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The FY 2026 Adopted Budget did not reflect the additional costs resulting from the approved rate estimated by OMB to be $527 million in FY 2026, $539 million in FY 2027, $574 million in FY 2028, and $612 million in FY 2029

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Adjusting for these costs (adding back the impact of prepayments and prior payables, as well as taking out unallocated reserves) provides a more accurate measure of the growth of spending over time

Furthermore, smoking induces vascular vasoconstriction, sinusoidal endothelial dysfunction, and smooth muscle proliferation, leading to hypoxia, capillarization of sinusoids, and further activation of HSCs [18]