{"edition":"usa","organization":"National Health Law Program","organizationId":"org:national-health-law-program","boundaryVersion":"USA-50-states-DC-v1","updated":"2026-09-14","model":{"version":"usa-nhelp-alpha-1","costScope":"Three years of all recipient programs/support at FY2025 audited resource cost including donated legal labor. One national implementation pathway quantified; other portfolio net health set zero, not a proven lower bound. Public treatment and wider social costs excluded.","geographicAttribution":"50-state/DC resident beneficiaries only; no headquarters share or California-only allocation. Immigration status does not exclude resident health. Territorial/foreign spillovers not counted.","formula":"A=sum(t=start..start+T−1)1/(1+discount)^t; V=N*r*u*A; H=V*q; Q_all=b*(p*a*H−h); Q_USA=g*Q_all; Cost=C*Y; Price10=10*Cost/Q_USA if positive. Central start=2,T=2. Local marginal rate assumes proportional capacity adjusted by b.","counterfactual":"Existing state litigation, other amici, public administrators, grants and clinical care continue. Only further work's change in strict versus less restrictive administration counts, not repeal or all losses. r removes forecast/remedy overreach, u removes replacement coverage, b removes financial substitution.","attribution":"p=.1 incremental coalition contribution, a=.1 NHeLP share and b=.25 funding additionality are separate subjective factors. Current amicus and strategy show a live role but identify none of them. Existing work receives no automatic future-donation credit.","uncertainty":"Weak-confidence best-estimate opinion, not measured return or statistical interval. Root may reject numeric acceptance if these judgments are insufficiently supported. Policy influence and funding additionality dominate; zero/harm explicitly retained.","nativeOutcomes":"Additional Medicaid enrollment, then genuinely additional insured person-years with effective access; finite QALY utility differences. Filings, fiscal transfers and legal wins are not health units.","inputs":[{"name":"C","value":13035827,"unit":"USD annual recipient resources","basis":"observed","rationale":"Full audited expense, all functions and recognized donated professional services; original review reused from CA worker.","sourceIds":["audit25"]},{"name":"Y","value":3,"unit":"funding years","basis":"judgment","rationale":"Three-year capacity cohort, not a priced brief; constant latest expense.","sourceIds":[]},{"name":"N","value":1900000,"unit":"annual Medicaid enrollment difference","basis":"observed","rationale":"Published forecast, not realized outcome: Figure 1 2028 8.6m−6.7m and 2029 8.8m−6.9m; visually verified rounded values. Point-in-year forecast treated as sustained for a full year; this is a temporal approximation, not an observed person-year integral.","sourceIds":["nhelp-manatt"]},{"name":"r","value":0.5,"unit":"realized/remediable share of forecast","basis":"judgment","rationale":"Half allows forecast error, narrower remedy and incomplete state implementation.","sourceIds":["nhelp-manatt","nhelp-amicus"]},{"name":"u","value":0.5,"unit":"share genuinely preventing uninsurance","basis":"judgment","rationale":"Half allows other public/private insurance and enrollment-accounting differences. Effective health among newly insured is separately q.","sourceIds":["oregon"]},{"name":"q","value":0.02,"unit":"QALYs per additional insured year","basis":"judgment","rationale":".02 transfer below Oregon's .05 self-rated mapping. No separate mortality, depression or financial benefit added. Assumes the utility improvement persists throughout each credited insured year.","sourceIds":["oregon"]},{"name":"p","value":0.1,"unit":"incremental coalition probability/intensity improvement","basis":"judgment","rationale":"Ten percentage points from further coalition work over three years beyond baseline public action; not overall litigation success probability.","sourceIds":["nhelp-prepare","nhelp-cms"]},{"name":"a","value":0.1,"unit":"NHeLP share of coalition effect","basis":"judgment","rationale":"Ten percent recognizes co-authorship and national expertise; 90% remains with states, other counsel and organizations. Not 1/71 arithmetic or filing credit.","sourceIds":["nhelp-amicus","cases"]},{"name":"b","value":0.25,"unit":"marginal capacity additionality","basis":"judgment","rationale":"Quarter allows grants, reserves and other donors; local linearity could fail and zero is possible.","sourceIds":["audit25","careers"]},{"name":"start","value":2,"unit":"first benefit year","basis":"judgment","rationale":"Year two approximately 2028, allowing preparation lag; no first-year credit.","sourceIds":[]},{"name":"T","value":2,"unit":"benefit years","basis":"judgment","rationale":"Two years approximately 2028–29 then paths reconverge; no perpetual entitlement credit.","sourceIds":[]},{"name":"discount","value":0.03,"unit":"annual discount fraction","basis":"judgment","rationale":"3% applied by health event year; no remaining-life multiplication.","sourceIds":[]},{"name":"g","value":1,"unit":"resident share of modeled population","basis":"judgment","rationale":"Population explicitly defined as resident beneficiaries in 50 states/DC; no foreign or territorial spillovers.","sourceIds":["nhelp-manatt"]},{"name":"h","value":0,"unit":"other net health harm before b","basis":"judgment","rationale":"Net zero for unpriced portfolio and public-resource displacement, not established zero; adverse sensitivities independent of p*a.","sourceIds":[]}],"scenarios":[{"id":"central","label":"Weak-confidence national implementation estimate","costUSD":39107481,"allPopulationQalys":44.12126725156421,"editionQalys":44.12126725156421,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0.02,\"p\":0.1,\"a\":0.1,\"b\":0.25,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":0}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=17648.50690062568."},{"id":"favorable","label":"Broader sustained effect","costUSD":39107481,"allPopulationQalys":7405.326138414443,"editionQalys":7405.326138414443,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":1,\"u\":0.8,\"q\":0.05,\"p\":0.3,\"a\":0.15,\"b\":0.6,\"start\":2,\"T\":4,\"discount\":0.03,\"g\":1,\"h\":0}; A=3.608833400786766; conditional discounted insured person-years=5485426.7691958845; conditional QALYs=274271.33845979423."},{"id":"poor","label":"Very weak influence and access","costUSD":39107481,"allPopulationQalys":0.0017909322273541334,"editionQalys":0.0017909322273541334,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.1,\"u\":0.2,\"q\":0.005,\"p\":0.02,\"a\":0.01,\"b\":0.05,\"start\":2,\"T\":1,\"discount\":0.03,\"g\":1,\"h\":0}; A=0.9425959091337544; conditional discounted insured person-years=35818.644547082666; conditional QALYs=179.09322273541332."},{"id":"health-mapping-high","label":"Use .05 health mapping","costUSD":39107481,"allPopulationQalys":110.30316812891056,"editionQalys":110.30316812891056,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0.05,\"p\":0.1,\"a\":0.1,\"b\":0.25,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":0}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=44121.26725156421."},{"id":"low-funding-additionality","label":"Only 5% additional capacity","costUSD":39107481,"allPopulationQalys":8.824253450312844,"editionQalys":8.824253450312844,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0.02,\"p\":0.1,\"a\":0.1,\"b\":0.05,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":0}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=17648.50690062568."},{"id":"no-policy-change","label":"No implementation change","costUSD":39107481,"allPopulationQalys":0,"editionQalys":0,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0.02,\"p\":0,\"a\":0.1,\"b\":0.25,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":0}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=17648.50690062568."},{"id":"no-health-change","label":"No additional health from coverage","costUSD":39107481,"allPopulationQalys":0,"editionQalys":0,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0,\"p\":0.1,\"a\":0.1,\"b\":0.25,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":0}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=0."},{"id":"no-capacity-change","label":"Only substitute existing financing","costUSD":39107481,"allPopulationQalys":0,"editionQalys":0,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0.02,\"p\":0.1,\"a\":0.1,\"b\":0,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":0}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=17648.50690062568."},{"id":"adverse","label":"No policy benefit plus 50 QALYs harm","costUSD":39107481,"allPopulationQalys":-12.5,"editionQalys":-12.5,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0.02,\"p\":0,\"a\":0.1,\"b\":0.25,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":50}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=17648.50690062568."},{"id":"other-harm","label":"200 QALYs other net harm","costUSD":39107481,"allPopulationQalys":-5.878732748435787,"editionQalys":-5.878732748435787,"assumptions":"{\"C\":13035827,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0.02,\"p\":0.1,\"a\":0.1,\"b\":0.25,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":200}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=17648.50690062568."},{"id":"double-cost","label":"Twofold future cost","costUSD":78214962,"allPopulationQalys":44.12126725156421,"editionQalys":44.12126725156421,"assumptions":"{\"C\":26071654,\"Y\":3,\"N\":1900000,\"r\":0.5,\"u\":0.5,\"q\":0.02,\"p\":0.1,\"a\":0.1,\"b\":0.25,\"start\":2,\"T\":2,\"discount\":0.03,\"g\":1,\"h\":0}; A=1.857737568486914; conditional discounted insured person-years=882425.3450312841; conditional QALYs=17648.50690062568."}],"sensitivity":["Conditional central H=17,648.51 QALYs; p*a=.01 and b=.25 reduce this to 44.12. Expected discounted attributable insured person-years are 2,206.06, not millions of observed recipients.","At other central inputs, p*a must exceed .088636 for $1 million per 10 USA QALYs, or .886364 for $100,000; central .01. These are requirements, not evidence of achievable influence.","Halving q or u doubles the price. A Medicaid enrollment forecast cannot replace genuinely additional insured person-years.","Other net harm above 176.485 QALYs over the three-year cohort erases central benefit before b; harm is not discounted by policy success probability.","The favorable four-year case is finite, not perpetual. Setting p, q or b to zero removes this pathway.","A social comparison needs public payer costs, uncompensated-care transfers, provider capacity and alternative government uses; recipient price does not include those.","If the point-in-year enrollment difference persists for only half of each modeled benefit year, health is halved and cost per 10 QALYs doubles. This temporal assumption is distinct from replacement coverage."],"missingInputs":["Costed unfunded implementation plan and staffing/output response given current grants and reserves.","Case/administrative outcomes with and without incremental NHeLP capacity, separate from states and other counsel.","Actual state implementation, remedy scope, duration, uptake and alternative coverage.","Current beneficiary utility, public treatment/opportunity costs and other portfolio health/harms."]},"sources":[{"id":"audit25","title":"2025 audited financial statements","publisher":"National Health Law Program","url":"https://healthlaw.org/wp-content/uploads/2026/03/20251231-National-Health-Law-Program-Inc.pdf","published":null,"retrieved":"2026-09-13"},{"id":"audit24","title":"2024 audited financial statements with 2023 comparative","publisher":"National Health Law Program","url":"https://healthlaw.org/wp-content/uploads/2025/03/National-Health-Law-Program-2024-Audit-Final.pdf","published":null,"retrieved":"2026-09-13"},{"id":"finance","title":"Current original financial-document index","publisher":"National Health Law Program","url":"https://healthlaw.org/financial-documents/","published":null,"retrieved":"2026-09-13"},{"id":"strategy","title":"Strategic framework 2023–2027","publisher":"National Health Law Program","url":"https://healthlaw.org/strategic-framework/","published":null,"retrieved":"2026-09-13"},{"id":"cases","title":"Current litigation portfolio","publisher":"National Health Law Program","url":"https://healthlaw.org/our-cases/","published":null,"retrieved":"2026-09-13"},{"id":"oregon","title":"The Value of Medicaid: Interpreting Results from the Oregon Health Insurance Experiment","publisher":"Finkelstein, Hendren and Luttmer, Journal of Political Economy","url":"https://pmc.ncbi.nlm.nih.gov/articles/PMC8081392/","published":null,"retrieved":"2026-09-13"},{"id":"careers","title":"Current job opportunities","publisher":"National Health Law Program","url":"https://healthlaw.org/careers/","published":null,"retrieved":"2026-09-13"},{"id":"donate","title":"Official donation route","publisher":"National Health Law Program","url":"https://healthlaw.org/?form=together","published":null,"retrieved":"2026-09-13"},{"id":"nhelp-prepare","title":"National Medicaid implementation strategy","publisher":"National Health Law Program","url":"https://healthlaw.org/prepare/","published":null,"retrieved":"2026-09-14"},{"id":"nhelp-amicus","title":"Medically-frail exemption amicus","publisher":"NHeLP and co-amici","url":"https://healthlaw.org/wp-content/uploads/2026/09/Mass.-v.-Oz.Amici-Brief-1.pdf","published":"2026-09-10","retrieved":"2026-09-14"},{"id":"nhelp-ifr-comments","title":"Work requirement IFR comments","publisher":"National Health Law Program","url":"https://healthlaw.org/wp-content/uploads/2026/08/7-31-26_NHeLP-Comments_FINAL.pdf","published":"2026-07-31","retrieved":"2026-09-14"},{"id":"nhelp-cms","title":"Nationwide Medicaid work requirement framework","publisher":"CMS","url":"https://www.cms.gov/newsroom/press-releases/cms-launches-nationwide-framework-implement-medicaid-work-requirements","published":"2026-06-01","retrieved":"2026-09-14"},{"id":"nhelp-manatt","title":"50-state additional coverage-loss model, Figure 1 and methodology","publisher":"Manatt Health / Boozang and colleagues","url":"https://assets-us-01.kc-usercontent.com/9fd8e81d-74db-00ef-d0b1-5d17c12fdda9/23b961e2-a654-4fd1-9358-1e3d42205358/Vital%20Signs%2050-State%20Tracking_CMS%20Medicaid%20Work%20Requirements%20Rule.pdf","published":"2026-07-16","retrieved":"2026-09-14"}]}