Skip to main content
Tag

AHPs

ashoup
In News, Stories

Two Fronts of a Continuing Assault: The GOP Finalizes Junk Insurance Plans and Announces Another Repeal Bill

This afternoon, conservative groups announced their latest plan to repeal the Affordable Care Act. Across town the Trump Administration announced a finalized rule on association health plans. In other words, it was just another day in the GOP’s war on Americans’ health care.

NO RAVES FOR REPEAL RETREAD

Wall Street Journal: “The Latest Plan Is One Front Of A Continuing Assault On The ACA By Republicans.” “The latest plan is one front of a continuing assault on the ACA by Republicans and conservatives in the aftermath of the failed previous effort to repeal it. While the Justice Department has asked a court to toss out key provisions of the health law, the 20 GOP state attorneys general in the lawsuit want the court to end the law altogether.” [WSJ, 6/19]

The Hill: “The Plan Eliminates Obamacare’s Essential Health Benefits.” “Experts note that block grants, though, could lead to cuts in health services if they do not grow over time in the way that the current open-ended system does. The plan also eliminates ObamaCare’s essential health benefits, which require plans to cover a range of services like mental health and prescription drugs. Backers argue this would lead to cheaper plans being available.” [The Hill, 6/19]

Los Angeles Times: “The New Approach Would Scrap Many Of The Current Law’s Insurance Protections.” “The new approach would scrap many of the current law’s insurance protections, including its system of guaranteeing coverage to low-income Americans through either Medicaid or subsidized commercial insurance. ‘The proposal would repeal the individual entitlement to premium and cost-sharing reduction subsidies and Medicaid expansion,’ note the authors… Many of the repeal proposals envisioned not only rolling back the current law but restricting federal funding for the entire Medicaid program, which covers more than 70 million low-income Americans.” [Los Angeles Times, 6/19]

Insurance News Net: Plan “Would Eliminate The ACA’s Medicaid Expansion As Well As The Subsidies That Help People Buy Coverage.” “Groups led by the Heritage Foundation, the Galen Institute and former Sen. Rick Santorum, R-Pa., drafted the plan, which will be formally announced Wednesday. It would eliminate the ACA’s Medicaid expansion as well as the subsidies that help people buy coverage. Instead, it would convert that money into block grants for the states… In addition, the plan would eliminate the essential health benefits that plans are required to cover under the ACA.” [Insurance News Net, 6/19]

National Review: “Broadly Speaking, This Is Similar To The Graham-Cassidy Bill.” [National Review, 6/19]

Center On Budget And Policy Priorities: New Proposal “Would Have The Same Severe Effects On Health Insurance Coverage, Access To Care, And Many Americans’ Health And Financial Security As Last Year’s Repeal Bills.”  “The new plan to repeal the Affordable Care Act (ACA) would have the same severe effects on health insurance coverage, access to care, and many Americans’ health and financial security as last year’s repeal bills.  Like them, it would eliminate the ACA’s Medicaid expansion for low-income adults, lead to sharply increased health care costs for millions of moderate-income individual-market consumers — especially older people — eliminate consumer protections that are especially crucial for people with pre-existing health conditions, and cause millions to lose coverage.” [CBPP, 6/19]

Center For American Progress: “Graham-Cassidy 2.0 Could Cut ACA Funding For Coverage By 31 Percent By 2028.” “Although this is a new plan, it merely recycles some of the worst elements of the failed Graham-Cassidy repeal bill—which experts consider the “the most harmful” repeal bill.5 Graham-Cassidy 2.0 would lead to the same disastrous results: Millions of Americans would lose health care coverage; Protections for pre-existing conditions would be decimated; Costs would increase for lower-income, older, and sick Americans; Massive disruption would occur, causing insurers to drop out of marketplaces… Based on the plan’s specifications and the Congressional Budget Office’s (CBO) updated baseline of ACA funding under current law, the Center for American Progress estimates that Graham-Cassidy 2.0 could cut ACA funding for health coverage by 31 percent by 2028 and by 26 percent  from 2022 to 2028.” [CAP, 6/19]

ASSOCIATION HEALTH PLANS PANNED

CNN: “The Move Could Weaken” Consumer Protections “And Make Coverage More Expensive.” “The Trump administration is taking the final step Tuesday in its plan aimed at making health insurance policies cheaper for some small businesses. But the move could weaken some of the Affordable Care Act’s consumer protections for those buying these plans and make coverage more expensive for those who remain on the Obamacare exchanges.” [CNN, 6/19]

Associated Press: “State Regulators Are Concerned About Association Health Plans Because Similar Plans In The Past Had Problems With Financial Solvency And Even Fraud.” “State insurance regulators are concerned about association health plans because similar plans in the past had problems with financial solvency and even fraud. A big concern about Tuesday’s announcement is to what degree state regulators will retain oversight over the Trump administration’s new plans.” [USA Today, 6/19]

New York Times: Plans “Could Drive Up Premiums, Which Have Increased As Mr. Trump And Republicans In Congress Have Undercut Many Elements Of The [ACA].” “But consumer groups, state officials and Blue Cross Blue Shield plans have long opposed such ideas. They say association health plans will tend to attract employers with younger, healthier workers, leaving behind sicker people in more comprehensive, more expensive plans that fully comply with the Affordable Care Act. That could drive up premiums, which have increased as Mr. Trump and Republicans in Congress have undercut many elements of the law, President Barack Obama’s signature domestic achievement.” [NYT, 6/19]

Washington Post: “The Move Could Be Characterized As Sort Of An ‘Obamacare Repeal Plan B.’” “Association plans have been around for years, but the Trump administration is expanding eligibility as a way to provide cheaper options for people to afford health insurance. The move could be characterized as sort of an ‘Obamacare Repeal Plan B’ made up of efforts by Trump appointees to pull back on the law administratively now that Congress has failed to eliminate the ACA.” [Washington Post, 6/19]

Chris Hansen, American Cancer Society: People With Serious Illnesses Like Cancer Could Face ‘Ever-Increasing Premiums For Comprehensive Coverage.” [NYT, 6/19]

Avalere: Rule Will “Increase Premiums As Much As 4 Percent.” “Avalere Health, a Washington D.C.-based consulting firm, predicted 4.3 million people would leave the individual and small-group markets, which would increase premiums as much as 4 percent by 2022. Avalere performed the analysis for America’s Health Insurance Plans, the lobbying group for the health insurance industry.” [USA Today, 6/19]

Wall Street Journal: Due To Plan, “Costs For Consumers Who Buy Their Own Coverage On The Individual Market Are Likely To Rise.” “While premiums for association plans will probably be significantly cheaper, costs for consumers who buy their own coverage on the individual market are likely to rise, analysts say. Those higher premiums are expected to increase the number of Americans without coverage.” [WSJ, 6/19]

Wall Street Journal: “Associations With A Preponderance Of Female Employees Could Be Charged More.” “Women couldn’t be charged more within individual plans, but associations with a preponderance of female employees could be charged more overall, according to the senior Labor Department official. Some critics have said women and older people will pay more, and they’ve said the plans will essentially be able to discriminate against consumers by offering some benefits and omitting others, such as cancer treatments or certain prescriptions.” [WSJ, 6/19]

CNBC: “Health Providers, Insurers And Medical Groups Have Warned That The Plans Could Drive Up Premiums And Make Insurance Unaffordable.” “These insurance plans would not be subject to requirements under the Affordable Care Act, which included mandatory coverage for 10 essential health benefits, such as maternity and newborn care, prescription drug costs and mental health treatment… Health providers, insurers and medical groups have warned that the plans could drive up premiums and make insurance unaffordable for some people by siphoning healthy consumers who want cheaper coverage, leaving behind a pool of sicker patients with higher medical costs in ACA plans.” [CNBC, 6/19]

Vox: AHPs “Are Not Required To Cover All Of The Essential Health Benefits Mandated By The Affordable Care Act.” “Association health plans, the subject of the new rules, do not have to follow the same rules as individual policies sold under Obamacare, meaning they are not required to cover all of the essential health benefits mandated by the Affordable Care Act, like maternity care, an important piece of the law’s protections for people with preexisting conditions.” [Vox, 6/19]

Larry Levitt, Kaiser Family Foundation: “The Clear Intent Of The Executive Order Is To Create A Parallel Insurance Market Exempt From Many Of The Consumer Protections In The Affordable Care Act.” “‘The clear intent of the executive order is to create a parallel insurance market exempt from many of the consumer protections in the Affordable Care Act,’ Larry Levitt at the Kaiser Family Foundation told me last year. ‘This has the potential to siphon off healthy people with skinnier benefits and cheaper premiums, leaving behind a sicker pool of people under ACA plans.’” [Vox, 6/19]

Karen Pollitz, Kaiser Family Foundation: “They Could Have A Destabilizing Effect.” “‘To the extent that these plans develop and serve as a parallel market, that could have a destabilizing effect,’ said Karen Pollitz of the nonpartisan Kaiser Family Foundation, an expert on individual health insurance. Pollitz also served as a consumer protection regulator in the Obama administration. ‘People who think they can get by without those (comprehensive) benefits will look for cheaper premiums,’ she added.” [USA Today, 6/19]

Politico: “Critics Warn The Steps Will Further Destabilize” Insurance Markets. “Critics warn the steps will further destabilize wobbly Obamacare markets by siphoning off younger and healthier customers, who are more likely to favor cheaper plans that cover less. The law’s insurance markets have already been beset by skyrocketing premiums and diminishing competition, problems that are likely to grow worse if the customer base becomes even smaller and sicker.” [Politico, 6/19]

Highmark CEO David Holmberg: Rule Change “Creates A New Set Of Uncertainties.” “Highmark CEO David Holmberg said the health insurer, which is finally making money on Obamacare customers after years of losses, is committed to remaining in the law’s markets in Delaware, Pennsylvania and West Virginia. However, he said the changes coming out of Washington are adding new challenges. ‘We can see a path where we could stabilize this, but we continue to see rule changes,’ Holmberg told POLITICO. ‘That creates a new set of uncertainties.’” [Politico, 6/19]

Families USA: “With Surgical Precision, The Proposed Rule Repeals The Most Important Limitations On AHP Sales.” “With surgical precision, the proposed rule repeals the most important current limitations on AHP sales: Under federal law, AHPs are supposed to be business associations offering insurance plans to their business members… Currently, when small businesses buy plans through an association like the chamber of commerce, those plans still must include the protections that apply to other small groups, and the plans are subject to state and federal oversight. This would all change under the proposed rule. An AHP could be offered by a supposed ‘association’ that does nothing but provide health insurance. That ‘association’s’ membership could be united by just residence in a common geographic area or work in the same trade or industry. While an AHP cannot explicitly exclude people or companies based on health status, health costs, or health conditions, an AHP can use ‘redlining’ to avoid high-cost members, excluding particular geographic areas or lines of work that tend to be associated with high health care expenses.” [Families USA, 6/19]

ashoup
In News, Stories

Trump Administration, Ignoring 95% of Health Care Groups, Finalizes Association Rule

Washington, D.C. – The Trump Administration just announced new mandates that force weak products that fail to cover critical consumer needs and force costs up for everyone else onto the health insurance markets. Over 95% of health care experts and advocates opposed the change. Protect Our Care Campaign Director Brad Woodhouse released the following statement about these junk plans in response:

“Association health plans fail to provide real coverage because they can refuse to cover critical consumer protections like prescription drug coverage, mental health care, and maternity care, and studies show that these types of plans have a long history of fraud and unpaid claims. These garbage health plans are just the latest Trump Administration attempt to undermine and sabotage our health insurance – sticking Americans with higher costs and chipping away protections for millions and millions of people with pre-existing conditions. The Republican war on health care continues to mean you pay more, you get less.”

OVER 95% OF COMMENTERS OPPOSED ASSOCIATION HEALTH PLANS

Not A Single Group Representing Patients, Physicians, Nurses Or Hospitals Voiced Support In The Public Comments. “Altogether, more than 95% — or 266 of 279 — of the healthcare groups that filed comments about the proposed association health plan regulation expressed serious concern or opposed it.” [Los Angeles Times, 5/30/18]

INSURANCE COMMISSIONERS AGREE THAT ASSOCIATION HEALTH PLANS ARE BAD FOR CONSUMERS

National Association of Insurance Commissioners: Association Health Plans Are Bad For Consumers. “AHPs would fragment and destabilize the small group market, resulting in higher premiums for many small businesses…AHPs would be exempt from state solvency requirements, patient protections, and oversight exposing consumers to significant harm.” [NAIC]

Pennsylvania Insurance Commissioner Concerned About Potential For Consumer Harm Under AHPs. “The proposed rule would also loosen existing commonality of interest requirements to allow associations to form simply based on membership in the same trade, industry or profession..If a self funded MEWA were permitted to form in a neighboring state and to sell to Pennsylvania association members under the metro area provision, Pennsylvania regulators would not have the ability to assist a Pennsylvania resident if problems arise with the other state’s association, including claim denials, or, worse yet, in the event of insolvency or fraud.” [PA Insurance Commissioner Jessica Altman, 3/6/18]

California Insurance Commissioner: “The Proposed Rule Is A Perfect Storm Of Bad Ideas.” “The AHPs proposed by this rule will harm consumers by degrading the individual and small group health insurance markets through adverse selection, and will impinge upon states’ rights while opening the door to fraud, insolvency and abuse…The proposed rule in no way limits the ability of states to regulate MEWAs, insurers offering coverage through MEWAs, and insurance producers marketing that coverage to employers. However, the checkered history of MEWAs instructs that unscrupulous actors will try and exploit any change which can be mischaracterized as constituting ERISA preemption.” [CA Insurance Commissioner Dave Jones, 3/6/18]

PATIENT GROUPS, HOSPITALS, AND KEY HEALTH STAKEHOLDERS CONDEMN AHPs

American Cancer Society Cancer Action Network: “We Are Also Concerned About The Proliferation Of AHPs Because Of Their History Of Fraud And Financial Instability.” “For a long time, these products were not traditionally subject to the same state insurance solvency and licensing requirements that allowed regulators to maintain necessary oversight. If an AHP lacked the financial resources to pay claims, then enrollees were left with no coverage and high out-of-pocket costs. Even in cases of well-meaning AHP sponsors, insolvencies led to millions of dollars in unpaid claims.” [ACS-CAN, 3/6/18]

American Hospital Association: AHPs “Ultimately Decreas[e] Access To Affordable Coverage.” “We are concerned that this rule fails to protect against discriminatory insurance practices and could contribute to instability in the individual and small group market, ultimately decreasing access to affordable coverage.” [American Hospital Association, 3/6/18]

Coalition Of 118 Patient And Community Organizations Urges Department Of Labor To Reconsider AHPs. “We believe that the proposed changes would negatively impact access to quality, affordable care for consumers, disrupt the individual and small business marketplace, and further strain the limited resources of state regulators…The intent of the President’s executive order was to increase consumer choice while curbing costs, however we believe that AHPs as proposed would invariably weaken the individual and small group markets leading to higher healthcare costs for all; higher premiums for those who stay in the marketplace, and high out of-pocket costs for those who are covered by AHPs for unexpected medical needs.” [Coalition Of 118 Patient And Community Organizations, 3/6/18]

AHPs ARE HOTSPOTS FOR FRAUD IN STATES

Florida

A Labor Department Lawsuit Revealed An AHP Had Concealed Financial Problems And Left $3.6 Million In Unpaid Claims. “The Labor Department filed suit last year against a Florida woman and her company to recover $1.2 million that it said had been improperly diverted from a health plan serving dozens of employers. The defendants concealed the plan’s financial problems from plan participants and left more than $3.6 million in unpaid claims, the department said in court papers.” [New York Times, 10/21/17]

In Florida, A Man Pleaded Guilty To Embezzling $700,000 In Premiums From the AHP He Ran in 2004 To Help Build A Home For Himself And Was Sentenced To 57 Months In Prison. “A Florida man was sentenced to 57 months in prison after he pleaded guilty to embezzling about $700,000 in premiums from a health plan that he had marketed to small businesses. The Labor Department and the Justice Department said he had used some of the plan premiums to build a home for himself.” [New York Times, 10/21/17]

In 2004, A Florida Woman Was Left With $500,000 In Unpaid Medical Bills While She Was Covered By Association Health Plan. “Joan Piantadosi, a small business owner bought health insurance from Employers Mutual LLC through an association for herself, her family, and her employees. She was left with more than $500,000 in unpaid medical bills for her husband’s treatment during the time she was covered by Employers Mutual LLC. On top of that, her husband needed a liver transplant to live. In her own words, “[W]e were informed that since we lacked insurance coverage, we would have to pay a deposit of $150,000 before my husband could enter the hospital’s Liver Transplant Inpatient program. We simply did not have $150,000 to cover the deposit. Consequently, my husband was removed from the recipient list…We feared, among other things, that my husband might die while we were attempting to deal with the predicament of being uninsured despite having paid premiums to what appeared to be a legitimate health insurer.” [United Hospital Fund, 3/6/18]

Louisiana

In Louisiana, Two People Pleaded Guilty To Using Money From The AHP For Spa Treatments, Diamond Cuff Links, Foreign Travel And Other Personal Expenses. “And in Louisiana, two people pleaded guilty to conspiracy charges after the government found that they had taken money from the medical benefit fund of a trade association and used it to pay for spa treatments, diamond cuff links, evening gowns, foreign travel and other personal expenses.” [New York Times, 10/21/17]

Texas

In Texas, Patients Thought They Were Insured Until Told Otherwise In A Moment Of Crisis. “Robert Loiseau, who represented fraud victims in Texas, recalled their shock when they tried to receive care. ‘People bought insurance coverage because it was cheap and seemed to provide them with coverage they needed,’ he said. ‘It had a veneer of legitimacy. But when they went to the doctor, they found out all of a sudden that their insurance company, their perceived insurance company, was in receivership and that they had no coverage.’” [New York Times, 10/21/17]

Between 2001 And 2003, Texas Shut Down 129 Unauthorized Insurance Operations. “In the last two years, the Texas Insurance Department shut down 129 unauthorized insurance companies, affiliates, operators, and their agents whose illegal actions affected more than 20,000 Texans.” [The Commonwealth Fund, August 2003]

New Jersey

In 2002, An AHP Became Insolvent With $15 Million In Outstanding Claims. “For example, when a long-standing AHP in New Jersey that covered 20,000 people became insolvent in 2002, it had $15 million in outstanding medical bills. This left participating businesses and their employees’ claims unpaid even though employers paid premiums to the AHP.” [Commonwealth Fund, 10/10/17]

A Health Plan For New Jersey Small Businesses Collapsed With $7 Million In Unpaid Claims. “In another case, a federal appeals court found that a healthplan for small businesses in New Jersey was ‘aggressively marketed but inadequately funded.’ The plan collapsed with more than $7 million in unpaid claims.” [New York Times, 10/21/17]

South Carolina

In South Carolina, A Man Pleaded Guilty To Diverting Nearly $1 Million From An AHP For Churches And Small Businesses, Leaving $1.7 Million In Unpaid Claims. “A South Carolina man pleaded guilty after the government found that he had diverted more than $970,000 in insurance premiums from a health plan for churches and small businesses. ‘His embezzlement and the plan’s consequent failure left behind approximately $1.7 million in unpaid medical claims,’ the Labor Department said.” [New York Times, 10/21/17]

Across State Lines: North Carolina, Maryland, And Beyond

One AHP Scheme Shows How AHPs Can Move From State To State.Families USA chronicled an AHP scheme involving the American Trade Association, Smart Data Solutions, and Serve America Assurance. They found:

  • “Even after one state identifies a problem, the company may continue to operate for years in other states. North Carolina issued a cease and desist order to stop many of the players in this case from selling insurance in 2008.”
  • “But by June 2010, when Maryland issued a cease and desist order, the plans sold by these players had been identified in at least 23 states.„ Estimates of total premiums paid to these companies for unauthorized, unlicensed plans range from $14 million to $100 million.”
  • “This particular scheme operated through associations that went by many different names. (At least one of the players in this case was involved in a previous case concerned with fraudulent insurance sold through an association of employers in 2001-2002.)”
  • “Consumers are often ill-protected when they buy coverage through an association, and the web of relationships among salespeople, associations, administrators, and actual insurers can be difficult for regulators to unravel and oversee. Consumers may be encouraged to join fake associations to buy health insurance so they have an illusion of coverage—and the insurers collect membership dues and premiums while illegally avoiding state oversight).” [Families USA, October 2010]

GAO Report In 1992 Showed Similar AHPs Left At Least 398,000 Participants With More Than $123 Million In Unpaid Claims And More Than 600 Plans In Almost Every State Failed To Comply With State Laws.“Back in 1992, the Government Accountability Office issued a scathing report on these multiple employer welfare arrangements (known as MEWAs; they’re pronounced “mee-wahs”) in which small businesses could pool funds to get the lower-cost insurance typically available only to large employers. These MEWAs, said the government, left at least 398,000 participants and their beneficiaries with more than $123 million in unpaid claims between January 1988 and June 1991. Furthermore, states reported massive and widespread problems with MEWAs. More than 600 plans in nearly every U.S. state failed to comply with insurance laws. Thirty-three states said enrollees were sometimes left without health coverage when MEWAs disbanded…’MEWAs have proven to be a source of regulatory confusion, enforcement problems and, in some instances, fraud,’ the GAO wrote at the time.” [Washington Post, 10/12/17]

ashoup
In News

President Trump Doubles Down on Health Care Sabotage at Bill Signing Ceremony

Washington, D.C. – After President Trump boasted about his Administration’s ongoing health care sabotage during a bill signing, saying that “we will have gotten rid of a majority of Obamacare” in relation to his Administration’s expected rules on short-term and association health plans, Protect Our Care Campaign Director Brad Woodhouse released the following statement:

“President Trump is bragging about his Administration’s continuing efforts to undermine and sabotage Americans’ health coverage through short-term junk and association health plans on the very same day that a new analysis shows unprecedented opposition to both proposals from over 90% of health care groups. Instead of forging ahead down this destructive path, Trump should listen to the vast majority of Americans, who oppose his repeal-and-sabotage agenda, and withdraw this harmful rule. It’s time for President Trump to end this partisan war on Americans’ health care.”

FACT SHEETS:

SHORT-TERM PLANS leave people who get sick with thousands of dollars in medical bills because they don’t have to cover basic medical services.

ASSOCIATION HEALTH PLANS may also refuse to cover basic medical services, and have a long history of fraud and unpaid claims.

ashoup
In News

President Trump Vows to Keep Sabotaging Affordable Care Act

Washington, D.C. – Today in Florida, President Trump vowed to continue his sabotage campaign against the Affordable Care Act, saying the GOP’s tax bill brought about “the end of Obamacare” and expressing his support for proposed association health plans, calling them ‘tremendous insurance.’ Protect Our Care Campaign Director Brad Woodhouse released the following statement in response:

“President Trump today continued his crusade against the Affordable Care Act and Americans’ health care. Trump’s war on our care already threatens millions of Americans’ insurance, is raising premiums by double-digits for millions more, and has seriously damaged the individual market – and in response, the President has decided to embrace junk insurance scams like association health plans, which have a history of fraud and have been condemned by experts across the country. The new junk plan regulation that Trump today pledged to finalize within months is likely illegal, and will certainly cause even more turmoil in the insurance markets just before next year’s rates are finalized. Plans that can deny coverage based on pre-existing conditions and refuse to cover key services like hospitalization are the exact opposite of ‘tremendous insurance,’ and they join a long list of Trump Administration actions set to cause tremendous rate hikes this fall.

“While President Trump may say that ‘nobody remembers’ the Senate health care repeal bill, the truth is that Americans have not forgotten that Republicans threatened our care. We remember that Republicans tried to put insurance companies back in control; we remember they tried to leave the one-in-four Americans with a pre-existing condition out in the cold; and we remember that Republicans ignored our voices while pushing the most unpopular legislation in decades. Standing up to the war on health care is Americans’ top priority at the polls this year. As the Trump Administration continues to attack our care through harmful regulations and Republicans in Congress plot Medicare and Medicaid cuts, Americans will keep remembering, and the President and his party are right to fear the consequences of their destructive actions.”

TRANSCRIPT:

PRESIDENT TRUMP: So we have the biggest tax cut in history, bigger than the Reagan tax cut, bigger than any tax cut. But what else? The individual mandate is gone. That’s on Obamacare, which is about the end of Obamacare. So we had Obamacare beat and one senator decided to go thumbs down. Do you remember that evening? No, nobody remembers. Thumbs down.

It’s all right, because Alex Acosta has come up and this is the plan that a lot of people have wanted for a long time, associations. And we’re going any tremendous sign-ups. Alex, when is that going to be ready where people can start signing and doing it in groups and through cooperatives, et cetera?

LABOR SECRETARY ACOSTA: That’s right, Mr. President, we hope to have that by this summer.

PRESIDENT TRUMP: It’s going to be incredible, you’re going to get tremendous insurance at a very low cost.

Close Menu