capita cap, which is likely to become progressively more stringent over the decade starting in 2027, and thereby spur growing reductions in insurance coverage over time.

Output: On September 13, Senators Graham and Cassidy, together with two other Republican colleagues, introduced legislation that would repeal major portions of the Affordable Care Act (ACA). Press reports indicate that the legislation has gained considerable support among Senate Republicans, and Senate Majority Leader McConnell’s office announced on Wednesday that the Senate would hold a vote on this legislation sometime during the week of September 25.


Instruction: create a high quality summary of the given input

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One Way for G.O.P. to Achieve Some Repeal Goals? It’s Already Part of Obamacare
 On Friday, Senator John McCain of Arizona announced that he would not support the latest Republican push to overhaul the health care system. He didn’t disapprove of the objectives of the bill, but to its process, which was too rushed and partisan, he said in a statement: “A bill of this impact requires a bipartisan approach.”

Mr. McCain’s vote most likely dooms the current Obamacare repeal effort, which can afford to lose the votes of only two Republican senators. (Senator Rand Paul of Kentucky and Senator Susan Collins of Maine are generally regarded as no votes as well.) But there is, in fact, a bipartisan effort that could help Congress achieve many of the goals that the recent bill’s authors say they hope to accomplish. The catch: It would be hard for Republicans to call it Obamacare repeal.

Senator Lindsey Graham of South Carolina, who brought the legislation with Senator Bill Cassidy of Louisiana, has said that one of his key goals was to eliminate Obamacare’s top-down approach, giving states more power to run their own health care systems according to local preferences and conditions. “I’m trying to take the money and power in Washington and send it back closer to the patient,” he said during a news conference Tuesday, adding that “government closer to the people is the best government.”

Mr. Cassidy has said he wishes to protect insurance coverage for Americans with pre-existing health conditions, though many independent analysts have questioned whether the text of the legislation would, indeed, offer such a protection.

Output: On Friday, Senator John McCain of Arizona announced that he would not support the latest Republican push to overhaul the health care system. He didn’t disapprove of the objectives of the bill, but to its process, which was too rushed and partisan, he said in a statement: “A bill of this impact requires a bipartisan approach.”


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Why the Latest Health Bill Is Teetering: It Might Not Work
 WASHINGTON — Health insurers, who had been strangely quiet for much of the year, came off the sidelines to criticize it. Many state Medicaid directors could not stomach it, either.

For months now, proposals to repeal and replace the Affordable Care Act have risen and fallen in the House and the Senate, almost always uniting health care providers and patient advocacy groups in opposition but winning support among conservatives, including Republican policy makers. But the version drafted by Senators Lindsey Graham of South Carolina and Bill Cassidy of Louisiana — and hastily brought into the spotlight last week — went further.

It brought much of the health care world together to stop it, an effort that appears to have succeeded — not for ideological reasons, but for the simple reason that administrators, caregivers, advocates and insurers believed it could not work.

Senate Republican leaders hoped to bring the measure to the Senate floor for a vote this coming week. But the bill is on life support after Senator John McCain, the unpredictable Arizona Republican whose dramatic “no” vote killed the previous repeal effort, announced on Friday that he could not “in good conscience” vote for the bill. He joined Senator Rand Paul, Republican of Kentucky, in opposition — and Senator Susan Collins, Republican of Maine, is leaning hard toward no.

Output: Health insurers, who had been strangely quiet for much of the year, came off the sidelines to criticize it. Many state Medicaid directors could not stomach it, either.


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If the U.S. Adopts the G.O.P.’s Health-Care Bill, It Would Be an Act of Mass Suicide
 The fundamental thing to understand about Senate Republicans’ latest attempt to repeal Obamacare is that the bill under consideration would not just undo the Affordable Care Act—it would also end Medicaid as we know it and our federal government’s half-century commitment to closing the country’s yawning gaps in health coverage. And it would do so without putting in place any credible resources or policies to replace the system it is overturning. If our country enacts this bill, it would be an act of mass suicide.

In my surgery practice in Boston, I see primarily cancer patients. When I started out, in 2003, at least one in ten of my patients was uninsured. Others, who had insurance, would discover in the course of their treatment that their policies had annual or lifetime caps that wouldn’t cover their costs, or that they would face unaffordable premiums going forward because they now had a preëxisting condition. When he was governor of Massachusetts, it was Mitt Romney, a conservative, who brought Republicans and Democrats together to make a viable state system of near-universal coverage. That system then served as a model for the A.C.A. The results have been clear: increases in coverage have markedly improved people’s access to care and their health. For the last four years, health-care costs in Massachusetts have risen more slowly than the national average—while the national numbers themselves have been at historic lows. I have not seen a single uninsured patient—zero—in a decade. And now comes an utterly reckless piece of legislation that would destroy these gains.

To review how we got to this point: last spring, the House passed a health-care-reform bill that proposed to hollow out the A.C.A.’s funding, insurance mandates, and protections for people with preëxisting conditions. It was immensely unpopular with the public. The problem was not just that twenty-three million Americans would lose their health insurance if the bill becomes law but also the Republicans’ vision of a health system where insurance with deductibles of five thousand dollars and more, and little or no primary-care coverage, would become the norm. This summer, Senate Republicans failed to secure enough votes to pass a modified version of the House bill. Later, in a dramatic late-night session, the Senate also rejected, by a single vote, a “skinny” repeal bill. That bill would have repealed only the parts of the A.C.A. that required large businesses to insure their workers and all Americans to carry coverage. It would have resulted in a mere sixteen million more uninsured people, according to estimates.

The Republican bill currently being rushed to a vote was put forward by a group of senators led by Lindsey Graham, of South Carolina, and Bill Cassidy, of Louisiana. As has become the apparent rule for Republican health-care bills, there have been no hearings or committee reviews of the Graham-Cassidy bill. And, this time, lawmakers and the public do not even have a Congressional Budget Office analysis of the effects the bill would have on the budget, insurance costs, or the uninsured rate.

This is unprecedented: senators are moving ahead with a vote on a bill that would alter the health care of every American family and the condition of a sixth of our entire economy, without waiting to hear any official, independent estimates of the consequences. The irresponsibility is as blithe as it is breathtaking. Before becoming a senator, Cassidy spent twenty-five years working as a physician in hospitals devoted to the uninsured. I find it baffling that a person with his experience would not recognize the danger of this bill. But here we are.

The Graham-Cassidy bill goes even further than the bill passed by the House. It would bring to a virtually immediate end not only the individual and employer mandates but also the whole edifice of the Medicaid expansion, insurance exchanges, and income-based coverage subsidies set up under the A.C.A. Graham-Cassidy expects all fifty states to then pass, and implement, alternative health systems for tens of millions of people within two years—with drastically less money, in most states, than the current law provides. This is not just impossible. It is delusional.

Like the House bill, Graham-Cassidy would cut Medicaid payments for traditional enrollees—the elderly in nursing homes, pregnant women in poverty, disabled children, etc.—by a third by 2026. A portion of the money saved would go into a short-term fund for states to use for health-care costs. The rationale is that this would give states “flexibility” to design coverage for their residents as they see fit. But the amount of funding provided is, by multiple estimates, hundreds of billions of dollars below what the A.C.A. provides. The bill also nakedly shifts funds from Democratic-leaning states that expanded Medicaid under the A.C.A. to Republican-leaning states that didn’t. Analyses indicate that states like California, Massachusetts, and New York will receive block-grant funding anywhere from thirty-five to almost sixty per cent below the health-care funding their residents would receive under current law. Much of those missing funds would be transferred to states like Texas, Mississippi, and Wisconsin. And special deals to make further shifts from blue states to red states such as Alaska are being negotiated to win votes.

As for what states can do with the funds they do receive, they would not be allowed to use them to enroll people in Medicaid, or able to establish a single-payer system. And states would not be receiving enough to continue Obamacare on their own. The only options for spending are for commercial coverage. States will be permitted to let insurers bring back higher costs for people with preëxisting conditions and to reinstate annual and lifetime limits on coverage. And then, starting in 2026, the funding turns out to only be temporary. Under the bill’s provisions, unless further action is taken then, four trillion dollars will be removed from health-care systems over twenty years.

With these massive sums being flung around, it is easy to forget that this is about our health as human beings. The evidence is that health-care programs like the A.C.A. save lives. The way they do so is by increasing the number of people who have affordable access to a regular source of care and needed medications. Such coverage has been shown to produce a substantial and increasing reduction in mortality—especially among those with chronic illnesses, such as heart disease, cancer, or H.I.V.—in as little as five years.

Virtually all of us, as we age, will develop serious health conditions. A critical test of any health reform, therefore, is whether it improves or reduces our prospects of having the continuous care and medicines we need when we come to have a chronic illness. The Graham-Cassidy bill fails this test. It will terminate Medicaid coverage and insurance subsidies for some twenty million people. The entire individual-insurance market will be thrown into a tailspin. Federal protections for insurance coverage will be gone.

Every major group representing patients, health-care professionals, health-care institutions, and insurers has come out vociferously against this plan. Governors from Alaska to Ohio to Virginia have opposed the bill. In a highly unusual, bipartisan statement, the national association representing the Medicaid directors of all fifty states has also opposed the bill. The top health official in Louisiana, Cassidy’s home state, has opposed the new plan. There is not a single metric of health or health care that the Graham-Cassidy plan makes better. This bill is a national calamity. It should not even come to a vote.

Output: The fundamental thing to understand about Senate Republicans’ latest attempt to repeal Obamacare is that the bill under consideration would not just undo the Affordable Care Act—it would also end Medicaid as we know it and our federal government’s half-century commitment to closing the country’s yawning gaps in health coverage.


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Money-Saving Offer For Medicare’s Late Enrollees Is Expiring. Can They Buy Time?
 About Insight Insight provides an in-depth look at health care issues in and affecting California. Have a story suggestion? Let us know.

[UPDATE: Since this article was published, Medicare officials extended the deadline for applying for an exemption to the Part B late enrollment penalty to Sept. 30, 2018. The announcement came in a fact sheet posted on Oct. 12, 2017.]

Many older Americans who have Affordable Care Act insurance policies are going to miss a Sept. 30 deadline to enroll in Medicare, and they need more time to make the change, advocates say.

A lifetime of late enrollment penalties typically await people who don’t sign up for Medicare Part B — which covers doctor visits and other outpatient services — when they first become eligible. That includes people who mistakenly thought that because they had insurance through the ACA marketplaces, they didn’t need to enroll in Medicare.

Medicare officials are offering to waive those penalties under a temporary rule change that began earlier this year, but the deal ends Sept. 30.

On Wednesday, more than 40 groups, including consumer health advocacy organizations and insurers, asked Medicare chief Seema Verma to extend the waiver deadline through at least Dec. 31, because they are worried that many people who could be helped still don’t know about it.

They also say more time is needed because of application delays at some Social Security Administration (SSA) local offices, where beneficiaries request the waiver.

This story also ran on NPR . It can be republished for free ( details ).

“We know there are people who can still benefit from it,” said Stacy Sanders, the federal policy director at the Medicare Rights Center, a Washington-based advocacy group that coordinated the request to Medicare. “We know there have been delays, and those are good reasons to extend it.”

Counselors at the Medicare Rights Center have helped seniors apply for the waiver in Arizona, California, Florida, Minnesota, Missouri, New Jersey and New York, she said.

Since the marketplaces opened in 2014, the focus has been on getting people enrolled, Sanders added. “There’s no reason to expect that people would understand how to move out of the marketplace into Medicare.”

The waiver offer applies not only to people over 65 who have kept their marketplace plans, but also to younger people who qualify for Medicare through a disability and chose to use marketplace plans.

The waiver also allows Medicare beneficiaries who earlier realized their mistake in keeping a marketplace plan and have switched to ask for a reduction or elimination of the penalty.

In all cases, people had to be eligible for Medicare after April 1, 2013.

Officials at the Centers for Medicare & Medicaid, which runs Medicare, would not provide details about the number of waivers granted or pending applications. Nor would they comment on the likelihood of an extension.

Barbara Davis said that when she initially applied, a Social Security representative didn’t know about the waiver. She eventually contacted the Medicare Rights Center, where a counselor interceded on her behalf in June. A day later, a Social Security representative told her she would not have a penalty.

“My advice would be, find out your rights before you apply,” said Davis, 68, who lives with her husband in rural western New York. “Because they don’t seem to want to give you information to help you, you have to know this on your own.”

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A Social Security spokeswoman said the agency is processing waiver applications from “across the country” but does not keep track of the number. She declined to comment on whether SSA employees know about the waiver.

Sanders suggested that people applying for the waiver ask Social Security officials for it by using its official name: “time-limited equitable relief.”

Since Medicare’s Part A hospitalization benefit is usually free, some seniors who liked their marketplace coverage thought — incorrectly — that they had nothing to lose by signing up for Part A and keeping their marketplace plan.

Some people receiving Social Security retirement or disability benefits opted to keep their marketplace plan and drop Part B after the Social Security Administration enrolled them automatically in Medicare when they became eligible.

If the temporary waiver expires, the only other way for beneficiaries to get an exemption is by proving they declined Part B because a government employee misinformed them.

The groups writing Verma argue that keeping the waiver in place past Sept. 30 could also help many beneficiaries who may be surprised by a little-known rule that will affect 2018 marketplace policies.

For the first time, insurers will be prohibited from issuing a marketplace plan if they know the member is eligible for Medicare and the 2018 policy is significantly different.

Those who find themselves without a marketplace plan could be in for another surprise: They won’t have insurance for outpatient care until July 1 because Medicare imposes a waiting period before Part B coverage kicks in for latecomers.

Extending the deadline “would lessen a significant hardship for many people … [who] are unaware of the repercussions that could result from keeping their marketplace coverage,” said Cathryn Donaldson, a spokeswoman for America’s Health Insurance Plans, an industry group.

For information on how to apply for the time-limited equitable relief waiver, go to the Medicare Rights Center’s Medicare Interactive webpage or call the center’s helpline at 1-800-333-4114.

This story was produced by Kaiser Health News, an editorially independent program of the Kaiser Family Foundation.

Output: Many older Americans who have Affordable Care Act insurance policies are going to miss a Sept. 30 deadline to enroll in Medicare, and they need more time to make the change, advocates say.


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Lyft teams up with USC to give low-income seniors rides to the doctor
 Lyft and the University of Southern California are getting $1 million from insurance giant UnitedHealth to help seniors more easily access the transportation they need.

As part of the grant, USC's researchers will study whether taking rides can reduce feelings of loneliness and isolation in seniors and improve their health by helping them get to medical appointments on time.

The funds will be used for a pilot program run by the AARP Foundation in Los Angeles. It will provide free Lyft rides to a group of USC Keck Medical Center patients over 60 who have missed at least 2 medical appointments within the past year and have an upcoming appointment on the books. The rides will be available for 3 months.

These patients will also receive a Fitbit activity tracker, and are encouraged to log their daily activities. Additional pilots are scheduled for Chicago and Atlanta in 2018.

Studies have found that transportation gaps result in many low-income seniors missing or delaying their doctor's visits, which is associated with worse health outcomes. It's also an expensive problem for insurance companies, as these patients are more likely to end up in the emergency room.

For Lyft, the business case is clear as it looks to engage new demographics, including seniors, and pick up new sources of revenue in the $6 billion non-emergency medical transportation market. Beyond this specific study, the company is working with a mix of commercial and government insurers will typically foot the bill.

"We want to study whether we can reduce these no-show rates and provide a better experience for elder populations," said Lyft's Dan Trigub, who works on health care solutions.

Lyft is providing training on how to use the app and it allows a phone-based service for those who lack a smartphone. In that case, the car typically arrives within 30 minutes.

Trigub said drivers will be be aware that they need to pickup riders with service animals. That's an issue that got Uber into legal trouble back in 2015.

He also said that there's no additional cost for caregivers to join the ride.

Ultimately, he said, "we want to be the premier solution for elder, low-income and underserved populations."

Uber has also made steps into the health and medical market. It ran its own pilot program in 2015 to deliver flu shot packages to workplaces and homes.

Output: Lyft and the University of Southern California are getting $1 million from insurance giant UnitedHealth to help seniors more easily access the transportation they need.


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At Florida Nursing Home, Many Calls for Help, but None That Made a Difference
 That same day, about 160 other nursing homes across Florida had no electricity, and most of those, like Hollywood Hills, had no generator capable of powering air-conditioning. But of all those places, the only one where a power loss is known to have caused multiple deaths was the home that advertised being “directly across the street from Hollywood’s Memorial Regional Hospital — so patients receive the finest health care day and night.”

Interviews with nursing home representatives, hospital personnel, residents’ families and government officials, as well as a review of emergency response records, show a preventable descent into the suffocating chaos of that early morning.

The nursing home’s state-approved emergency plan was confounded by a foreseeable electrical failure. The home said its repeated requests for help from state and county officials, and to the power company, yielded no results.

Gov. Rick Scott and other state and local officials say they never had any indication from Hollywood Hills that residents were in distress, though records show that a facility that shared the building reported that the conditions were “adversely affecting patients.” In any event, the officials and the power company said, it was the nursing home’s responsibility to ensure its residents’ safety. The local medical examiner’s office is still investigating the cause and manner of the deaths.

As Irma threatened and then passed, nursing home workers reassured families that their loved ones would be safe. But fans and portable coolers were not enough for some residents, with one so overcome by the heat that she lay nearly naked on a bed in the second-floor hallway. When firefighters were finally summoned to rush people out, they said the conditions reminded them of battling a fire.

Output: The emergency room workers at Memorial Regional Hospital rushed the first patient to Room 9, which was devoted to the hope and practice of arresting death. They threaded fluid lines into her veins and readied a breathing tube. Even through gloves, they could feel the heat corseting the 84-year-old woman’s body.


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Dublin authority faces €30m loss on new-home tax exemption rule
 “It’s inequitable. New apartments at Lansdowne Place in Ballsbridge have prices ranging from €825,000 to €6.5 million. The property tax on €6.5 million is €16,000 a year,” said Paddy McCartan. Photograph: Bryan O’Brien

Dublin local authorities stand to lose in the region of €30 million by 2019 in Local Property Tax (LPT) foregone on new homes, figures compiled by Dublin City Council indicate.

The rate of property tax paid by homeowners is based on the value of the property in May 2013. Houses and apartments bought from a builder since 2013 are exempt from property tax. The exemption was introduced when the tax came into effect in July 2013 and was due to last until October 2016.

However, in 2015 the then minister for finance Michael Noonan announced the valuation thresholds for LPT would be frozen until October 2019, meaning households paying the tax will not see an increase in their bill until then.

This extension was also applied to the exemption on homes sold by builders after the 2013 valuation date, giving new home owners an extra three LPT-free years.

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Figures compiled by the city council’s finance department show the council has already lost an estimated €5.6 million in potential property tax revenues on exempt new homes.

The figures, which the council's head of finance Kathy Quinn stresses are a rough estimate, are based on approximately 4,800 new homes sold in the city since mid-2013, and use an average valuation of €250,000 per home.

While at the standard LPT rate homeowners would owe the council an average of €405 each, the council applies a 15 per cent discount, resulting in an average annual charge of €344.25. Cumulatively that would amount to €5,594,063 foregone to the city council alone.

Cumulative costs

However, Fine Gael councillor and member of the council's finance committee Paddy McCartan said when the losses of the other three Dublin local authorities are taken into account and the figures are projected to the end of 2019, the cumulative costs are in the region of €30 million.

“The finance department agree with my calculations which show that the city council alone will be facing the potential loss of €15 million to the end of 2019, because the property tax is a cumulative charge,” Mr McCartan said.

“The three other local authorities between them collect approximately the same amount of property tax as the council, so the combined total wouldn’t be far short of €30 million.”

There was a basic unfairness, Mr McCartan said, with the vast majority of homeowners paying a tax that others, some of who would be high earners, were escaping.

"It's inequitable. New apartments at Lansdowne Place in Ballsbridge have prices ranging from €825,000 to €6.5 million. The property tax on €6.5 million is €16,000 a year."

The Government could benchmark new homes on what similar housing was valued at in 2013, he said.

“The council can’t afford to be at a loss of revenue of this magnitude and I will be calling on the Government to close this loophole.”

A Government report by Dr Don Thornhill in 2015 recommended the exemption should not be renewed when the revaluation takes place. A spokesman for the Department of Finance yesterday said it would be considering the recommendations of the Thornhill report "in due course in line with the 2019 timeline".

Output: An exemption on charging property tax for new homes may deprive Dublin’s authorities of €30m ($35m) in revenue by 2019, according to the city council. The provision originally applied to homes built between July 2013 and October 2016, but a new property tax rule introduced in 2015 extended that to October 2019. The council has already lost about €5.6m in potential tax revenue from the 4,800 houses and apartments built since the exception was brought in. The scheme has also been criticised for disproportionately favouring wealthier owners, as they can afford the newer builds. A government report recommended ending the exemption in 2019.


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One Last Visit to See My Patient
 Still, I was intensely grateful that this patient remained comfortable, happy, pain-free and able to remain in her home with her loving family. Just as the data predicted, she was living far longer than any of us would have expected, given her congestive heart failure and her severe respiratory disease. It was now 18 months since we started the hospice care.

The paradox is that a patient can qualify for hospice care only if he or she has a life expectancy of six months or less, if the disease runs its normal course. My patient certainly fit that definition, but as we focused intensely on making her more comfortable, she was living longer. Every six months I recertified that my patient indeed had end-stage cardiac and respiratory disease. And although she was clearly frailer at each certification, she remained comfortable and pain-free.

Most patients, sadly, get referred to hospice only in the very last days or weeks of their illness, which explains the misperception that “nothing” is done for the patient other than fluff the pillows on the way to death. Even for patients with end-stage cancer, the earlier they are referred to palliative care (care focused on patient comfort), the longer they usually live.

These thoughts circled in my head as I slogged through the torrential rain toward my patient’s home. I’d asked her daughter if maybe we could reschedule for the next day, when it would be less monsoon-like. “I think you should probably come today,” her daughter replied. Her voice was straightforward and unhurried, but as soon as she said that I angled my umbrella into the downpour and didn’t lift it until I arrived at her building, 20 sopping blocks later.

Their apartment was brimming with ferns, vines and succulents. It was almost as if they’d recreated the jungle of their home country in the concrete of New York City. In the midst of this verdant lair, my patient reclined comfortably on the couch, her face radiating warmth and welcome amid the greenery and medical equipment surrounding her. She gave me a big hug and invited me onto the couch next to her. A breathing mask from a nearby BiPAP machine covered her mouth and nose, but she could still talk. It was obvious how proud she was of her two daughters who sat nearby.

Sitting there, it dawned on me that my patient had won the lottery. She’d lived a long and happy life, with a loving extended family in two countries. Her final days were being spent on her own couch, among her plants and family, her favorite TV shows and music.

After 45 minutes visiting, I kissed her goodbye and shared hugs with the daughters. I headed back out into the rain, nursing a sadness and a relief at the same time.

Output: The rain was coming down in torrents and my shoes were not up to the job. Nevertheless, I pressed forward along the soggy blocks. My 91-year-old patient and I had been together for some 20 years — honestly I’d lost count — so this was the least I could do.