Testimony

Reforming Health Care in Alaska

Committee on Health, Education, and Social Services
Alaska Senate

Mr. Chairman, Senators:

My name is Michael Tanner and I appreciate the invitation to appear today and the opportunity to share my perspective on the vital issue of reforming health care and what Alaska should and should not do to help resolve this issue.

For the past 14 years, I have been director of health & welfare studies for the Cato Institute in Washington, DC. Before that I served as legislative director for the Georgia Public Policy Foundation and as legislative director for health & welfare with the American Legislative Exchange Council. In all, I have spent more than 20 years studying the American health care system and am the author of five books on health care reform, most recently Healthy Competition: What’s Holding Back American Health Care and How to Free It.

During my time studying this issue, I have concluded that, in developing health policy it is vital to keep in mind one pertinent fact: for all its problems, the United States offers the highest quality health care in the world. Most of the world’s top doctors, hospitals, and research facilities are located in the United States. Eighteen of the last 25 winners of the Nobel Prize in Medicine either are U.S. citizens or work in this country.1 U.S. companies have developed half of all the major new medicines introduced worldwide over the past 20 years.2 In fact, Americans played a key role in 80 percent of the most important medical advances of the past 30 years.3 Nearly every type of advanced medical technology or procedure is more available in the United States than in any other country.4 By almost any measure, if you are diagnosed with a serious illness, the United States is the place you want to be. That is why tens of thousands of patients from around the world come to this country every year for treatment.

Of course, I’m aware that, as critics of American health care often point out, other countries have higher life expectancies and lower infant mortality rates, but those two indicators are not a good way to measure the quality of a nation’s health care system. In the United States, very low-birth-weight infants have a much greater chance of being brought to term with the latest medical technologies. Some of those low-birth-weight babies die soon after birth, which boosts our infant mortality rate, but in many other Western countries, those high-risk, low-birth-weight infants are not included when infant mortality is calculated.

And life expectancy is a poor measure of a health care system. Life expectancies are affected by exogenous factors such as violent crime, poverty, obesity, tobacco and drug use, and other issues unrelated to health care. As the OECD explains, “It is difficult to estimate the relative contribution of the numerous non-medical and medical factors that might affect variations in life expectancy across countries and over time.”5 Consider the nearly three year disparity in life expectancy between Utah (78.7 years) and Nevada (75.9 years), despite the fact that the have essentially the same health care systems.6 In fact, these exogenous factors are so distorting that if you correct for homicides and accidents, the U.S. rises to the top of the list for life expectancy.7

On the other hand, when you compare the outcome for specific diseases like cancer or heart disease, the United States clearly outperforms the rest of the world. Take prostate cancer, for example. Even though American men are more likely to be diagnosed with prostate cancer than their counterparts in other countries, we are less likely to die from the disease. Less than one out of five American men with prostate cancer will die from it, but 57 percent of British men and nearly half of French and German men will. Even in Canada, a quarter of men diagnosed with prostate cancer, die from the disease.

Similar results can be found for other forms of cancer. For instance, just 30 percent of U.S. citizens diagnosed with colon cancer die from it, compared to fully 74 percent in Britain, 62 percent in New Zealand, 58 percent in France, 57 percent in Germany, 53 percent in Australia, and 36 percent in Canada. Similarly, less than 25 percent of U.S. women die from breast cancer, but 46 percent of British women, 35 percent of French women, 31 percent of German women, 28 percent of Canadian women, 28 percent of Australian women, and 46 percent of women from New Zealand die from it.8

Clearly, there are problems with the U.S. health care system. Costs are rising and distributed in a way that makes it difficult for some people to afford the care they want or need. Moreover, while the number of uninsured Americans is often exaggerated, there are far too many Americans without health insurance. And while the U.S. provides the world’s highest quality health care, that quality is uneven and too often Americans don’t receive the standard of care that they should.

It is important, therefore, that any reform of the health care system, either nationally or here in Alaska, not destroy those things that make our health care system so effective-individual choice and free markets. In particular, you should avoid the temptation to increase government regulation and control over the state’s health care system. I am concerned, therefore, that SB 160 is headed down the wrong road to reform.

Let me start, though, by mentioning something important that SB 160 gets right. SB 160 is not a single-payer plan. For this, the people of Alaska can be profoundly grateful. After all, the one common characteristic of single-payer health care systems is that they ration care. Indeed, recently the Canadian Supreme Court struck down a portion of that country’s national health care system, noting that, “Access to a waiting list is not access to health care…there is unchallenged evidence that in some serious cases people die as a result of waiting lists for public health care.”9

I also want to commend the authors of SB 1690 for recognizing a couple of very important concepts for health care reform. Health care reform must maximize consumer choice and competition within the health care marketplace. And subsidies within the health care system should be focused on the individual, not on hospitals, insurers, or other institutions. SB 160 is flawed in how it addresses these concerns, but it is important that the authors have raised them.

In the end, however, I there are several very troublesome elements of SB 160:

Employer Mandate: SB 160 requires employers to provide workers with health insurance or pay 1-2 percent of payroll into the Alaska Health Fund, a “play or pay” mandate on businesses.10 There are two major problems with such an approach. First, the net result of a health care mandate on businesses will be to hurt the workers that the mandate was designed to help. It is simple economics. The amount of compensation each worker receives is a function of his or her productivity. The employer is indifferent to the makeup of that compensation between wages, taxes, insurance premiums, or other costs associated with that worker’s employment. Mandating an increase in a worker’s compensation (through the provision of health insurance) increases the worker’s operating costs without increasing the worker’s productivity. Employers must therefore find ways to offset the added costs imposed by the mandate. Options include raising prices (which is unlikely in a competitive market), lowering wages, reducing wage increases, reducing other health costs (such as drug coverage or retiree health benefits), reducing other benefits (such as pensions), instituting layoffs, replacing workers with automation, reducing hiring, hiring ineligible workers including undocumented aliens, out-sourcing work overseas, or even moving their operations out of state or out of the country. Thus, it is workers who will ultimately bear the cost of any mandate.

Moreover, by imposing an employer mandate SB 160 would further lock us into our current-employer based health care system. Employer-based health insurance is an historical accident, stemming from a combination of labor shortages and wage-price controls during World War II. It limits consumer choice by giving decisions over insurance coverage to employers rather than workers. It means that workers who lose their jobs lose their insurance, the primary driver for the lack of insurance coverage. And it means that individuals who do not receive employer-provided insurance face an increased financial burden when they try to purchase insurance on their own.

Health care reform should move us away from employer-based insurance, not extend it.

Individual Mandate: On top of its mandate on business, SB 160 would also impose an individual mandate. All Alaskans who do not already have insurance meeting certain minimum standards would be required to participate in the Alaska Health Care Program.11 As I read this bill’s language, the mandate for participation does not apply just to those below 300 percent of the poverty level, who will receive vouchers under the plan, but to all Alaskans. This represents a significant expansion of government power and intrusion into the personal health decisions of Alaskans.

In fact, until Massachusetts passed an individual mandate last year, no state had ever required that an individual, simply by virtue of living in a state and for no other reason, purchase a specific government-defined product. As the Congressional Budget Office has noted, such a mandate is an “unprecedented” level of state intervention in personal decision-making. 12

It is of course understandable why legislators might wish to require participation in the Alaska Health Plan. There is a legitimate-if overstated-issue, uncompensated care or “free riders” on the current health care system. When an individual without health insurance becomes sick or injured, he or she still receives medical treatment. In fact hospitals have a legal requirement to provide care regardless of ability to pay. Physicians do not face the same legal requirement, but few are willing to deny treatment because a patient lacks insurance. However, such treatment is not free. The cost is simply shifted to others, those with insurance, or more often, taxpayers.

In addition, those most likely to go without health insurance are the young and relatively healthy. For example, although 18 to 24 year olds are only 10 percent of the U.S. population, they are 21 percent of the long-term uninsured.13 For these young, healthy individuals, going without health insurance is often a logical decision. However, this becomes a form of adverse selection. Removing the young and healthy from the insurance pool means that those remaining in the pool will be older and sicker. This results in higher insurance premiums for those who are insured.

And of course for many, universal insurance coverage is the primary goal of health care reform. Currently, more than 650,000 Alaskans, 16.5% of the state’s population, do not have health insurance coverage.14 get the care they need or may face ruinous costs if they do. An individual mandate is seen as a way to achieve universal coverage without either the job-killing burden of an employer mandate or the high taxes and inevitable rationing associated with a single-payer system.

These are legitimate concerns and cannot be casually dismissed, but ultimately I find them unconvincing.

First, uncompensated care is a real cost and one that we all pay through higher taxes and/or higher insurance premiums. Yet those costs are generally less than the hospital industry and others often portray. Therefore, it is important to distinguish between often-cited hospital charges and actual costs. Nationally, actual uncompensated care costs account for approximately 2-5 percent of total health care spending. Even assuming Alaska is at the high end of the estimate, uncompensated care represents a problem, but not a sufficient crisis to justify the very serious problems that stem from an individual mandate.

Second, the relative absence of the young and the healthy from the insurance pool is an issue only if there are cross subsidies in existing pools. If everyone’s rates are actuarially fair, then young people’s explicit or implicit premiums do not result in lower or higher premiums for anyone else. If Alaska is truly concerned with bringing more young and healthy people into the insurance market, it should take steps to reduce the cost of insurance for those people by, for instance, removing mandated benefits and encouraging young people to purchase catastrophic coverage.

Third and perhaps most significantly, there’s a big difference between universal coverage and actual access to care. Simply saying that people have insurance is meaningless. Many countries provide universal insurance but deny critical procedures to patients who need them. For example, at any given time, 850,000 Britons are waiting for admission to National Health Service hospitals, and shortages force the NHS to cancel as many as 50,000 operations each year. Next door in Canada, more than 800,000 patients are currently on waiting lists for medical procedures.15 According to Canadian Supreme Court Chief Justice Beverly McLaughlin, many of these individuals suffer chronic pain and some will die awaiting the treatment they’ve been promised.16 Truly increasing the number of insured is ultimately a product of implementing other reforms correctly. Simply giving people a piece of paper that says they have insurance does nothing to increase their access to care.

Many advocates of an individual mandate for health insurance liken it to requirements that drivers purchase auto insurance. This is an imperfect analogy. First, it has long been recognized that driving is a privilege, subject to all manner of regulatory requirements. If one does not like the regulations, including an insurance mandate, one can choose not to drive. A health insurance mandate does not give people such a choice. Second, states mandate auto insurance to protect others not one’s self.

However, auto insurance does provide a useful guide to how difficult it will be to enforce the mandate. Alaska requires proof of auto insurance to register a car. If caught driving without coverage, the driver’s license can be suspended from 90 days to a year.17 Despite this, roughly 15 percent of all Alaska drivers remain uninsured.18 In fact, 47 states currently require automobile insurance, yet roughly 14.5 percent of drivers in those states are uninsured. In some states like Texas, the uninsured motorist rate runs as high as 18 percent, and as many as 25-30 percent of Los Angeles drivers are uninsured. By comparison, in the three states without mandatory auto insurance, roughly 15 percent of drivers are uninsured, the same rate as Alaska despite the mandate. 19

SB 160 does not specify how Alaska will track who does and does not have insurance or what penalties will be imposed on those who fail to comply. Indeed, it would appear that even someone receiving a voucher could simply decide not to use it. Massachusetts used its state income tax system to enforce its mandate. Alaska does not have that option. One questions how the state will track down every last resident, including the transient, the homeless, the mentally ill, and illegal aliens, to force their participation.

But while an individual mandate is unlikely to achieve universal coverage, or significantly reduce health care costs, the mandate crosses an important line: accepting the principle that it is the government’s responsibility to ensure that every Alaskan has health insurance. In doing so, it opens the door to further widespread regulation of the health care industry and political interference in personal health care decisions. The result will be a slow but steady spiral downward toward a government-run health care system.

For example, if Alaska chooses to mandate insurance coverage, the state must define what insurance meets that requirement. SB 160 does so, or rather authorizes the Alaska Health Board to do so.20 So it appears that those Alaskans who have insurance today and are satisfied with that insurance, but whose insurance does not meet the Board’s definition of an insurance plan providing “essential health services,” will be required to give up their current plan and purchase a plan which meets the Board’s criteria.

This brings me to my second concern with SB 160.

The Alaska Health Board: SB 160 creates an appointed body, the Alaska Health Board, to oversee the plan.21 This includes determining which insurers qualify as “accountable health care plans.” The exact powers of this Board are broad and undefined, but it is clear that it becomes a new regulatory body with the power to limit what insurance can be sold in Alaska. At a time when over-regulation of insurance is a serious problem, this seems like the wrong road to follow.

As mentioned earlier, the Board is given the authority to determine what constitutes “essential health services.”22 The Board is given no guidance as to what that entails, but we can presume from similar definitions other states have applied, that any definition of “essential” will be far from the simple catastrophic coverage that is the purpose of insurance.

It is important to realize that the purpose of insurance is to spread catastrophic risk. That is, it takes an event that has little likelihood of occurring, but a high cost if it does occur, and spreads that risk and cost over a large pool of people. Take home owners insurance for example. The odds of your home burning down are quite small. But if it does happen, few people have the resources to rebuild on their own. Therefore, people purchase insurance to spread that risk across a large number of homeowners.

Health insurance should be treated the same way. That is, it should spread risk, not simply be a mechanism for prepaying for routine or anticipatable health expenses. I am skeptical that the Alaska Health Board will take such an approach in defining “essential” care.

But whatever the Board’s initial definition, special interests representing various health care providers and disease constituencies can certainly be expected to lobby for the inclusion of additional services or coverage under any mandated benefits package.

Public choice dynamics are such that providers (who would make money from the increased demand for their services) and disease constituencies (whose members naturally have an urgent desire for coverage of their illness or condition) will always have a strong incentive to lobby legislators for inclusion under any minimum benefits package. The public at large will likely be unaware of the debate or will see resisting the small premium increase caused by any particular additional benefit as unworthy of the effort. It is a simple case of concentrated benefits and diffused costs.

If more benefits were continuously added, the cost of the mandate would increase. This will place legislators in a very difficult position. If you increase the size of the vouchers to keep pace with the rising cost of the mandate, the cost of the program will explode. On the other hand, if you hold the size of the vouchers steady, the increased cost will be borne by consumers, who would have no choice but to continue purchasing the ever more expensive insurance. Since the consumers would have little or no leverage over insurers (they can no longer refuse to buy their products), they can eventually be expected to turn to the government for relief.

This creates a second dilemma for lawmakers. Attempts to scale back benefits would certainly meet political opposition from powerful constituencies and complaints about “cuts.” The only other alternative would be for the state to intervene directly by capping premiums. But, insurers unable to charge more for an increasingly expensive product can be expected to trim costs by cutting back on their reimbursement rates to hospitals and physicians. The result will ultimately be rationing, the lack of available health care goods and services.

One should always be careful of “slippery slope” arguments. Yet in this case, we’ve already seen how the slippage can take place. In Massachusetts, their version of the Alaska Health Board, the “Connector,” has already added a mandate for prescription drug coverage and outlawed insurance policies with more than a $2,000 deductible.

I would urge Senators to think very carefully before putting such wide-ranging legislative power in the hands of an unelected Board.

Subsidies: SB 160 provides for vouchers on a sliding scale for those with incomes up to 300 percent of the federal poverty level.23 That means subsidies would be available for those with incomes ranging from $30,480 for a single individual to as much as $62,000 for a married couple with two children.

There are two significant dangers to subsidies of this magnitude. First, the expansion of subsidies will greatly increase the number of people dependent on government. Given that the median household income in Alaska is $51,571, the subsidies under SB 160 extend government welfare programs well into the middle class. As with all means-tested government programs, we can expect this new middle-class welfare benefit to discourage work, family formation, wealth accumulation, and self-sufficiency, while creating a voting constituency for ever-expanding benefits.

Second, the subsidies are liable to squeeze out unsubsidized coverage. Many Alaskans receiving vouchers will already have health insurance, either provided by their employer or purchased themselves. This will create incentives for small businesses and others employing large numbers of low-income workers to stop offering coverage, allowing taxpayers to pick up the slack. Likewise, taxpayers will be forced to pay at least part of the insurance bill for many people who are currently paying that bill for themselves.

This crowding-out phenomenon has been readily apparent with both the traditional Medicaid and S-CHIP programs. A Robert Wood Johnson Foundation survey of 22 studies of the relationship between government insurance programs and private coverage concluded that substitution of government for private coverage “seems inevitable.”24 Other studies have shown that when government programs are cut back, private coverage increases.25 And, the Congressional Budget Office estimates that of every three children added to the S-CHIP program, one was already covered by private health insurance.

This last issue highlights yet another problem with the proposed subsidies under SB 160-they are poorly targeted. Many of those eligible for coverage already have health insurance. Therefore the subsidies should not be seen just as a method of increasing coverage, but as a way of shifting a large portion of insurance costs from individuals to the tax system. It becomes simply another form of income redistribution. While many taxpayers may accept such redistribution to the truly poor, how will they feel about financing transfers to the middle class?

Managed Competition: Essentially SB 160 sets up a system of managed competition. Managed competition, which was the underlying theory behind both the 1983 Clinton health care plan and Mitt Romney’s reforms in Massachusetts is designed to take advantage of market competition, but within an artificial and carefully regulated marketplace.26

But any competition would take place on a very constrained basis. Since all plans are required to offer the same core benefits package, there will be no more than marginal competition based on benefit design. In addition, the ability of insurers to manage risk is constrained by the bill’s guaranteed-issue requirements27 (and since guaranteed issue is meaningless in the absence of some kind of community rating, we should assume that restriction will follow). This situation is particularly problematic since an inability to price according to risk generally causes insurers to retreat toward the mean, resulting in overprovision of care to the healthy and under provision to the sick.28 Some limited price competition is likely to occur, but because plans cannot reduce costs by managing risks or through benefit design, even that will be marginal.

Supporters of managed competition are critical of a health insurance marketplace that they see as “fragmented” and “balkanized;” my good friends at the Heritage Foundation argue, “Markets sometimes work more efficiently and effectively when there is a single place to facilitate diverse economic activity.”29

Supporters of the managed competition liken it to something like CarMax. “There are many different kinds of cars to choose from, all offered through one giant dealership.”30 However, CarMax is not the only dealership. If you don’t like what CarMax has to offer you can shop on Vehix.com, visit local dealerships, or simply choose not to buy a car. No such options would be available under the Alaska Health plan.

As University of Chicago law professor Richard Epstein has pointed out, “Managed competition is not so much a coherent government plan as an oxymoron. It is possible to have either managed health care or competition in health care services. It is not possible to have both simultaneously.”31 Even Alain Enthoven, the father of managed competition, agrees that “managed competition is not a free market.”32

A Better Approach: If the Alaska Health Plan is not the answer, what can Alaska do to improve its health care system? The unfortunate reality is that the state’s options are limited because both the real villains and solutions to America’s health care problems lie in Washington, and specifically with the federal tax code, beyond the reach of state lawmakers. However, there are some important steps that this state can take that will reduce the cost of health care and increase the number of people who are insured, while preserving-and even improving-the quality of the current system.

First, Alaska should do what it can to reduce the cost of health insurance. After all, the number one reason that people give for not purchasing insurance is cost.33 This is particularly true for young and healthy individuals; precisely the people who should be encouraged to enter the insurance market before they become older and sicker. Yet current state regulations drive up the cost of health insurance and make it a reasonably logical decision for these young, healthy individuals to remain uninsured.

For example, Alaska currently has 28 mandated benefits. These include alcoholism treatment, breast reconstruction, cervical and prostate cancer screening, diabetes treatment, mammography screening, and treatment for phenylketonuria.34

These mandates in total add significantly to the cost of insurance. Many of the other mandates add 1-3 percent each to insurance costs.35 Clearly, people should be able to purchase coverage for such conditions and providers if they desire it. But just as clearly, those who wish to purchase a less inclusive but also less expensive policy should be able to do so. Repealing such mandates would be one of the most effective steps that Alaska could take to reduce the cost of health insurance and thereby increase the number of people with insurance.

Of course repealing such mandates will encounter fierce resistance from special interests and may prove politically difficult. There is a potentially easier step that Alaska could take to achieve similar, indeed possibly more comprehensive, results. The state could amend its insurance laws to allow the sale of any health insurance plan approved for sale by any state.

Currently, health insurance consumers are stuck with the regulatory regime of the state in which they reside. Alaskan businesses and individuals are held hostage by the state’s insurance regulation. But if free to purchase health insurance regulated by states other than their own, customers could avoid regulations that added unwanted costs. They could in effect, “purchase” another state’s set of regulations by purchasing insurance from an insurer chartered in that state. If Alaskans do not wish to purchase all 28 required coverage mandates, they could purchase insurance from, say, Idaho, where there are only 14, or from any state whose laws are more closely aligned with their own preferences.

Not only would such a simple change to your state’s insurance laws benefit consumers, reduce costs, and increase the number of people with insurance, but the same competitive process that drives producers to improve quality and reduce costs in other products could help produce higher quality regulations. Alaska would have to compete for the best regulatory environment in the same way it currently competes with other states for the best tax environment.

Secondly, the state should institute a thorough review of how it can reduce the cost of providing health care. In particular it should look at such issues as expanding the scope of practice for non physician professionals, and removing barriers to hospital competition.

Third, the state should continue to do all it can to expand the use of consumer-oriented health plans such as Health Savings Accounts.

I regret that I have not been able to come here and offer a silver bullet to fix the problems with Alaska’s health system. Indeed, some may be disappointed that so much of my advice is in the form of what not to do. This is because I believe, that in pursuing health care reform, legislators should be guided by the Hippocratic admonition, “First do no harm.”

It is understandable that Alaskans are frustrated by the inability of Congress to address the undeniable need for health care reform. Yet it is sadly true that the keys to health care reform lie in federal, not state, legislation. There are limited steps that Alaska can take to make the situation better. But, in the end, you should be extremely careful to make sure that impatience does not push you into taking steps that will ultimately make the problem far worse, hurting Alaskan taxpayers, businesses, health care providers, and perhaps most importantly, patients.

I thank you once again for your time and consideration. I would be happy to answer any questions.


1“Nobel Prize in Physiology or Medicine Winners 2006-1901,” The Nobel Prize Internet Archive, http://almaz.com/nobel/medicine/medicine.html.

2Pharmaceutical Manufacturers Association, “Facts about the U.S. Pharmaceutical Industry,” 2002.

3Economic Report of the President (Washington: Government Printing Office, 2004), p. 192

4Gerard Anderson et al., “It’s the Prices Stupid: Why the United States Is So Different from Other Countries,” Health Affairs 22, no. 3 (May/June 2003): 99.

5“Health at a Glance: OECD Indicators, 2005,” Paris, OECD Publishing, 2005.

6U.S. Census Bureau, 2000 Census.

7Robert L. Ohsfeldt, John E. Schneider, The Business of Health: The Role of Competition, Markets, and Regulation (Washington AEI Press, 2006).

8Varduhi Petrosyan, and Peter Hussey, Multinational Comparisons of Health Systems Data, 2002 (New York: The Commonwealth Fund, 2002), pp. 55-62; Gerard Anderson and Peter Hussey, Multinational Comparisons of Health Data Systems Data, 2000 (New York: The Commonwealth Fund, 2000), pp. 17-18; Gerard Anderson and Bianca Frogner, Multinational Comparisons of Health Data Systems Data, 2005 (New York: The Commonwealth Fund, 2006).

9Chaoulli v. Quebec (Attorney General), 2005 SCC 35, p. 4.

10Sec 18.06.050(d).

11Sec 18.06.050.

12“The Budgetary Treatment of an Individual Mandate to Buy Health Insurance,” Congressional Budget Office Memorandum, August 1994.

13Rob Stewart and Jeffrey Rhoades, “The Long-Term Uninsured,” Research Note, U.S. Census Bureau, http://aspe.hhs.gov/health/long-term-uninsured04/report.pdf.

14“Income, Poverty and Health Insurance Coverage in the United States: 2006.” US Census Bureau, Housing and Household Economic Statistics Division, August 2007.

15Nadeem Esmail, Michael Walker, and Dominika Wrona, “Waiting Our Turn 16th Edition: Hospital Waiting Lists in Canada,” Fraser Institute, 2006.

16Chaoulli v. Quebec (Attorney General) 2005 SCC.

17“Alaska Car Insurance Requirements,” Department of Motor Vehicles, www.dmv.org/as-alaska/car-insurance.php. last visited August 29, 2007

18Insurance Research Council, “Uninsured Motorists, 2000 Edition,” December 2000.

19Stephanie Jones, “Uninsured Drivers Travel Under the Radar,” Insurance Journal, August 18, 2003.

20Sec. 18.06.030(1)

21Sec 18.06.020.

22Sec 18.06.030(4) (A).

23Sec. 18.06.050(B & C)

24Getsur Davidson et al., “Public Program Crowd-Out of Private Coverage: What Are The Issues?” Robert Woods Johnson Foundation Research Synthesis Report no. 5, June 2004.

25George Borjas, “Welfare Reform, Labor Supply, and Health Insurance in the Immigrant Population,” Journal of Health Economics.22 (2003): 956-957.

26Sec. 18.06.050(B & C)

27See Alain Enthoven, “The History and Principles of Managed Competition,” Health Affairs, supplement (1993).

28John Goodman and Gerald Musgrave, “A Primer on Managed Competition,” National Center for Policy Analysis Policy Report no. 183, April 1994.

29Edmund Haislmaier, “The Significance of Massachusetts Health Reform,” Heritage Foundation WebMemo no. 1035, April 11, 2006

30Edmund Haislmaier, “The Significance of Massachusetts Health Reform,” Heritage Foundation WebMemo no. 1035, April 11, 2006.

31Richard Epstein, “Unmanageable Care,” Reason, May 1993.

32Alain Enthoven, “The History and Principles of Managed Competition,” Health Affairs, supplement (1993), p. 44.

33“The Uninsured: A Primer, Key Facts About Americans Without Health Insurance,” Kaiser Family Foundation, December 2003

34Victoria Craig Bunce, JP Wieske and Vlasta Prikazsky, “Health Insurance Mandates in the States 2007,” Council for Affordable Health Insurance, 2007.

35Ibid.