"The Department estimates that the NPRM will impose aggregate costs of $939.4 million over the first five years, much of which will be concentrated in the first year of implementation. Consideration of the notable omissions, errors, and questionable assumptions found in the Department's analysis suggests that the actual cost may be several times higher. Costs of this magnitude are a burden that may sensibly affect the cost and availability of health insurance and of health care services, adversely impacting achievement of the Affordable Care Act's goals of expanding access to health insurance and of improving the health of citizens. The Department has not adequately considered these indirect, derivative impacts of the NPRM."