This article originally appeared on The Conversation. You can read it here.

With an eye on replacing the Affordable Care Act, the Trump administration took one particularly critical action in October 2017. It discontinued cost-sharing reduction subsidy payments to health insurers participating in the ACA marketplaces.

But the response to those cuts was likely not what President Trump expected. State insurance commissioners and insurers used them to make marketplace health plans more affordable.

Premium decreases were large – so large that 4.2 million potential enrollees had the option to purchase a marketplace plan for free in 2019.

These changes made us wonder: Did President Trump’s effort to sabotage the Affordable Care Act backfire? I’m a health economist at the University of Pittsburgh. Along with my colleague David Anderson, a policy expert on the Affordable Care Act, we tried to answer that question shortly after the payment cuts. We discovered that more than 200,000 people, using the Healthcare.gov platform in 2019, gained insurance in 37 states due to the Trump administration’s actions. This finding may even be more important now as massive unemployment from the coronavirus pandemic leads to huge losses of employer-based insurance coverage – and ultimately more people enrolling in the marketplaces.


Subsidies and silver loading

People who sign up for a plan in the Health Insurance Marketplaces may qualify for two types of subsidies. The first type is the advanced premium tax credit, which reduces the premium paid by the enrollee; lower-income enrollees receive larger premium tax credits. The second type is the cost-sharing reduction subsidy, which decrease deductibles and co-pays.

Premium tax credits may be applied to any marketplace plan, though they’re based on silver plan premiums, which cover 70% of an average enrollee’s health care expenses. Cost-sharing reduction subsidies can only be applied to silver plans; that means qualifying enrollees in less generous bronze plans and more generous gold plans don’t benefit from reduced deductibles and co-pays provided by these subsidies.

When Trump ended those payments, marketplace insurers were suddenly in a bind. They are legally required to provide cost-sharing reduction subsidies to enrollees whether or not the federal government was paying. The expectation: marketplace insurers, forced to make up the lost revenue, would either increase premiums or exit the marketplaces altogether. And Obamacare would implode.

But that’s not what happened. Why did the plans become more affordable? Insurers increased only the premiums of their silver plans. That approach – known as silver loading – did two things. First, the cost of silver plan premiums rose drastically. Second, premium tax credits increased along with premiums. So those enrollees receiving premium tax credits saw no increase in the premiums of their silver plans.

At the same time, non-silver plans became cheaper. Many bronze plans, already costing less, became so cheap they were free after applying premium tax credit subsidies. Lower-income enrollees benefited the most.

The silver lining in silver loading

In 2019, 4.2 million enrollees could enter the marketplace for free through a zero-dollar bronze plan, largely due to silver loading. Without those zero-premium plans, our analysis showed more than 200,000 lower-income marketplace enrollees would have gone uninsured.

Another 60,000 would have gained insurance had California and New Jersey eliminated regulations that prohibited zero premium plans — and if Indiana, Mississippi and West Virginia had adopted silver loading. Many more likely got coverage in states not included in our study.

All this is clearly not what the Trump administration had in mind when it cut subsidy payments. Other changes to the marketplaces probably masked some coverage gains that occurred. Notably, cuts in the public outreach for Healthcare.gov, along with the elimination of the individual mandate, decreased enrollment. But the popularity of zero premium plans resulting from silver loading likely stopped much of the damage – and Trump’s attempt to destabilize the marketplaces.

Increasing health coverage post-2020

Now states can take advantage of the attractiveness of zero premium plans to increase health coverage through the marketplaces. One way: States requiring marketplace insurers to provide extra benefits – again, like California and New Jersey – can pick up the small tab for those extras. For example, California enrollees pay for abortion coverage through a one-dollar monthly premium surcharge. This is not covered by premium tax credits. By shifting premiums from even one dollar to zero dollars, our estimates indicate enrollment would increase by approximately 13% among those with lower incomes.

Another way: States without silver loading should adopt it. This is not a partisan issue. Conservative states – or at least, GOP-controlled states like Alabama, Wyoming and Florida – have silver-loaded. State governments pay nothing, revenue for insurers is increased, and most critically, lower-income Americans are provided with affordable health insurance. Put simply, there’s no downside for states.

The Trump administration is prevented from restricting silver loading through 2021. However, a forthcoming Supreme Court case, Texas v. Azar, may yet repeal the entire ACA. If the court’s conservative majority rules in favor of the GOP plaintiffs, they will put affordable health insurance out of reach for the 11.4 million Americans that purchased health insurance in the marketplaces. They will also eliminate Medicaid coverage for an additional 16.9 million Americans.

If the case succeeds, the uninsured rate could easily surpass levels not seen since the height of the Great Recession. And for millions of Americans, access to health insurance – desperately needed, particularly during the COVID-19 pandemic – will be eliminated.

Coleman Drake is Assistant Professor, Department of Health Policy and Management, University of Pittsburgh Graduate School of Public Health, University of Pittsburgh

David Anderson is Health policy research scientist, Duke University



  • Reclaiming water from contaminated brine can increase water supply and reduce environmental harm
    Photo credit: Dean Musgrove/MediaNews Group/Los Angeles Daily News via Getty Images The Hyperion Water Reclamation Plant in Los Angeles handles a massive amount of sewage and wastewater.

    The world is looking for more clean water. Intense storms and warmer weather have worsened droughts and reduced the amount of clean water underground and in rivers and lakes on the surface.

    Under pressure to provide water for drinking and irrigation, people around the globe are trying to figure out how to save, conserve and reuse water in a variety of ways, including reusing treated sewage wastewater and removing valuable salts from seawater.

    But for all the clean water they may produce, those processes, as well as water-intensive industries like mining, manufacturing and energy production, inevitably leave behind a type of liquid called brine: water that contains high concentrations of salt, metals and other contaminants. I’m working on getting the water out of that potential source, too.

    The most recent available assessment of global brine production found that it is 25.2 billion gallons a day, enough to fill nearly 60,000 Olympic-sized swimming pools each day. That’s about one-twelfth of daily household water use in the U.S. However, that brine estimate is from 2019; in the years since, brine production is estimated to have increased due to the continued expansion of desalination plants.

    That’s a lot of water, if it could be cleaned and made usable.

    How is brine disposed?

    Today, most brine produced along the coastline is released into the ocean. Inland cities without this option typically leave brine in ponds to evaporate, blend it with other wastewater, or inject it into deep wells for disposal.

    However, most of these methods require strict environmental protections and monitoring strategies to reduce harm to the environment.

    For instance, the extremely high salt content in brine from desalination plants can kill fish or drive them away, as has happened increasingly since the 1980s off the coast of Bahrain.

    Evaporation ponds require specialized liners to prevent the brine from leaching into the ground and polluting groundwater. And when all the water has evaporated, the remaining solids must be promptly removed to prevent them from blowing away as dust in the wind. This happens in nature, too: As the Great Salt Lake in Utah dries up, salty windblown dust has already contributed to significant air pollution, as recorded by the Utah Division of Air Quality.

    Brine injected into the earth in Oklahoma, including into wells used for hydraulic fracking of oil and natural gas, was one of several factors that led to a 40-fold increase in earthquake activity in the five-year period from 2008 to 2013, as compared to the preceding 31 years. And wastewater has been documented to leak from the underground wells up to the surface as well.

    A short video clip shows dust blowing over an area.
    Plumes of dust rise from the bed of the Great Salt Lake in Utah in January 2025. Utah Division of Air Quality

    Emerging treatment technologies

    Researchers like me are increasingly exploring brine’s potential not as waste but as a source of water – and of valuable materials, such as sodium, lithium, magnesium and calcium.

    Currently, the most effective brine reclamation methods use heat and pressure to boil the water out of brine, capturing the water as vapor and leaving the metals and salts behind as solids. But those systems are expensive to build, energy-intensive to run and physically large.

    Other treatment methods come with unique trade-offs. Electrodialysis uses electricity to pull salt and charged particles out of water through special membranes, separating cleaner water from a more concentrated salty stream. This process works best when the water is already relatively clean, because dirt, oils and minerals can quickly clog or damage the membranes, reducing the performance of the equipment.

    Membrane distillation, in contrast, heats water so that only water vapor passes through a water-repelling membrane, leaving salts and other contaminants behind. While effective in principle, this approach can be slow, energy-intensive and expensive, limiting its use at larger scale.

    A trailer containing a small water reclamation system.
    A trailer containing a small water reclamation system. Mervin XuYang Lim, CC BY-SA

    A look at smaller, decentralized systems

    Smaller systems can be effective, with lower initial costs and quicker start-up processes.

    At the University of Arizona, I am leading the testing of a six-step brine reclamation system known as STREAM – for Separation, Treatment, Recovery via Electrochemistry and Membrane – to continuously reclaim municipal brine, which is salty water left over from sewage treatment.

    The system combines conventional methods such as ultrafiltration, which removes particles and microbes using fine filters, and reverse osmosis, which removes dissolved salts by forcing water through a dense membrane, alongside an electrolytic cell – a method not typically employed in water treatment.

    Our previous study showed that we can recover usable quantities of chemicals such as sodium hydroxide and hydrochloric acid at one-sixth the cost of purchasing them commercially. And our initial calculations indicated the integrated system can reclaim as much as 90% of the water, greatly reducing the volume of what remains to be disposed. The cleaned water in turn is suitable for drinking after final disinfection using ultraviolet or chlorine.

    We are currently building a larger pilot system in Tucson for further study by researchers. We hope to learn if we can use this system to reclaim other sources of brine and study its efficacy in eliminating viruses and bacteria for human consumption.

    We have partnered with other researchers from the University of Nevada Reno, the University of Southern California and the U.S. Army Corps of Engineers to help communities in the Southwest secure reliable water supplies by safely reusing municipal wastewater to serve everyday water use.

    This article originally appeared on The Conversation. You can read it here.

  • ‘Bouncing back’ is a myth – resilience means integrating hard experiences into your life story, not ignoring them
    Photo credit: Anastasiia Voloshko/Moment via Getty ImagesInto each life some rain must fall.

    When Maria looked at herself in the mirror for the first time after her mastectomy, she stood very still.

    One hand rested on the bathroom counter. The other hovered near the flat space where her breast had been. The scar was raw and angry. The loss was quiet but enormous. Her body felt foreign.

    In moments like these, people are often urged to be resilient – which can feel like being told to show no weakness, to push through no matter what. Or they imagine resilience as bouncing back: returning somehow unscathed to be the person you were before.

    But standing in that bathroom, Maria knew there was no going back. And toughness wouldn’t change what had happened. The real question was how she could move forward, carrying this experience into her new reality.

    Maria’s story, one I came to know personally, is far from unique. Loss, trauma and illness often bring the same wrenching questions of identity and the painful uncertainty of what comes next.

    I’ve spent more than two decades studying resilience, particularly among individuals and families navigating these kinds of life-changing events. I am also a four-time cancer survivor and author of a new book, “Falling Forward: The New Science of Resilience and Personal Transformation.” If there is one myth I wish society would retire, it’s the idea that resilience means “toughness” or “bouncing back.”

    woman wearing hat seated in wheelchair looks outside
    Resilience doesn’t rely on relentless positivity in the face of traumatic challenges. pocketlight/iStock via Getty Images Plus

    Rethinking resilience based on research

    Moments like Maria’s reveal something important: The way people tend to talk about resilience often doesn’t match how people actually live through adversity.

    In popular culture, resilience is often equated with grit, toughness or relentless positivity. People celebrate the warrior, the fighter, the triumphant survivor.

    But across research, clinical practice and lived experience, resilience is something far more nuanced, raw and human.

    It’s not a personality trait that some people simply have and others lack. Decades of research show resilience is a dynamic process. It’s shaped by the small, everyday decisions and adjustments individuals make as they adapt to significant adversity while maintaining, or gradually regaining, their psychological and physical footing over time.

    And importantly, resilience does not mean the absence of distress.

    Research on people facing serious life disruptions shows that distress and resilience often coexist. For example, in my study of adolescent and young adult cancer survivors, participants reported being upset about finances, body image and disrupted life plans, while simultaneously highlighting positive changes, such as strengthened relationships and a greater sense of purpose.

    Resilience, in other words, is not about erasing pain and suffering. It is about learning how to integrate difficult experiences into a life that continues forward.

    How resilience really works

    At one point, Maria told me she had started avoiding mirrors, intimacy, even conversations that made others uncomfortable.

    “Well, you’re strong,” people would tell her. “Just stay positive. This too shall pass.”

    But strength, she said, felt like a performance.

    What ultimately shifted for Maria was not an increase in toughness. It was permission to grieve.

    She began speaking openly about the loss of her breast; not just as a medical procedure but as a symbolic loss tied to identity, sexuality and womanhood. She joined a support group. She allowed herself to feel anger alongside gratitude for survival.

    This kind of emotional processing turns out to be central to resilience.

    My colleagues and I have found that people who actively process loss, rather than suppress it, demonstrate better long-term adjustment. Tamping down negative feelings may provide short-term relief, but over time it is associated with greater stress on your body and more difficulty adapting.

    In other words, resilience is not about sealing the wound and pretending it no longer aches. It is about learning how to carry the wound without letting it consume your entire story.

    Neuroscience supports this integration model. When people engage in meaning-making – reflecting on their experiences and incorporating them into a coherent life narrative – brain networks associated with emotional regulation and cognitive flexibility become more active. The brain, quite literally, reorganizes as you adapt to new realities.

    Maria described the change simply.

    “I don’t like what happened,” she told me. “But I’m not at war with my body anymore.”

    That is resilience.

    Arms in sweater with hand writing in a journal
    Acknowledging what’s been lost can be part of the process of resilience. Grace Cary/Moment via Getty Images

    Practices that help build resilience

    If resilience is about integration rather than toughness and bouncing back, how can you cultivate it? Research across psychology, neuroscience and chronic illness points to several evidence-based strategies:

    • Allow emotional complexity: Resilient people are not relentlessly positive. They allow space for the full range of emotions, such as gratitude and grief, hope and fear. Paying attention to your feelings through strategies such as reflective writing or psychotherapy have been linked to improved psychological adaptation.
    • Build a coherent narrative: Human beings are storytellers. Trauma can shatter one’s sense of self, but constructing a narrative that acknowledges loss while identifying continuity and growth supports adaptation. The goal is not to spin suffering into silver linings, but to situate it within a broader life story. For example, someone might say, “Cancer derailed my plans and changed my body, but it also clarified what matters to me and how I want to move forward.”
    • Lean into connection: Isolation magnifies suffering. Social support is one of the strongest predictors of how well people are able to cope and move forward after illness or trauma. For Maria, connection with other women who had had mastectomies normalized her experience and reduced shame.
    • Practice deliberate pauses: Intentionally give yourself some time to breathe. Mindfulness and contemplative solitude can strengthen your ability to regulate emotions and recover from stress. Pausing allows experience to be processed rather than avoided.
    • Expand identity: Illness, loss and trauma reshape how you think of yourself. Rather than clinging to who you were, resilience often involves expanding who you are becoming. Research on post-traumatic growth shows that people often report deeper relationships, clarified priorities and renewed purpose – not because trauma was good, but because it forced reevaluation. Maria no longer describes herself simply as a breast cancer patient. She is a survivor, yes, but also an advocate, a mentor, a woman whose sense of femininity is self-defined rather than dictated by her anatomy.

    Moving forward

    We are living in a time of widespread burnout and rising mental health challenges, where cultural pressure to appear strong often leaves people silently struggling. An insistence on grit and relentless optimism can backfire, making people feel inadequate when they inevitably feel pain.

    Resilience is not about returning to who you were before illness, loss or trauma. It is about becoming someone new: someone who carries the scar, remembers the loss and still chooses to engage with life.

    Maria still pauses when she sees her reflection. But she no longer turns away.

    “This is my body,” she told me recently. “This is my story.”

    Resilience is not forged in the denial of vulnerability, but in its acceptance. Not in bouncing back, but in integrating what has happened into who you are becoming.

    And that, I believe, is where real strength lives.

    This article originally appeared on The Conversation. You can read it here.

  • Trauma patients recover faster when medical teams know each other well, new study finds
    Photo credit: SDI Productions/E+ Collection/via Getty ImagesWhen someone is badly hurt, their potential for survival often depends on what happens in the first minutes after they arrive at the hospital.

    When a trauma patient enters the emergency department, their potential for survival often depends on what happens within the first minutes after their arrival. After studying trauma resuscitation teams at UPMC Presbyterian in Pittsburgh, the largest major trauma center in Pennsylvania, it’s clear that trauma teams aren’t organized ahead of time – they’re formed on the fly. Some team members may have worked together many times before, while others may be meeting for the first time.

    Those minutes can be chaotic, fast-paced and high-stakes. The patient is usually rolled in on a stretcher, bleeding, barely breathing and surrounded by alarms and shouting. At the bedside are emergency physicians, anesthesiologists, surgeons, nurses and respiratory therapists – a large team of dedicated health care providers. Everyone has a job. Everyone is moving fast. When it works well, it looks almost effortless. When it doesn’t, small delays can have big consequences.

    Medical professionals often say that “teamwork matters” in health care. But only a few studies show how teamwork affects patient outcomes or point to concrete, practical ways to make teams work better together.

    This knowledge gap motivated us to get together to study this issue. One of us is an intensive care unit physician and the other is an organizational scientist who studies teams in a variety of settings. We based our approach on a classic concept from behavioral science called transactive memory systems.

    Traumatic injuries, such as car crashes, falls and gunshot wounds, are the leading cause of death for young people worldwide. Across all ages, trauma is one of the top killers. Because trauma is widespread, even small adjustments to how emergency teams coordinate can help save lives and shorten recovery periods for patients.

    Doctor wearing blue gloves prepares to intubate a male patient.
    Few studies assess how trauma teamwork affects patient outcomes. picture alliance/picture alliance collection via Getty Images

    This is where transactive memory systems, TMS, come in. TMS are a shared understanding within a team of who knows what and who is good at what. A team doesn’t succeed because everyone knows everything, but because people rely on one another’s expertise. The team works best when each person knows what they are responsible for, what other team members are experts in, and whom to turn to when a specific problem comes up.

    Team familiarity shapes outcomes

    Think of a group of friends playing basketball. The best basketball teams aren’t the ones where everyone has the same skills. They’re the ones where one person is great at rebounding, one person can shoot from a long distance, and another is good at dribbling the ball up the floor. Importantly, everyone knows each other’s skills, so when a certain skill is needed, they know whom to go to.

    In trauma care, this kind of knowledge could save lives. When seconds matter, the team needs to instantly know who would be best at placing a breathing tube and who would be best at reading the ultrasound. Strong TMS means fewer questions, less hesitation and smoother coordination.

    Black doctor in blue scrubs talks with medical team at nurse's station.
    The more often medical teams work together, the better they know each other’s skills and how they coordinate their tasks. FS Productions/Tetra images collection via Getty Images

    For each trauma patient, we measured three things: shared team experience, transactive memory systems and patient outcomes, based on how long patients stayed in the ICU and in the hospital overall. We were looking for teamwork that showed good coordination, trust in expertise and clear division of responsibility.

    The science behind ‘who knows what’

    Our results were striking. First, teams with more shared experience had stronger transactive memory systems. The more often people had worked together before, the better they seemed to know each other’s skills and coordinate their tasks. If you add up how many times two team members had worked together on a previous resuscitation and divide by the number of dyads, or pairs, on the team, the average in our study was 10 times. As that number increased, transactive memory systems became stronger.

    Second, stronger transactive memory systems were linked to better patient outcomes. These improvements were substantial: Patients cared for by teams that were well above average in their transactive memory systems stayed in the hospital about three fewer days and spent nearly two fewer days in the ICU.

    Third, TMS explained why shared experience mattered. It wasn’t just that experienced teams were better, but that shared experience helped teams build a clearer mental “map” of each other’s expertise. That map is what helped patients get better faster.

    Trauma care is unpredictable – you can’t always control who is on a team or how often people work together. But it may be possible to design training procedures and work schedules that help teams build transactive memory faster.

    More broadly, our study suggests that improving health care isn’t just about developing new technology or training better doctors. It’s about leveraging the power of teams, helping people quickly understand and trust each other’s strengths when it matters most. For us, one coming from the bedside and the other from organizational science, that’s the exciting next step: turning the science of teamwork into practical tools that help trauma teams save lives.

    This article originally appeared on The Conversation. You can read it here.

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