The changes in the proposed rule would force up to two million more Americans to lose their health insurance. “The proposed rules would make the situation worse, making people less healthy, driving up health care costs and medical debt, and pushing patients off of health insurance.” The proposal has multiple provisions that, if enacted, will raise health care costs for everyone, no matter the type of insurance. Under these plans, health insurance coverage does not begin until significant maximum out of pocket costs (MOOP) have already occurred. As the letter explains, taken together, these and other proposed changes could lead to a “death spiral” in health insurance markets.