Amicus Curiae Brief — King v. Burwell, 135 S. Ct. 475 (2014) (No. 14-114)
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No. 14-114
U.S.
IN THE
JAN 28 2015
Supreme Court of the United
OFFICE OF THE CLERK
Davip KING, et al.,
Petitioners,
v.
SyLvia MATHEWS BuRWELL,
SECRETARY OF HEALTH AND Human SERVICES, et ai.,
Respondents.
On Wait or CERTIORARI TO THE UNITED STATES
Court or APPEALS FOR THE Fourtu Cigcurt
AMICI CURIAE BRIEF OF PUBLIC HEALTH
DEANS, CHAIRS, AND FACULTY AND THE
AMERICAN PUBLIC HEALTH ASSOCIATION
IN SUPPORT OF RESPONDENTS
TT
SI
H. Guy Co.Luier
Counsel Of Record
Ankur J. GOEL
Catuy Z. SCHEINESON
AMANDEE?P S. SIDHU
THoMAS J. TYNAN
LauUREN A. D’AGosTino
McDermott WILL & Emery LLP
The McDermott Building
500 North Capital Street, NW
Washington, DC 20001
(202) 756-8000
gceollier@mwe.com
Counsel for Amici Curiae
6
COUNSEL PRESS
(8u™ 274-8a21 + (800) 359-6859
i
TABLE OF CONTENTS
enn eee eee eee eee ee ee ee ee eee eee 2
I. ELIMINATING ACCESS TO
PREMIUM TAX CREDITS FOR
RESIDENTS OF THE 34 STATES
THAT HAVE NOT ESTABLISHED A
SBE WILL DEFEAT THE PUBLIC
HEALTH GOALS OF THE ACA AND
HARM POPULATION HEALTH
A.
The ACA Rests on a Population-
Wide Health Goal of Near-
Universal Access to Insurance—a
Goal of Special Importance in
States that Have Not Established
Eliminating Access to the
Premium Tax Credit for FFE
State Residents Will Exacerbate
Already-Existing Income-Based,
Racial, and Ethnic Health
Disparities that Affect the
Populations of FFE States
Compared to the Rest of the
EE INES OP ATE EEGs eect
il.
i
TABLE OF CONTENTS
(continued)
Page
Because Most of the FFE States
Also Have Opted Out of
Expanding Their State Medicaid
Programs, Additional Numbers of
Near-Poor Residents in Those
States Are Entirely Dependent
on the Premium Tax Credit for
Affordable Insurance Coverage........
THE OVERRIDING PURPOSE OF
THE ACA WAS TO ENACT
NATIONAL HEALTH REFORM,
SPECIFICALLY BY ENSURING THE
AVAILABILITY OF AFFORDABLE
HEALTH INSURANCE COVERAGE
FOR ALL AMERICANS
A.
Congress Recognized that
Universal Health Insurance
Coverage Improves Access to
Health Care and Health
The ACA’s Purpose Was to Enact
Comprehensive Health Reform
on & National Scale.............0..c.0....0s..
The ACA’s Structure
Underscores That Exchanges
Exist as a National Public Health
Intervention to Connect
Americans to Affordable
IIL, i cctitaicganicitealitadasnidddenesiigadadateed
CCCP CeO eee eee eee eee
TABLE OF CONTENTS
(continued)
Page
D. Congress Recognized the
Correlation Between Insurance
Coverage and Population Health
and the ACA Was Structured to
Achieve a Nationwide, Positive
NY ascites entsnetrameneette 25
E. Eliminating the Premium Tax
Credits and Thus Diminishing
the Affordability and Likelihood
of Insurance in the Very States
Whose Residents Most Need
Coverage Would Eviscerate the
ACA’s Public Health Goals................ 27
F. This Court Should Affirm the
Fourth Circuit’s Decision in
Order to Avoid Conflicts with the
Text of the ACA That Would
Unnecessarily Lead to
Devastating Population Health
Impact, Including Increasing the
Uninsured Population by 8.2
Million People and Costing
Thousands of Lives Annually............ 28
ee tincceesatiitinnstsrainntetgecetinnselpuiniiininciées 30
APPENDIX A: LIST AND AFFILIATIONS
OF AMICI CURIAE PUBLIC HEALTH
DEANS, CHAIRS, AND FACULTY ........... A-1
APPENDIX B: DATA TABLES ........................4. A-20
iv
TABLE OF AUTHORITIES
Page
CASES
Burwell v. Hobby Lobby Stores, Inc.,
Be ie Ci ee IO dscchanscedacscsslacatininitiiadachasezeass 7
Comm 'r v. Brown,
ee re eG ID ences saroeccucinticeaseceSeccecieecadectaconmatce 29
In Re Trans Alaska Pipeline Rate Cases,
a a TE cridesesecckercciintcstnctbemnsivuscunacuiiens 29
Kloeckner v. Solis,
BO rT ica ard a eta 29
Nat Fed’n of Indep. Bus. v. Sebelius,
i. as CY CRE iesescd. ca deicnctsdeics nies seidestvianecdesesten 7
United States v. Kirby,
I es I nc 29
United States v. Lee,
I es I CII wicties ca dese diceccencosecedinndhcneidiebacedandicn 7
REGULATIONS
42 U.S.C. § 18041(c)(1)(B)G) and (ii) ............00 6
ACA § 1312(d), codified at 42 U.S.C.
EY PEL 0D deiae capcenidetnapedasecesuisserseeierianiosestate 24
ACA § 1501(a)(2), codified at 42 U.S.C,
i SEED TIT ELD cnduvauncsndsesecépsietsnnivensuseumesisiorecieuns 21
Vv
TABLE OF AUTHORITIES
ACA § 1502(a)(2)(E), codified at 42 U.S.C.
I Un i tN 21
ACA § 3001, codified at 42 U.S.C. § 280;
8) RTT PE RE AUREUS Say or etre Meee ea Renee Come LOR 22
ACA § 4001(a), codified at 42 U.S.C. § 300u-10
SEELTRD didgtaeiiaduiundeasihentsadinedetbndinabdediaiabidauaibaiitebisee 22
ACA § 4004(a), codified at 42 U.S.C. § 300u-
Nop kc cies eps ectecinereuplleanatscucalons 22
S. Con. Res. 6, 111th Cong., 155 Cong. Rec.
NIN II ch icccSatatactituamphascedtecgeimnidenetendosbakiis 17
OTHER AUTHORITIES
Amy Burke, Arpit Misra, and Steven
Sheingold, Premium Affordability,
Competition, and Choice in the
Health Insurance Marketplace, 2014,
Office of the Assistant Secretary for
Planning and Evaluation (ASPE),
Da | Ee ee eS A-21, A-23
Andrew P Wilper, et al., Health Ins. and
Mortality in US Adults, AM. J. PUB. HEALTH,
RAR RR RE IR ee BNE AE OA AS 20
Benjamin D. Sommers, M.D., Ph.D., et al.,
Healih Reform and Changes in Health
Insurance Coverage in 2014, NEW ENG. J.
| FR TA, Fl, BE TIE wxncewseecsnnnscnenccesssneenees 26
v1
TABLE OF AUTHORITIES
Benjamin D. Sommers, MD, PhD; Sharon K.
Long, PhD; and Katherine Baicker, PhD,
Changes in Mortality after Massachusetts
Health Care Reform: A Quasi-experimental
Study, ANN. INTERN. MED., May 2014, at
Cancer Prevention & Early Detection Facts &
Figures, Tables and Figures 2014, American
Cancer Society, 2014
Christine Eibner and Evan Saltzman,
Assessing Alternative Modifications to the
Affordable Care Act, Rand Corporation, at
19 (Table 2) (Oct. 2014)
Comm. on the Consequences of Uninsurance;
Bd. on Health Care Servs. (HCS) & Inst. of
Med., CARE WITHOUT COVERAGE: TOO
LITTLE, TOO LATE (The National Academies
I i ceiadebaenien 17, 18, 19, 20
Comm. on the Consequences of Uninsurance;
Bd. on Health Care Servs. (HCS); & Inst. of
Med., A SHARED DESTINY: COMMUNITY
EFFECTS OF UNINSURANCE (The National
Academies Press ed. 2003)
Health Insurance Marketplace: January
Enrollment Report for the Period: October
1, 2013 — Feb. 1, 2014 (Dep’t Health &
Human Serv. Feb. 12, 2014)
vil
TABLE OF AUTHORITIES
Investing in America’s Health: A State by State
Look at Public Health Funding and Key
Health Facts, Trust for America’s Health,
Apr. 2013......cccccccccecesosececeeececsscecscasseseceesesesececeee. A-28
J. Michael McWilliams, Health Consequences
of Uninsurance Among Adults in the United
States: Recent Evidence and Implications,
MILBANK Q, June 2009, at 443. .........000..02. eee 18
John Z. Ayanian, et al., Unmet Health Needs
of Uninsured Adults in the United States,
rm, Tee. Bi, BG, GE BOGE. cvncccecccccnesecsccscssseces 20
Linda J. Blumberg, Matthew Beuttgens, and
John Holahan, The Implications for a
Supreme Court Finding for the Plaintiffs in
King v Burwell: 8.2 Million More Uninsured
and 35% Higher Premiums, Urban Institute
IRIN, SPITE n.cccisgiscccenusncecanascncssesusssessiaionacgiaccsedshicaccosss 4
Michelle Andrews, Deaths Rising for Lack of
Ins., Study Finds, N.Y. TIMES, Feb. 26, 2010...... 17
National Health and Nutrition Examination
Survey (“NHANES”), 2011-2012 (Dep't
Health & Human Serv. Centers for Disease
Control and Prevention Nat’] Center for
EARN IES IR: Pare nors eee 14
People in Medically Underserved Areas (%),
National Women’s Law Center..................2.20..- A-28
TABLE OF AUTHORITIES
Prevalence and Trends Data, Office of
Surveillance, Epidemiology, and Laboratory
Services, Behavioral Risk Factor
I INI ooo sesictticcnstaccsnivnssactnciainsincnwsn A-28
Richard Kronick, Health Insurance Coverage
and Mortality Revisited, 44 HEALTH SERVS.
RACH, Ptats. BOG, GE UBT .ccccccccsccocesessnsccessess 20
Theda Skocpol, Why Congressional Budget
Office Reports Are The Best Evidence Of
Congressional Intent About Health
Subsidies, Scholars Strategy Network,
Harvard University (Jan. 2015)................:cc22ce0 22
U.S. CENSUS BUREAU, 2013 American
IT CII viccrccnicctentntecstcienarstcniiesnenies 2, A-20
U.S. CENSUS BUREAU, Current Population
Survey (2014), CPS Table Creator.................... A-24
INTERESTS OF AMICI!
Amici curiae Public Health Deans, Chairs, and
Faculty and The American Public Health Association
(“APHA”) submit this brief in support of Respondent
Sylvia Mathews Burwell, in her official capacity as
Secretary of the Department of Health and Human
Services. Amici curiae urge this Court to affirm the
District Court’s order granting Summary Judgment
to Respondent Burwell.
Amici curiae are deans, departmental chairs,
and faculty members of public health and public
health law. Amici include deans, chairs, and faculty
from some of the leading schools of public health in
the United States listed in Appendix A. Amici curiae
are engaged in the policy and science of protecting
and improving the health of communities through
education, promotion of healthy lifestyles, and
research to reduce disease and prevent injury.
Amici believe that the public’s health will be
adversely affected if the decision of the United
States Court of Appeals for the Fourth Circuit is not
affirmed.
Amict curiaz also include APHA, an organization
that champions the health of all people and all
communities and strengthens the profession of
public health, shares the latest research and
' It is hereby certified that counsel for the parties have
consented to the filing of this brief. It is further certified that
no counsel for a party authored any portion of this brief and
that no person other than these amici curiae or their counsel
made a monetary contribution to the preparation of this brief.
information, promotes best practices and advocates
for public health issues and policies grounded in
research. APHA is the only national health
organization that combines a 140-plus_ year
perspective, a broad-based member community
working to improve the public’s health, and the
ability to influence federal policy to improve the
public’s health. It has been APHA’s longstanding
position that access to health care is a fundamental
right and integral to the health and well-being of
individuals and to the broader public health.
Further, APHA supports the increased access to
health care provided by the Patient Protection and
Affordable Care Act of 2010 (*ACA”). APHA believes
that the public’s health and the health of individuals
will be adversely affected if the decision of the
Fourth Circuit is overturned.
INTRODUCTION AND SUMMARY OF
ARGUMENT
Based upon the incontrovertible evidence that
health insurance coverage improves access to health
care and overall health, Congress structured the
ACA to provide near-universal access to affordable
insurance. To ensure that coverage is affordable, the
ACA creates a federal Health Insurance Premium
Tax Credit (“Premium Tax Credit”) that is projected
to benefit approximately 26.7 million Americans who
otherwise lack public or private health insurance
and have qualifying incomes.? Thirty-four states'—
2 See U.S. CENSUS BUREAU, 2013 American Community
Survey, http://factfinder2.census.gov/faces/nav/jsf/pages/searchr
esults.xhtml?refresh=t.
some for political reasons, others out of practical
considerations—have chosen to use the
federally-funded exchange (“FFE”), an _ option
provided under the ACA, to link lower-income
residents with affordable health insurance coverage.
An estimated 18 million children and adults—nearly
70% of this 26.7 million-person total—reside in these
FFE states.
By conditioning Premium Tax Credits on
whether states can and will run a state-based
exchange (“SBE”), Petitioners seek to eliminate
payments of subsidies to millions of Americans who
are not before this Court, even though doing so
completely undermines the law’s fundamental goal
of near-universal coverage for Americans.
3 The 34 FFE states include the seven partnership Exchange
states (Arkansas, Delaware, Illinois, Iowa, Michigan, New
Hampshire, and West Virginia) and the 27 states whose
Exchanges were run fully by the FFE in 2014: Alabama,
Alaska, Arizona, Florida, Georgia, Indiana, Kansas, Louisiana,
Maine, Mississippi, Missouri, Montana, Nebraska, New Jersey,
North Carolina, North Dakota, Ohio, Oklahoma, Pennsylvania,
South Carolina, South Dakota, Tennessee, Texas, Utah,
Virginia, Wisconsin, and Wyoming. Health Insurance
Marketplace: January Enrollment Report for the Period: Oct.
1, 2013 — Feb. 1, 2014, 22-24 (Dep’t Health & Human Serv.
Feb. 12, 2014) [hereinafter HHS Report]. Fourteen states (plus
the District of Columbia) have implemented their own SBEs:
California, Colorado, Connecticut, Hawaii, Kentucky,
Maryland, Massachusetts, Minnesota, Nevada, New York,
Oregon, Rhode Island, Vermont and Washington. Jd. Idaho
and New Mexico were federally supported SBEs for 2014; that
is, they were using the FFE website platform for 2014. Zd.
4 Td.
The FFE states—home to approximately
two-thirds of the American population—were given
no notice of the harsh consequences that might befall
their residents as a result of their choice to use the
FFE. Those receiving subsidies through the FFE are
even poorer as a group than residents of states with
SBEs. Many FFE states have also elected to opt out
of the adult Medicaid expansion authorized under
the ACA which impacts millions of individuals whose
incomes fall between 100% and 138% of the federal
poverty level and, therefore, would have qualified for
Medicaid had their states not opted out. Compared
to residents of SBE states, residents of states using
the FFE will be disproportionately adversely affected
by a loss of the Premium Tax Credit. They are not
only poorer as a group but are also in worse health,
using a broad range of population health indicators.
Preventable mortality is higher in the FFE states, as
measured by infant mortality and death rates for
cardiovascular disease and cancer. Diabetes, high
blood pressure, and depression rates—all associ» ed
with premature mortality—-are higher in the group
of states whose residents depend on the FFE.
Eliminating subsidies in these states would deprive
precisely those individuals of affordable health
insurance.
If the Court reverses the Fourth Circuit’s
decision, one expert study reports that over 9.3
million residents of FFE states will lose subsidies by
2016, resulting in an 8.2 million-person increase in
the number of uninsured people.© Other experts
5 Linda J. Blumberg, Matthew Beuttgens, and John Holahan,
The Implications for a Supreme Court Finding for the Plaintiffs
(continued...)
have estimated that such a decision could result in
the loss of subsidies by 68% of those individuals who
currently receive them.®
Because of the _ interrelationship between
insurance coverage, health care access, and
population health, a decision striking down the IRS
rule can be expected to lead to a loss of
improvements in access to care, worsening health,
and more preventable deaths. Applying the results
of a prior study estimating mortality declines linked
to the first four years of health reform in
Massachusetts, a loss of health insurance by
estimated 8.2 million persons can be expected to
translate into over 9,800 additional] deaths annually.
Nothing in the ACA requires these terrible
health outcomes; indeed, the text of the law requires
the opposite result. The Court should affirm the
Fourth Circuit’s Order preserving access to Premium
Tax Credits for the 18 million eligible people living
in FFE states.
in King v Burwell: 8.2 Million More Uninsured and 35% Higher
Premiums, Urban Institute (Jan. 2015),
http://www.urban.org/U ploadedPDF/2000062-The-! mplications-
King-vs-Burwell.pdf.
6 Christine Eibner and Evan Saltzman, Assessing Alternative
Modifications to the Affordable Care Act, Rand Corporation, at
19 (Table 2) (Oct. 2014),
http://www.rand.org/content/dam/rand/pubs/research_reports/R
R700/RR708/RAND_RR708.pdf.
ARGUMENT
I. Eliminating Access to Premium Tax
Credits for Residents of the 34 States
That Have Not Established a SBE Will
Defeat the Public Health Goals of the
ACA and Harm Population Health.
A. The ACA Rests on a Population-
Wide Health Goal of Near-Universal
Access to Insurance—a Goal of
Special Importance in States that
Have Not Established a SBE.
Despite the clear evidence that Congress
intended to provide Americans with near-universal
access to insurance, Appellants would deny
affordable insurance to an estimated 18 million
subsidy-eligible people simply because they happen
to live in one of 34 states that has elected not to
establish a SBE and has instead chosen to rely on an
FFE, either wholly or as state partners.
About two-thirds of the nation’s population—
roughly 200 million people—live in the 34 FFE
states.? The states electing to use the FFE did so
with no notice of the dire consequences that would
befall their residents were they to make such an
’ A total of 37 states use the FFE, but three of these states—
Oregon, Nevada, and New Mexico—have established a SBE
and use the FFE only for operational purposes in the individual
market, as provided under 42 U.S.C. § 18041(c)(1)(B){i) and (ii).
These states, however, have SBEs and are not FFE states
under the law.
election; indeed, states reasonably relied on the
Treasury rule when making their decisions.
For millions of people, access to affordable
health insurance rests on the availability of
Premium Tax Credits for qualified health plans
purchased on the FFE or on a SBE (collectively
referred to as “the Exchange” or “the Exchanges”).
As this Court has previously explained, the ACA
“attempts to achieve near-universal health
insurance coverage by spreading its costs to
individuals, insurers, governments, hospitals, and
employers—while, at the same time, offsetting
significant portions of those costs with new benefits to
each group.” Nat’ Fed’n of Indep. Bus. v. Sebelius,
132 S. Ct. 2566, 2670 (2012) (emphasis added).
Unlike Medicaid, financial assistance based on
federal tax policy does not contemplate state-to-state
variation. Instead, as this Court has acknowledged,
social welfare legislation that rests on tax policy
contemplates a nationally uniform approach and
cannot be subjected to individual objections. Cf,
Burwell v. Hobby Lobby Stores, Inc., 134 S. Ct. 2751,
2784 (2014) (quoting United States v. Lee, 455 U.S.
252, 260 (1982)) (in the context of religious objections
to taxation, the Court noted that “[t]he obligation to
pay the social security tax initially is not
fundamentally different from the obligation to pay
income taxes’ [and] [b]ased on that premise, [the
Court] explained that it was untenable to allow
individuals to seek exemptions from taxes based on
religious objections to particular Government
expenditures e
To deprive residents of these 34 FFE states of
Premium Tax Credits simply because their state
elected to utilize the FFE—whether for philosophical
or practical reasons—will leave millions without
access to affordable coverage and thereby undermine
the public’s health. It will also further exacerbate
the significant racial, ethnic, and income-based
health disparities that already exist between the
populations of FFE states and residents of states
that have elected to establish a SBE.
The characteristics of the residents in the 34
FFE states—depicted in Figure 1 (below)—provide
some insight into the catastrophic consequences of a
ruling by this Court that invalidates their residents’
access to Premium Tax Credits.
Figure 1: State-Based Exchanges and
Federally-Facilitated Exchanges for Open
Enrollment 2015
im gf i
As shown in Table 1 (App. B), these 34 states
accounted for 171.6 million out of 264.8 million (64%)
nonelderly U.S. residents in 2013. The residents of
the 34 FFE further accounted for an even greater
share—66%, or 84.8 million out of 127.2 million U.S.
residents whose 2013 incomes made them eligible
for Premium Tax Credits, with family incomes
between 100% and 400% of the poverty level.§
The FFE states are also home to the nation’s
most vulnerable populations. As of April 2014, FFE
states accounted for nearly 4.7 million of all people
receiving Premium Tax Credits in 2014, 87% of all
recipients. Table 2 (App. B). Experts further
project that by 2016, the number of tax credit
recipients in the FFE states will exceed 9.3 million
people.1°
The FFE states benefit heavily from Premium
Tax Credits, because the great majority of the
uninsured U.S. population resides in these states.
Census data show that prior to implementation of
the ACA system of subsidized insurance available
through the Exchanges, residents of the 34 FFE
® In Medicaid expansion states, the income threshold for
Premium Tax Credits begins at 139% of the Federal Poverty
Level (“FPL”) (the point at which Medicaid income eligibility
ceases) and phases out at 400% of the FPL. In states that have
not expanded Medicaid to cover all non-elderly adult residents
with incomes up to 138% of the FPL, the threshold income
eligibility for Premium Tax Credits begins at 100% and phases
out at 400% of the FPL.
9 Table 2 includes Idaho and New Mexico, which as of the time
of the study, had elected to establish a SBE but relied on the
federal IT platform. Together these states account for slightly
less than 100,000 of the 4.7 million premium subsidy recipients
in FFE states.
10 See supra n.5 and Table 4 (App. B).
10
states accounted for 68% of all uninsured
Americans—30.6 million out of 45.2 million
uninsured U.S. residents. If residents of the 34 FFE
states were deprived of Premium Tax Credits as a
result of this Court’s ruling. More than 4.6 million
people who had received assistance as of April 2014
would lose nearly $15 billion in tax credits. Table 2
(App. B). By 2016, the number of people receiving
Premium Tax Credits in the FFE states is expected
to rise to 9.346 million, representing a total of $28.8
billion in expected tax credits ($3,090 per person, on
average). As a result, the number of uninsured
people resulting from the loss of Premium Tax
Credits is expected to rise by approximately 8.2
million.}!
Moreover, uninsured Americans are
disproportionately concentrated in FFE states to
begin with (15.1% of all residents compared to the
national average of 14.5%). Table 3 (App. B). This
disproportionate concentration of the uninsured is
depicted in Figure 2.
1 Jd.
11
Figure 2: Percent Uninsured Residents in
Federally-Facilitated Exchange States in 2013
Percent Uninsured Residents in Federally-
Facilitated Exchange (FFE) States In 2013
so , - ——— eee
17 outof MFFE satesh ad unesred
rates exc cerirg the overage for SHE
states 2013 ™
| ~wO ~ >
| —
{ an”
¢ Average Percent Unwnared 2 @*
a FFE States=15 1% ur (Oe
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oe ©
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Biuso sees
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sf -_ ry: va Average Pescert Unrrmaused m Stare
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ag “et Based Excharge (SBE) Stares= 13 4%
wo ons ce - — -
50 - — —- -
Fecderalty fac) wred fac nhange Stats
Seweve Arwtyees of 2015 ACS One
Were Premium Tax Credits to be terminated in the
FFE states, these coverage disparities would widen
over time as the number of insured residents of FFE
states falls ever further behind in the number of
insured residents in the SBE states. The public
health consequences of these widening disparities
would be severe, exacerbating the already poor
population health measures in the FFE states.
Just as the FFE states constitute approximately
two-thirds of the United States’ population, these
states are home to the majority of low-to-moderate-
12
income uninsured African-Americans who would be
affected by the loss of Premium Tax Credits (15
million out of 19 million African Americans with
incomes between 100% and 400% of the federal
poverty level). Table 4 (App. B). Similarly, the vast
majority of uninsured African-Americans live in FFE
states (2.6 million out of 3.1 million), and moreover,
that African American residents of FFE states are
disproportionately likely to be uninsured (17.6%
versus 12.7%). Id. Similarly, the majority of low-
to-moderate-income uninsured Hispanic-Americans
live in the 34 FFE states. Jd. In sum, non-Hispanic
African-Americans and Hispanic-Americans residing
in one of the 34 FFE states are more likely to be both
low-to-moderate income and uninsured. IZd.
B. Eliminating Access to the Premium
Tax Credit for FFE State Residents
Will Exacerbate Already-Existing
Income-Based, Racial, and Ethnic
Health Disparities that Affect the
Populations of FFE States
Compared to the Rest of the Nation.
Poverty and poor health are more concentrated
within the FFE states to begin with and eliminating
Premium Tax Credits for residents of these states
accordingly carries especially grave implications.
Population health disparities between the FFE and
SBE states were clearly evident even before
implementation of the subsidized Exchange. Table
5 (App. B) underscores that compared to residents of
SBE states, residents of the 34 FFE states are more
iikely to report being unable to see a doctor due to
cost (16.5% versus 14.9%). Id. They are more likely
13
to live in medically underserved areas that lack
adequate access to primary health care (12.4%
versus 10.1%). Id. Residents of FFE states are more
likely to experience health risks amenable to health
care: deaths from cardiovascular disease (258.6
deaths per 100,000 versus 236.8 deaths), infant
mortality (6.5 deaths per 1000 live births versus 5.2
deaths); and deaths from cancer (194.2 deaths per
100,000 residents versus 181.0 deaths). Id.
Female residents of FFE states are less likely to
have had a mammogram in the preceding year and
adult residents are more likely to have been
diagnosed with diabetes (a condition that can lead to
the loss of limbs, kidney disease, and heart attacks).
Id. FFE state residents are more likely to have been
told that they have high blood pressure and
depression and are more likely to be overweight and
smoke. Regular and ongoing medical care—
accessibility of which turns heavily on being
insured—has been shown to be associated with
reduced risks for all of these conditions.
The FFE states are two-thirds less likely than
SBE states to be in a position to invest in public
health services ($61 per resident to $103). Jd. This
figure underscores the weaker economies and higher
poverty in FFE-reliant states, a reality that
intensifies the implications of withdrawing premium
tax subsidies from residents of those states.
The role that insurance plays in addressing
these population health disparities has _ been
extensively documented. Improved infant health,
better management of obesity, and reduced health
14
risks from conditions such as diabetes are associated
with access to timely, appropriate and quality health
care, which in turn is significantly associated with
health insurance. For example, evidence drawn
from the 2011-2012 National Health and Nutrition
Examination Survey shows that 32% of uninsured
people with diabetes remain undiagnosed, compared
with 15% of people with diabetes who have
insurance.'2 This is because health insurance
facilitates access to affordable medical care at an
earlier point, when it is possible to avert often-fatal
consequences by treating and managing serious
health conditions.
ad Because Most of the FFE States Also
Have Opted Out of Expanding Their
State Medicaid Programs,
Additional Numbers of Near-Poor
Residents in Those States Are
Entirely Dependent on the Premium
Tax Credit for Affordable Insurance
Coverage.
The loss of access to Premium Tax Credits in the
FFE states would compound an already bad
situation, because in addition to the millions of
people with incomes between 139% and 400% of the
federal poverty level, census data show that
approximately 3.9 million residents of FFE states
have incomes between 100% and 138% of the FPL
12 See National Health and Nutrition Examination Survey
(“NHANES’), 2011-2012 (Dep’t Health & Human Serv. Centers
for Disease Control and Prevention Nat'l Center for Health
Statistics 2012).
15
and also depend on FFE subsidies.'3 These people
depend on the FFE because, as of January 2015, 22
out of 34 FFE states also had opted out of the ACA-
authorized Medicaid expansion.’ See Figure 3
(below). This means that nonelderly adults with
incomes up to 138% of the FPL and not otherwise
eligible for traditional Medicaid coverage have no
Medicaid eligibility pathway.'® Instead, these
people, falling into the insurance gap !eft by their
state’s decision not to expand Medicaid, are able to
use Premium Tax Credits to purchase insurance on
the Exchanges, since in the non-Medicaid expansion
states, subsidy eligibility commences at 100 percent
of the federal poverty level.
18 As states elect to expand Medicaid, the number of persons
with incomes between 100% and 138% of the FPL who obtain
affordable coverage using Premium Tax Subsidies can be
expected to decline. However, most of the states (including the
largest states of Texas and Florida) that have placed residents
in the “coverage gap” by failing to expand Medicaid have, as of
January 2014, shown no inclination to change their decisions.
14 These 22 states are: Indiana, Tennessee, Maine, Virginia,
North Carolina, South Carolina, Florida, Georgia, Tennessee.
Alabama, Mississippi, Louisiana, Texas, Missouri, Oklahoma,
Kansas, Nebraska, South Dakota, Utah, Wyoming, Montana,
and Alaska.
15 By contrast, all SBE states (except Idaho) have expanded
Medicaid to cover this population. Thus, in these states,
residents with incomes between 138% and 400% of the FPL are
eligible for the Premium Tax Credit.
16
Figure 3: Marketplace Status and Medicaid
Expansion for Open Enrollment 2015
i ee ae ong Medes |
i ee
If this Court reverses the decision of the Fourth
Circuit, these people will lose their premium
subsidies—and will remain ineligible for Medicaid
coverage, as well, due to their states’ election not to
expand Medicaid.
II. The Overriding Purpose of The ACA Was
to Enact National Health Reform,
Specifically By Ensuring the Availability
of Affordable Health Insurance Coverage
for All Americans.
A. Congress Recognized that Universal
Health Insurance Coverage
Improves Access to Health Care and
Health Outcomes.
The ACA rests on the fundamental premise that
universal coverage is vital to improving the health of
17
the American population. This premise was front
and center in Congress, even at the earliest point in
the debate over health reform.'® In fact, irrefutable
evidence shows that access to health insurance
promotes individual and community health and that
Congress was aware of this nexus in enacting the
ACA. In the earliest stages of the ACA debate,
Members of Congress focused on the nexus between
health reform and population health.’? The seminal
body of research Congress relied on is a multi-year
study undertaken by the Institute of Medicine
(“IOM”),'® whose 2002 exploration of the
consequences of being uninsured led to a pivotal
conclusion: more than 18,300 American adults died
annually because they lacked health insurance.'9
16 See S. Con. Res. 6, 111th Cong., 155 Cong. Rec. S2164-02
(2009) (Senate Concurrent Resolution 6 — Expressing the Sense
of Congress that National Health Care Reform Should Ensure
that the Health Care Needs of Women and All Individuals in
the United States are Met).
17 See supra n.16, at S2165 (“Whereas the Institute of Medicine
estimates that the cost of achieving full health insurance
coverage in the United States would be less than the loss in
economic productivity from existing coverage gaps....”); see also
Michelle Andrews, Deaths Rising for Lack of Ins., Study Finds,
N.Y. TIMES, Feb. 26, 2010,
http://prescriptions.blogs.nytimes.com/2010/02/26/deaths-
rising-due-to-lack-of-insurance-study-
finds/?_php=true&_type=blogs& r=0 (summarizing the IOM
research and reporting on a later update of its estimates).
18 The IOM is the medical/public health component of the
Congressionally-chartered National Academy of Sciences.
19 Comm. on the Consequences of Uninsurance; Bd. on Health
Care Servs. (HCS) & Inst. of Med. (““IOM”), CARE WITHOUT
COVERAGE: Too LITTLE, Too LATE 163 (The National
(continued...)
18
The IOM Committee found that: (1) health
insurance is associated with better health outcomes
among adults and with the receipt of appropriate
care across a range of preventive, chronic, and acute
care; (2) older adults with chronic conditions are the
most likely to realize the health benefits of coverage
because of their greater need for health care; (3)
populations facing the highest health risks (those
with low incomes and members of racial and ethnic
minority groups) stand to benefit the most from
coverage, thereby leading to a _ reduction in
disparities in health and health care; (4)
comprehensive coverage (of the type that ultimately
would be made available through subsidized,
qualified health plans offered on an Exchange) was
most strongly associated with improved health; and
(5) with stable insurance coverage, the health of
uninsured adults improves over time.”°
A range of studies have shown that uninsured
adults, especially those without insurance for over a
year, have more unmet health needs than those
adults with stable coverage, because they encounter
greater barriers to early detection and treatment of
chronic illnesses, delay seeking medical care, and
even forgo necessary care for potentially serious
symptoms.2! The IOM studies show that uninsured
Academies Press ed. 2002) [hereinafter “CARE WITHOUT
COVERAGE’}.
20 Id. at 91-103.
21 Jd.; CARE WITHOUT COVERAGE, supra note 19, at 47—90; J.
Michael McWilliams, Health Consequences of Uninsurance
Among Adults in the United States: Recent Evidence and
Implications, MILBANK Q, June 2009, at 443, 485.
19
patients with chronic diseases are less likely to
receive appropriate care to manage their conditions
and have worse clinical outcomes than insured
patients.22 They also show that uninsured patients
who are hospitalized are more likely to die in the
hospital, receive fewer services, and experience more
adverse medical events due to negligence than
insured patients.23 Further, the IOM studies have
found that uninsured patients are more likely to
experience worse health outcomes than among those
with private insurance coverage.”
Finally, the IOM research extended beyond the
individual impact of being uninsured and considered
community-wide effects of populations at elevated
risk for being uninsured. The IOM concluded that
communities with high rates of uninsured have
worse access to health care and report higher
proportions of low income families in fair to poor
health, as opposed to communities with low
uninsured’ rates.”® Hospitalization rates for
conditions amenable to early treatment with
ambulatory care are higher in communities
experiencing a greater proportion of lower income
and uninsured residents, including both access
problems and greater severity of illness.2® Finally,
22 CARE WITHOUT COVERAGE, supra note 19, at 57-71.
23 Id. at 73-76.
24 Id. at 80-82.
26 Comm. on the Consequences of Uninsurance; Bd. on Health
Care Servs. (HCS); & Inst. of Med. (10M), A SHARED DESTINY:
COMMUNITY EFFECTS OF UNINSURANCE 140 (The National
Academies Press ed. 2003) [hereinafter “COMMUNITY EFFECTS
OF UNINSURANCE’].
26 Jd. at 142.
20
the incidence oof vaccine-preventable and
communicable disease was shown to be higher in
areas with high uninsured rates that experience
chronic underfunding of local public health
agencies.?7
Subsequent studies echoed the IOM’s findings.”®
One study, which updated the earlier IOM estimate
regarding the impact of being uninsured on life and
health, significantly increased the earlier estimate—
from 18,314 excess deaths in 2001 among Americans
ages 25-64 to 35,327 in 2005. This study concluded
that the uninsured are 1.4 times more likely to die
from preventable causes.29 This disparity in deaths
could be attributed in part to the fact that uninsured
adults are less likely than adults with insurance to
receive timely, appropriate, and quality health
care.2° Subsequent studies found that the absence of
health insurance significantly affected the health
outcomes of patients with the most serious
27 Jd. at 147.
28 One study issued in 2009 argued that it is not possible to
draw causal inferences between insurance coverage and death.
Richard Kronick, Health Insurance Coverage and Mortality
Revisited, 44 HEALTH SERVS. RESEARCH, Aug. 2009, at 1211.
However, the IOM has not altered its previous estimates, and
no additional studies supporting this contrary finding have
been published.
22 Andrew P. Wilper, et al., Health Ins. and Mortality in US
Adults, AM. J. PUB. HEALTH, Dec. 2009, at 2289, 2292.
30 CARE WITHOUT COVERAGE, supra note 19, at 47-90
(reviewing the empirical literature on the association between
insurance and health care and health outcome).
21
conditions such as cancer, principally because of
delayed diagnosis.*!
B. The ACA’s Purpose Was to Enact
Comprehensive Health Reform on a
National Scale.
Congress cited the link between coverage and
health outcomes and set national public health
improvement goals that hinge on achieving near-
universal coverage. The ACA’s text provides
evidence of Congressional intent to raise the health
of the entire American population—regardless of
whether their state elects to operate its own
Exchange or, as permitted under the law, to rely on
the FFE. No state was ever told that relying on the
FFE would sacrifice the profound health and health
care advantages for its at-risk population that flow
from being insured. Congressional findings make
clear that being uninsured burdens the national
economy and _ interstate commerce. ACA
§ 1501(a)(2), codified at 42 U.S.C. § 18091(2) (2011).
By extending the coverage mandate to all
Americans—facilitated by access to affordable health
insurance through the use of Premium Tax Credits—
Congress intended to improve the nation’s health
and to reduce the annual costs of $207 billion to the
national economy that flow from the poorer health
and shorter lifespan of the uninsured. ACA
§ 1502(a)(2)(E), codified at 42 U.S.C. § 18091(2)(E)
(2011).
31 John Z. Ayanian, 2t al., Unmet Health Needs of Uninsured
Adults in the United States, JAMA, Oct. 25, 2000, at 2061.
22
Congress signaled its intent in the ACA to couple
a nationwide system of affordable insurance with
other national strategies to improve the public
health. For instance, the ACA directed the
Secretary of Health and Human _ Services
(“Secretary”) to identify national priorities to
establish a strategy to improve the delivery of health
care services, patient health outcomes, and
population health. ACA § 3001, codified at 42 U.S.C.
§ 280} (2011). The ACA directed the President to
establish the National Prevention, Health
Promotion, and Public Health Council to coordinate
and lead all federal departments and agencies on
prevention, wellness and health promotion practices,
the public health system, and integrative health care
strategy nationwide. ACA § 4001(a), codified at 42
U.S.C. § 300u-10 (2011). Congress further directed
the Secretary to undertake a “national public-private
partnership for a prevention and health promotion
outreach and education campaign to raise public
awareness of health improvement across the life
span.” ACA § 4004(a), codified at 42 U.S.C. § 300u-
12(a) (2011).
These national programs demonstrate that the
ACA is a comprehensive health care reform effort on
a national scale.32 Read in its entirety, the ACA is a
32 Further demonstrating Congress never intended for
Premium Tax Credits to be restricted to SBE states, a recent
study analyzed 68 separate analyses related to the ACA and
performed by the Congressional Budget Office (“CBO”). See
Theda Skocpol, Why Congressional Budget Office Reports Are
The Best Evidence Of Congressional Intent About Health
Subsidies, Scholars Strategy Network, Harvard University
(Jan. 2015),
(continued...)
law with a pathway to affordable insurance coverage
that is national in scope, not one reserved for states
23
that happen to run their own Exchanges.
a The ACA’s Structure Underscores
That Exchanges Exist as a National
Public Health Intervention
Connect Americans to Affordable
Coverage.
The health insurance Exchanges—which were to
be created for each and every state—are one element
of the ACA’s national health care reform strategy.
The Petitioners’ position that seeks to deny Premium
Tax Credits to an otherwise eligible taxpayer based
on her state of residence contravenes this national
approach.
http://www.scholarsstrategynetwork.org/content/why-
congressional-budget-office-reports-are-best-evidence-
congressional-intent-about-health-.
that:
Id.
|t}hroughout hard-fought debates about health reform,
lawmakers in both parties looked for ways to save
taxpayer money. Partial subsidies would have greatly
reduced costs, so the total absence of this kind of
analysis among the 68 [estimates, reports, and
responses) prepared by CBO for the 11ith Congress
(and its continuing absence in reports done for the next
Congress) is the best objective evidence we have that
no one in Congress considered premium subsidies
restricted to certain states to be either possible or
desirable. If Congress intended to threaten states with
withheld subsidies, nobody said so.
Professor Skocpol noted
24
Rather, to bring about national health care
reform under the ACA, Congress designed the FFE
to serve as an operational fallback to accomplish
what a state either could not or would not do—
operate an Exchange for its citizens. Irrespective of
the entity running the Exchange machinery,
hawever, Congress intended the ACA to transform
the national market for health insurance.
The ACA’s market reforms, designed to ensure
access to coverage regardless of health status (e.z.,
guaranteed insurance coverage regardless of
preexisting conditions), apply in all states, thereby
restructuring the health insurance market on a
national scale. Furthermore, Congress preserved
(albeit in regulated form) the health insurance
market outside the Exchange structure, thereby
ensuring that any individual who wished to
discharge the personal responsibility obligation by
purchasing coverage on the open market could do so.
ACA § 1312(d), codified at 42 U.S.C. § 18032(d)
(2011) (expressly preserving the operation of the
private insurance market outside the Exchanges).
The Exchanges added a unique feature that is
essential to maintaining a reformed insurance
market in all states, by extending financial
assistance to individuals who need subsidies in order
to secure coverage.
Viewed in this light, the Exchanges exist as a
national structure designed to ensure affordable
coverage in all states—including the FFE fallback
system for states that either could not or would not
establish their own Exchanges. Petitioners’ position
would punish residents of states that refuse to
25
establish an Exchange for political reasons, as well
as residents of states that ardently desire to operate
their own Exchange yet must depend on the FFE
because they lack the resources to operate their own
system. This is an absurd result contrary to the
ACA’s text, structure, and purpose. Given the
myriad technical issues that have arisen as the
states have attempted to constr ct and
operationalize the web-based platform necessary to
implement the ACA-mandated Exchanges, to argue
that Congress meant to place entire populations at
heightened health risk simply because their states
rely on the FFE is legally and factually untenable.
Accepting Petitioners’ reading of the ACA would
thwart its overriding stated goal.
D. Congress Recognized the
Correlation Between Insurance
Coverage and Population Health
and the ACA Was Structured to
Achieve a Nationwide, Positive
Health Impact.
Studies published subsequent to ACA enactment
have borne out the wisdom of Congress’ decision to
improve access to health care and population health
through insurance reform. In this regard, two
seminal studies are instructive. The first examined
the impact on adult mortality of Massachusetts’
2006 health reform law, which is widely regarded as
the prototype for the ACA.*3 That study found that
33 Benjamin D. Sommers, MD, PhD; Sharon K. Long, PhD; and
Katherine Baicker, PhD, Changes in Mortality after
Massachusetts Health Care Reform: A Quasi-experimental
(continued...)
26
adults in Massachusetts experienced a 2.9% drop in
mortality in the wake of health reform compared to
individuals in other’ states with similar
socioeconomic characteristics. The most dramatic
results were seen in Massachusetts counties with
the lowest incomes and the highest rates of
uninsured adults. The authors concluded that such
results could be attributed to significant gains in
health insurance coverage and access to health care
for conditions such as diabetes or cardiovascular
disease that threaten life and health but are
amenable to treatment.
The second study was nationwide and directly
examined the effects of the ACA’s first open
enrollment period on health insurance coverage and
access to health care. This study found more than a
five percentage point drop in the uninsured rate
among U.S. adults between fall 2013 and April
2014.54 The drop in the proportion of uninsured
Americans coincided with the 2013-2014 open
enrollment period, meaning that the first open
enrollment period under the new law is associated
with a 25% decline in the proportion of nonelderly
Americans who are uninsured. The sub-populations
at highest risk for being uninsured saw the most
significant gains and people with incomes within the
premium subsidy eligibility range saw significantly
Study, ANN. INTERN. MED., May 2014, at 585,
http://annals.org/article.aspx?articleid=1867050.
4 Benjamin D. Sommers, M.D., Ph.D., et al., Health Reform
and Changes in Health Insurance Coverage in 2014, NEW ENG.
J. MED., Aug. 28, 2014, at 867, 871,
http://www.nejm.org/doi/full/10.1056/NEJMsr1406753.
27
greater rates of coverage in all states. Expanded
insurance coverage resulted in _ significant,
measurable gains in access to care and a significant
decline in the proportion of adults who reported
being unable to afford medical care.*5
E. Eliminating the Premium Tax
Credits and Thus Diminishing the
Affordability and Likelihood of
Insurance in the Very States Whose
Residents Most Need Coverage
Would Eviscerate the ACA’s Public
Health Goals.
Congress envisioned that all Americans in need
of assistance in order to make coverage affordable
would receive it, thus benefiting the entire nation.
The coverage mandate, applicable to all states—not
just those with a SBE—is a central pillar of the
legislative framework for ensuring near-universal
access to affordable coverage. Since Congress saw
creation of a robust yet affordable health insurance
marketplace as the key to achieving this level of
coverage, it logically previded for federal subsidies in
both types of Exchange—state and federa]l—in order
to ensure affordability for residents of all states.
As described above, the FFE states, as a group,
are poorer and have markedly worse population
health status than the SBE states. This is especially
true for minority populations in these states. They
are also, for the most part, the same states that have
eschewed federally-funded expansion of their
36 Jd. at 870.
28
Medicaid programs. They ace the very states whose
populations most need access to affordable health
insurance, but who would be the least likely to
achieve it in the absence of Premium Tax Credits.
The ACA’s overriding statutory purpose is
clear—to expand access to health insurance.
Interpreting a provision of the law in a manner that
would essentially eliminate access to affordable
health insurance for low income residents of two-
thirds of the states—that happen to be those very
states where residents are poorer and have worse
health—would be contrary to the ACA’s most
fundamental population health improvement aims.
F. This Court Should Affirm the
Fourth Circuit’s Decision in Order
to Avoid Conflicts with the Text of
the ACA That Would Unnecessarily
Lead to Devastating Population
Health Impact, Including
Increasing the Uninsured
Population by 8.2 Million People
and Costing Thousands of Lives
Annually.
As noted earlier in this brief, previous research
has documented the public health implications of
Massachusetts’ health reform law, which expanded
coverage using a health insurance marketplace and
subsidies that closely resemble the scheme under the
ACA.%6 Researchers found that, in the first four
years of the law in Massachusetts, for every 830
3% See supra n.33 and accompanying text.
29
adults gaining insurance coverage there was one
fewer death per year.*? Using the national estimate
that 8.2 million people can be expected to lose health
insurance in the absence of subsidies on the federal
marketplace, this ratio equates to over 9,800
additional Americans dying each year. Although the
specific policy context and population impacts of any
policy cannot be directly extrapolated from one
setting to another, the general magnitude and power
of these findings from the Massachusetts study
demonstrate that even when approached cautiously,
these earlier findings carry enormous public health
implications for withdrawing subsidies and coverage
from millions of Americans.
Petitioners’ interpret the Premium Tax Credit
provision of the ACA in a manner that produces
absurd results, such as the elimination of health
insurance coverage for those that need it most. Cf.
Kloeckner v. Solis, 133 S. Ct. 596, 606—07 (2012). A
statute’s nominal plain language must give way if it
would conflict with Congress’ manifest purposes or
lead to absurd results. “This Court, in interpreting
the words of a statute, has some scope for adopting a
restricted rather than a literal or usual meaning of
its words where acceptance of that meaning would
lead to absurd results or would thwart the
obvious purpose of the statute ..” In Re Trans
Alaska Pipeline Rate Cases, 436 U.S. 631, 643 (1978)
(quoting Comm’ v. Brown, 380 U.S. 563, 571 (1965)
(internal quotations omitted); see also United States
uv. Kirby, 74 U.S. 482, 486-87 (1868) (“All laws
-_~-
37 Id.
30
should receive a sensible construction . . . [and] [t]he
reason of the law in such cases should prevail over
its letter”).
In this case, Premium Tax Credits represent a
critical element of the ACA to ensure that lower
income Americans across the nation can afford
insurance coverage. If two-thirds of otherwise
eligible Americans lose their Premium Tax Credit
simply because of their state residence, the goals of
the ACA—to improve the public health and bring
about near-universal coverage—will be thwarted.
CONCLUSION
For the reasons set forth above and in the brief
of the Respondent, Amici Curiae Public Health
Deans, Chairs, and Faculty and the APHA urge the
Court to affirm the decision of the Fourth Circuit.
Respectfully submitted,
H. Guy COLLIER MCDERMOTT WILL &
Counsel of Record EMERY LLP
ANKUR J. GOEL The McDermott Building
CATHY Z. SCHEINESON 500 North Capitol St. NW
AMANDEEP S. SIDHU Washington, D.C. 20001
THOMAS J. TYNAN (202) 756-8000
LAUREN A.
D’ AGOSTINO
Counsel for Amici Curiae
January 28, 2015
A-1
APPENDIX A:
LIST AND AFFILIATIONS OF AMICI CURIAE
PUBLIC HEALTH DEANS, CHAIRS, AND
FACULTY
DEANS
Craig H. Blakely, Ph.D., M.P.H
Professor and Dean
School of Public Health and Information Sciences
University of Louisville
Paul Brandt-Rauf, DrPH, M.D., Sc.D.
Professor and Dean
School of Public Health
Environmental & Occupational Health Sciences
University of Illinois at Chicago
Paul D. Cleary, Ph.D.
Dean
Anna M.R. Lauder Professor of Public Health
Yale School of Public Health
Ayman E]-Mohandes, M.D., M.P.H.
Dean
CUNY School of Public Health
Gregory Evans, Ph.D., M.P.H.
Dean
Jiann-Ping Hsu College of Public Health
Georgia Southern University
A-2
John R. Finnegan, Jr., Ph.D.
Professor and Dean
University of Minnesota School of Public Health
Assistant Vice President for Public Health at the
University of Minnesota
Sandro Galea, M.D., DrPH
Professor and Dean
School of Public Health
Boston University
Lynn R. Goldman, M.D., M.S., M.P.H.
Michael and Lori Milken Dean
Professor of Environmental and Occupational Health
Milken Institute School of Public Health
The George Washington University
Jody Heymann, M.D., Ph.D.
Dean
UCLA Fielding School of Public Health
Michael J. Klag, M.D., M.P.H.
Dean
Johns Hopkins Bloomberg School of Public Health
Richard S. Kurz, Ph.D.
Professor and Dean
UNTHSC School of Public Health
Philip C. Nasca, M.S., Ph.D., FACE
Dean, School of Public Health
Professor of Epidemiology
University at Albany
A-3
Michael G. Perri, Ph.D., ABPP
Dean, College of Public Health and Health
Professions
The Robert G. Frank Endowed Professor of Clinical
and Health Psychology
University of Florida
Martin A. Philbert, Ph.D.
Dean and Professor
School of Public Health
University of Michigan
George G. Rhoads, M.D., M.P.H.
Interim Dean
Rutgers School of Public Health
Barbara K. Rimer, DrPH
Dean
Alumni Distinguished Professor
UNC Gillings School of Global Public Health
Joshua M. Sharfstein, M.D.
Associate Dean for Public Health Practice and
Training
Johns Hopkins Bloomberg School of Public Health
Laura A. Siminoff, Ph.D.
Dean and Laura H. Carnell Professor of Public
Health
College of Public Health
Temple University
A-4
Edwin Trevathan, M.D., M.P.H.
Dean, College for Public Health and Social Justice
Professor of Epidemiology, Pediatrics, and Neurology
Saint Louis University
CHAIRS
Robert W. Blum, M.D.
William H. Gates Sr. Chair
Department of Population, Family & Reproductive
Health
Johns Hopkins Bloomberg School of Public Health
Gregory L. Burke, M.D., M.Sc.
Professor and Director
Division of Public Health Sciences
Wake Forest School of Medicine
Doug Easterling, Ph.D.
Professor and Chair
Department of Social Sciences and Health Policy
Wake Forest Schoo] of Medicine
Kyle L. Grazier, DrPH, M.S., M.P.H.
Chair, Department of Health Management and
Policy
Richard Carl Jelinek Professor of Health Systems
Management
School of Public Health
University of Michigan
A-5
Paula Lantz, Ph.D.
Chair, Department of Health Policy and
Management
Milken Institute School of Public Health
The George Washington University
Aviva Must, Ph.D.
Professor and Chair, Department of Public Health &
Community Medicine
Dean, Public Health & Professional Degree
Programs
Tufts University School of Medicine
Oladele A. Ogunseitan, Ph.D, M.P.H.
Professor of Public Health
Professor of Social Ecology
Chair, Department of Population Health & Disease
Prevention
Director of Research Education, Training and Career
Development
Institute for Clinical and Translational Science
University of California, Irvine
Melissa J. Perry, Sc.D, M.H.S.,
Fellow of the American College of Epidemiology
Professor and Chair of Environmental and
Occupational Health, and
Professor of Epidemiology
Milken Institute School of Public Health
Professor of Biochemistry and Molecular Biology
School of Medicine and Health Sciences
The George Washington University
A-6
David Rosenbloom, Ph.D.
Interim Chair
Department of Health Policy and Management
School of Public Health
Boston University
Laura Rudkin, Ph.D.
Professor and Chair
Centennial Chair in Preventive Medicine &
Community Health
The University of Texas Medical Branch
José Szapocznik, Ph.D.
Professor & Chair, Department of Public Health
Sciences
Professor of Architecture, Psychology, and
Counseling Psychology & Educational Research
Director, Miami Clinical & Translational] Science
Institute
University of Miami Miller School of Medicine
James M. Tielsch, Ph.D.
Professor and Chair
Department of Global Health
Milken Institute School of Public Health
The George Washington University
Heather A. Young, Ph.D., M.P.H.
Associate Professor/Associate Chair
MPH Epidemiology Co-Director
Dept. of Epidemiology & Biostatistics
Milken Institute School of Public Health
The George Washington University
A-7
PROFESSORS
Heidi L. Allen, Ph.D.
Assistant Professor
Columbia University School of Social Work
Nancy E. Avis, Ph.D.
Professor of Public Health Sciences
Wake Forest School of Medicine
Taylor L. Burke, J.D., L.L.M.
Associate Professor of Health Policy and
Management
Milken Institute School of Public Health
The George Washington University
Lara Cartwright-Smith, J.D., M.P.H.
Associate Research Professor, Health Policy and
Management
Milken Institute School of Public Health
The George Washington University
Alan B. Cohen, Sc.D.
Professor of Health Policy and Management
Boston University School of Management
José F. Cordero, M.D., M.P.H.
Professor, Human Development
Graduate School of Public Health
Medical Sciences Campus
University of Puerto Rico
A-8
Marisa Elena Domino, Ph.D.
Professor
Department of Health Policy and Management
The Gillings School of Global Public Health
Director of the Program on Mental Health and
Substance Abuse Systems and Services Research,
Cecil G. Sheps Center for Health Services Research
Training Program Director for the UNC-Duke
Training Program in Mental Health Systems &
Services
The University of North Carolina at Chapel Hill
Mark A. Espeland, Ph.D.
Professor of Public Health Sciences
Wake Forest School of Medicine
Capri G. Foy, Ph.D., M.S.
Assistant Professor
Division of Public Health Sciences
Department of Social Sciences and Health Policy
Wake Forest School of Medicine
Leonard H. Friedman, Ph.D., M.P.H., FACHE
Professor
Milken Institute School of Public Health
The George Washington University
Brant E. Fries, Ph.D.
Professor, Health Management and Policy, School of
Public Health and
Research Professor, Geriatrics Center, School of
Medicine, University of Michigan and
Chief, Health Systems Research, Ann Arbor VA
Geriatric Research, Education, and Clinical Center
A-9
H. Jack Geiger, M.D., MS Sci. Hyg.
Arthur C. Logan Professor of Community Medicine
City University of New York
Sabina Gesell, Ph.D.
Assistant Professor of Public Health Sciences
Wake Forest School of Medicine
Debora Goetz Goldberg, Ph.D., M.B.A., M.H.A.
Assistant Research Professor of Health Policy and
Management
Center for Healthcare Quality
Milken Institute School of Public Health
The George Washington University
Jay Graham, Ph.D.
Assistant Professor
Director of the MPH in Global Environmental
Health
Milken Institute School of Public Health
The George Washington University
John A. Graves, Ph.D.
Assistant Professor
Vanderbilt University School of Medicine
Department of Health Policy
Institute for Medicine and Public Health
Sandra B. Greene, DrPH
Professor of the Practice and Interim Chair
Health Policy and Management
Gillings School of Global Public Health
The University of North Carolina at Chapel Hill
A-10
Scott L. Greer, Ph.D.
Associate Professor, Health Management and Policy
University of Michigan School of Public Health
Peter Jacobson, J.D., M.P.H.
Professor of Health Law and Policy
Director, Center for Law, Ethics, and Healt!:
University of Michigan School of Public Health
Holly Jarman
Assistant Professor
Center for Law, Ethics & Health /
Department of Health Management & Policy
University of Michigan School of Public Health
David Kindig, M.D., Ph.D.
Emeritus Professor of Population Health Sciences
University of Wisconsin School of Medicine and
Public Health
Nancy M. P. King, J.D.
Professor and Co-Director, Center for Bioethics,
Health, & Society
Wake Forest University
Leighton Ku, Ph.D., M.P.H.
Professor of Health Policy and Management
Milken Institute School of Public Health
The George Washington University
Michael S. Lawlor
Professor of Economics and Public Health
Wake Forest University
A-11
David J. Lee, Ph.D.
Professor
Project Director/PI, Florida Cancer Data System
Sylvester Comprehensive Cancer Center
Director of Graduate Programs
Department of Public Health Sciences
University of Miami Miller School of Medicine
Shoou-Yih D. Lee, M.S., Ph.D.
Professor
Department of Health Management and Policy
The University of Michigan School of Public Health
Jeffrey Levi, Ph.D.
Professor of Health Policy and Management
Executive Director, Trust for America’s Health
Milken Institute School of Public Health
The George Washington University
Suhui Li, Ph.D.
Assistant Professor, Health Policy and Management
Milken Institute School of Public Health
The George Washington University
Jay Maddock, Ph.D.
Professor & Director
Office of Public Health Studies
University of Hawaii at Manoa
A-12
Manya Magnus, Ph.D., M.P.H.
Associate Professor, Epidemiology and Biostatistics
Co-Director, MPH Program in Epidemiology
Milken Institute School of Public Health
The George Washington University
Mary-Beth Malcarney, J.D., M.P.H.
Assistant Research Professor, Health Policy and
Management
Milken Institute School of Public Health
The George Washington University
Wendy K. Mariner
Edward R. Utley Professor of Health Law
School of Public Health
Professor of Law
School of Law
Boston University
Anne Rossier Markus, J.D., Ph.D., M.H.S.
Associate Professor, Health Policy and Management
Milken Institute School of Public Health
The George Washington University
Stephen A. McCurdy, M.D., M.P.H.
Professor and Director
UCD Master of Public Health Program
Division of Environmental and Occupational Health
Department of Public Health Sciences
University of California Davis School of Medicine
A-13
Melissa McCarthy, Sc.D.
Associate Professor, Departments of Health Policy
Management & Emergency Medicine
Milken Institute School of Public Health and the
School of Medicine and Health Sciences
The George Washington University
Dr. John E McDonough, DrPH, M.P.A., Professor
Director, Executive & Continuing Professional
Education
Harvard School of Public Health
Phyllis D. Meadows, Ph.D., M.S.N., R.N.
Associate Dean for Practice
Clinical Professor, Health Management and Policy
University of Michigan School of Public Health
Michelle M. Mello, J.D., Ph.D.
Professor of Law, Stanford Law School
Professor of Health Research and Policy, Stanford
University School of Medicine
Alan C. Monheit, Ph.D.
Professor of Health Economics
Associate Dean for Academic and Faculty Affairs
Rutgers University School of Public Health
Cheryl B. Oakman, Ph.D., LSW, ACSW
Assistant Professor
School of Social Work
College of Public Mealth
Temple University
A-14
Janet A. Phoenix, M.D., M.P.H.
Assistant Research Professor, Health Policy and
Management
Milken Institute School of Public Health
The George Washington University
Patricia Pittman, Ph.D.
Associate Professor, Department, of Health Policy
and Management
Milken Institute School of Public Health
The George Washington University
Marsha Regenstein, Ph.D.
Professor, Health Policy and Management
Milken Institute School of Public Health
The George Washington University
Thomas C Ricketts, Ph.D., M.P.H.
Professor of Health Policy and Management
UNC Gillings School of Global Public Health
Deputy Director
Cecil G. Sheps Center for Health Services Research
The University of North Carolina at Chapel Hill
Richard Riegelman, M.D., M.P.H., Ph.D.
Professor and Founding Dean
Milken Institute School of Public Health
The George Y’ashington University
Elizabeth Rigby, Ph.D.
Associate Professor
Trachtenberg School of Public Policy
The George Washington University
A-15
Kim Robien, Ph.D., RD, CSO, FAND
Associate Professor
Department of Exercise and Nutrition Sciences
Department of Epidemiology and Biostatistics
Milken Institute School of Public Health
The George Washington University
Carlos Jose Rodriguez, M.D., M.P.H., FACC,
FAHA
Associate Professor of Epidemiology and Medicine
(Cardiology)
Associate Director of Research, Maya Angelou
Center for Health Equity
Wake Forest School of Medicine
Sara Rosenbaum, J.D.
Harold and Jane Hirsh Professor of Health Law and
Policy
Milken Institute School of Public Health
The George Washington University
Brendan Saloner
Assistant Professor
Department of Health Policy & Management
Johns Hopkins School of Public Health
John Sandberg
Associate Professor, Global Health
Milken Institute School of Public Health
The George Washington University
Mark Schlesinger
Professor of Health Policy
Yale University School of Public Health
A-16
Lisa Benz Scott, Ph.D.
Director, Program in Public Health
Associate Professor, Health Technology &
Management; Preventive Medicine; Dental Medicine
Stony Brook University Health Sciences Center
Naomi Seiler, J.D.
Associate Research Professor, Health Policy and
Management
Milken Institute School of Public Health
The George Washington University
Peter Shin, Ph.D., M.P.H.
Associate Professor, Health Policy and Management
Director of Geiger Gibson/RCHN Community Health
Milken Institute School of Public Health
The George Washington University
Pam Silberman, J.D., DrPH
Professor of the Practice
Department of Health Policy and Management
UNC Gillings School of Global Public Health
Sam Simmens, Ph.D.
Research Professor of Epidemiology and Biostatistics
Director
Biostatistics and Epidemiology Consulting Service
(BECS)
Milken Institute School of Public Health
The George Washington University
A-17
Sean L. Simpson, Ph.D.
Assistant Professor
Department of Biostatistical Sciences
Division of Public Health Sciences
Wake Forest School of Medicine
Sally A. Shumaker, Ph.D.
Professor
Department of Social Sciences & Health Policy
Division of Public Health Sciences
Wake Forest School of Medicine
Benjamin Sommers, M.D., Ph.D.
Assistant Professor of Health Policy and Economics
Harvard School of Public Health
Health Policy and Management
Eliot Sorel, M.D., DLFAPA
Professor
School of Medicine Health Sciences
Milken Institute School of Public Health
The George Washington University
Freya Spielberg, M.D., M.P.H.
Director of Community Oriented Primary Care
Associate Professor, Prevention and Community
Health
Milken Institute School of Public Health
The George Washington University
Katherine Swartz, Ph.D.
Professor of Health Economics and Policy
Department of Health Policy and Management
Harvard School of Public Health
A-18
Joel Teitelbaum, J.D., LL.M.
Associate Professor, Health Policy and Management
Milken Institute School of Public Health
The George Washington University
Harsha Thirumurthy, Ph.D.
Assistant Professor of Health Economics
Department of Health Policy and Management
Gillings School of Global Public Health
Faculty Fellow, Carolina Population Center
University of North Carolina at Chapel Hill
Jane Hyatt Thorpe, J.D.
Associate Professor of Health Policy and
Management
Milken Institute School of Public Health
The George Washington University
Elanah Uretsky, Ph.D.
Assistant Professor, Global Health and Anthropology
Milken Institute School of Public Health and the
Elliot School of Internationa! Affairs
The George Washington University
Susan F. Wood, Ph.D.
Associate Professor of Health Policy and
Management and Environmental & Occupational]
Health
GW Milken Institute School of Public Health
The George Washington University
Mark Wolfson, Ph.D.
Professor
Department of Social Sciences and Health Policy
Division of Public Health Sciences
A-19
Wake Forest School of Medicine
Brad Wright, Ph.D.
Assistant Professor
Department of Health Management & Policy
College of Public Health
University of Iowa
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APPENDIX B: DATA TABLES
Table 1: Number and Characteristics of
Nonelderly' Residents of Federally-Facilitated
Exchange vs. State-Based Exchange? States in
20133
“Federal” Inchodes Portmarship State But a
Txriedes Original Stxte Based Strtes
State Based FedernBy Facilitated |
Pepelstice Criteria | Exchange States Exchange States _| Total Unieed States |
Number of States, i
ing D.C 17 | 34 51
Total noweldexty |
om (milons) | 932 Ei oat. Late lt
People with incomes |
below 100% of
poverty (millions) 150 i 29? | a7
% of people below
10M cfpovery | 61% | 17.3% me Gee
People with mcomes
between 100%. |
400% of poverty |
_{millions) - | ae SE re USP Beek
' Universe consists of the civilian non-institutionalized
population for whom poverty status is determined.
2 Includes states that have elected to establish a state
Exchange, but are using the federal IT platform.
* Based on analyses of the U.S. CENSUS BUREAU, 2013
American Community Survey,
http://factfinder2.census.gov/faces/nav/jsf/pages/searchresults.x
html?refresh=t.
A-21
Table 2: Estimated Number of People
Receiving Federal Premium Tax Credits,
Average Monthly Value of Tax Credits, and
Annual Value of Tax Credits in Federally-
Facilitated Exchange States as of April 20144.5.6
Estimated
Estimated Sie Annual
Number of | Percentof | Monthly | Vatue of
Federally- People Exchange c = A Tax
Facilitated Receiving Enrollees Value Credits
Exchange Tax Credits Receiving (S/person) (million
| _ State (1000s) Tax Credits ” 3)"
TOTAL,
FFE States 4,685.8 87% $264 $14,821
Alabama 83.2 85% $258 $258
Alaska 11.3 88% $413 $56
Arizona 92.5 76% $159 $176
Arkansas 39.1 89% $293 $137
Delaware 11.4 81% $263 $36
Florida 895.2 91% $278 $2,987
Georgia 275.4 87% $287 $948
Idaho 70.0 91% $207 $174
Illinois 167.5 76% $202 $406
Indiana 117.9 89% $336 $475
4 Based on April 2014 data as reported in Amy Burke, Arpit
Misra, and Steven Sheingold, Premium Affordability,
Competition, and Choice in the Health Insurance Marketplace,
2014, Office of the Assistant Secretary for Planning and
Evaluation (ASPE), HHS, June 18, 2014,
http://aspe.hhs.gov/health/reports/2014/Premiums/2014MktPla
cePremBrf.Pdf.
5 Universe consists of the civilian non-institutionalized
population for whom poverty status is determined.
6 Includes Idaho and New Mexico, which as of the date of the
ASPE study, had elected to establish a SBE but used the
federal IT platform.
7 Estimated annual value is the product of the number of tax
credit recipients times the average value times 12 months.
A-22
Estimated
Estimated Average | Anoual
Number of | Percent of “— thly | Value of
Federally- People Exchange C vane Tax
Facilitated Recetving Enrollees Value Credits
Exchange Tax Credits Receiving ) (million
State (1000s) | Tax Credits (perso: $)’
lowa 24.5 83% $242 $71
Kansas 45.0 78% $223 $121
Louisiana 89.6 88% $314 $337
Maine 39.8 a9% $344 $164
Michigan 237.1 87% $246 $700
Mississippi 67.8 94% $415 $288
Missouri 129.5 85% $286 $444
Montana 31.5 R5% $246 $93
Nebraska 37.4 87% $214 $96
New
Hampshire 31.0 76% $290 $108
New Jersey | 135.9 44% $317 $517
New Mexico 25.3 78% $214 $65
North
Carolina 325.4 91% $300 $1,171
North
Dakota 9.0 84% $218 $24
Ohio 131.5 84% $250 $394
Oklahoma 64.7 79% $202 $133
Pennsylvania 257.6 81% $246 $761
South
Carolina 104.1 87% $283 $354
South
Dakota 11.8 89% $271 $38
Tennessee 121.1 78% $195 $283
Texas 616.4 R4% $233 $1,723
Utah 73.6 86% $159 $140
| Virginia 177.4 82% $254 $541
West
| Virginia 17.1 85% $302 $62
Weconsin 127.2 90% $316 $482
Wyoming 11.1 93% i $422 $56
A-23
Table 3: Health Insurance Coverage by Age in
34 States Electing Not to Establish a
State-Based Exchange®9
=
|
Residents of Federaity |
Faciiitated Exchange States | Total United States |
Total Unmsured Population
' SE ee __ ws 5 + as | ae
Millions of uninsured adults, |
18-44 years (2013) ak 179 26.7 4
Millions of uninsured adults, |
45-64 years (2013) C bettille 2. a Sead |
% of people uninsured, all
a San _1S.1% 14.5%
® Universe consists of the civilian non-institutionalized
population for whom poverty status is determined.
® These items are based on analyses of the ACA. See id.
A-24
Table 4: Economic and Health Insurance
Status of Minority Populations: States Electing
State-Based Exchanges versus States Electing
Not to Establish a State-Based Exchange
Residents of
State-Based
Exchange
States
Non-Hispanic
African-Americans
Residents of
Federally-
Facilitated
States
Millions of Non-
Hispanic African-
Americans between
100%-400% of
poverty (2013) '*
4.0
15.0
19.0
% of Non-Hispanic
Afncan- Americans
who are between
100%-400% of
poverty (2013)
46.4%
51.5%
50.3%
Millions of
Uninsured Non-
Hispanic African-
Americans between
100%-400% of
poverty (2013)
0.5
2.6
3.1
% of Non-Hispanic
African- Americans
between 100%-400%
of poverty who are
uninsured (2013) _
12.7%
l 7.6%
16.6%
10 See Census Bureau’s March 2014 Current Population Survey
(“CPS”) (indicating income and health insurance status in
2013). The data was tabulated using the U.S. CENSUS BUREAU,
Current Population Survey (2014),
http://www.census.gov/cps/data/cpstablecreator html.
CPS Table
Creator,
A-25
Residents of | Residents of
State-Based Federally- Total
Exchange Facilitated United
States States States
Hispanics
Millions of Hispanics
between 100%-400%
of poverty (2013) 13.4 18.4 31.7
% of Hispanics who
are between 100%-
400% of poverty
(2013) 59.1% 58.3% 58.6%
Millions of
Uninsured Hispanics
between 100%-400%
of poverty (2013) 2.9 5.3 8.2
% of Hispanics
between 100%-400%
of poverty who are
uninsured (2013) 21.5% 29.1% 25.9% |
A-26
Table 5: Key Health Indicators for Residents
in States with State-Based Exchanges (SBEs)
and Federally-Facilitated Exchanges (FFEs,
including Partnership States)
Average Average
| Health Indicator Level for Level for
Residents of | Residents of
17 SBE 34 FFE
States States
| Mortality Rates
1. psoas ARON rate of 236.8 258.6
I
cardiovascular deaths
(e.g., heart attacks,
j
strokes, etc.) per 100,000 |
residents, 2010-12 [1]
cancer deaths per
190,000 residents, 2010-
12 [1]
Infant mortality rate per
,000 live births, 2011-12
[2] ;
! Access to Realth Services ~~
4.
}-—
Percent of adults who
Cr re +4
on
tN
needed to see a doctor in |
the past year but could
not, due to cost, 2013 [3]
ereent oftesidents” ~~
living in medically
underserved areas, 2010
[4]
Percent of women (40-64
years) who had a
mammogram in the past
year, 2012 [5]
and state public health
expenditures per
resident, 2011-2012 [6]
7.” Average annual federal —
_ Health Status , Conditions ;}and
Behaviors
8. Petcehtaladults who
report they are in
excellent or very good
'
'
58.6%
“T
A
—
o'
Ca:
‘
as % tae ie bO6R-~
SO seen wate | ey
A-27
Average Average
Health Indicator Level for Level for
Residents of | Residents of
17 SBE 34 FFE
States States
health (as oppoeed to
good, fair or poor
health), 2013 [3}
9% Percent of adults who 9.7% | 10.5%
| have been diagnosed | |
| with diabetes, 2013 [3] |
"10 Percent of adulta who” | ~ 36.7% 33.4%
have been told they have |
| high blood pressure, |
| 2013 [3] |
||. Percent of adults who 17.1%. 18.1% |
have been told they have |
depression, 2013 |3) |
~~ 13 Bercent of adults wks mm 8 — 16.1% | 19.3%
13
currently smoke, 2013 [3] |
Percent of adults who 25.8% | 29.7"
are obese (body mass | |
index of 30 or higher, a
measure of weight
relative to height), 2013
= =
Sources:
1.
State-level multi-cause mortality data from the
National Center for Health Statistics, Centers for
Disease Control and Prevention, weighted to account
for the number of state residents. America’s Health
Rankings, United Health Foundation (drawn from
http://www.americashealthrankings.org/, accessed Dec.
11, 2014)
State-level infant mortality data from the National
Center for Health Statistics, Center for Disease Contro!
and Prevention, weighted to account for the number of
live births in each state. America’s Health Rankings,
United Health Foundation (drawn from
http://www.americashealthrankings.org/, accessed Dec.
11, 2014)
A-28
Data reported by the Center for Disease Control and
Prevention’s Behavioral Risk Factor Surveillance
Survey, 2013, weighted to account for the number of
adults (18 or older) in each state. Prevalence and
Trends Data, Office of Surveillance, Epidemiology, and
Laboratory Services, Behavioral Risk Factor
Surveillance System, (drawn from
https://apps.nced.cdc.gov/brfss/, accessed Dec. 10, 2014)
Based on data reported by the National Women’s Law
Center, using criteria defined by the Health Resources
and Services Administration. People in Medically
Underserved Areas (%), National Women’s Law Center,
http://hre.nwlc.org/status-indicators/people-medically-
underserved-areas (last updated June 7, 2010),
weighted to account for the number of state residents.
Based on data reported by the American Cancer
Society, weighted to account for the number of 40-64
year old women in each state. Cancer Prevention &
Early Detection Facts & Figures, Tables and Figures
2014, American Cancer Society, 2014,
http://www.cancer.org/acs/groups/content/@research/doc
uments/document/acspc-042924 pdf, accessed Dec. 9,
2014.
Based on data reported by the Trust for America’s
Health, weighted to account for the number of residents
in each state. Investing in America’s Health: A State by
State Look at Public Health Funding and Key Health
Facts, Trust for America’s Health, Apr. 2013,
http://healthyamericans.org/assets/files/T FAH 201 3Invs
tgAmrcsH!th05%20FINAL.pdf, accessed Dec. 11, 2014.
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