Reforming Health Care in Kansas

Committee on House Insurance and Financial Institutions

Mr. Chairman:

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 Kansas can and cannot do to help resolve this issue.

For the past 13 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. The University of Kansas Hospital, for example, is considered a center of excellence in cancer treatment. 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 expectancies are affected by exogenous factors like violent crime, poverty, obesity, tobacco and drug use, and other issues unrelated to health care. In contrast, when you compare the outcome for specific diseases like cancer or heart disease, the United States clearly outperforms the rest of the world.5

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.6

It is important, therefore, that any reform of the health care system, either nationally or here in Kansas, 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.

After all, the one common characteristic of all national health care systems is that they ration care. Sometimes they ration it explicitly, denying certain types of treatment altogether. More often, they ration more indirectly, imposing global budgets or other cost constraints that limit the availability of high-tech medical equipment or imposes long waits on patients seeking treatment. For example, one million Britons are waiting for admission to National Health Service hospitals at any given time, and shortages force the NHS to cancel as many as 100,000 operations each year. Roughly 90,000 New Zealanders are facing similar waits. In Sweden, the wait for heart surgery can be as long as 25 weeks, while the average wait for hip replacement surgery is more than a year. And, in Canada more than 800,000 patients are currently on waiting lists for medical procedures.7

Still, there are clearly problems with the US and Kansas health care systems that need to be addressed. For example, too many Kansans lack health insurance. Some 300,000 Kansas citizens were uninsured for at least part of 2005, roughly 10.9 percent of the state’s population.8 While this is considerably less than the national uninsurance rate, it nonetheless represents a problem for the state for several reasons.

First, while we should be careful about equating insurance coverage with access to health care and access to better health, we should be concerned about whether uninsured Kansans are receiving the health care they need. The academic evidence is quite mixed about whether being uninsured results in poorer health outcomes. However, there appears to be some evidence that those without health insurance may delay receiving treatment or receive less preventive care. Certainly, you have all encountered anecdotal evidence of hardships encountered by the uninsured. These hardships should not be discounted.

In addition, we should understand that 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. Thus, to a large degree individuals without health insurance are “free-riding” on the rest of us. We should not, however, overstate these costs. Nationally, the cost of uncompensated care amounts to 3-5 percent of total health care spending.9 This is a problem, to be sure, but not a crisis.

We should also be aware that 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.10 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, at least to the degree that 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.)

Generally, states are exploring three possible-and equally problematic—avenues toward achieving universal coverage.

The first is to have the government pay for health care. At its most radical, this means embracing a single-payer health care system such as those in Canada or Europe. However, as I mentioned at the beginning of my remarks, the one common characteristic of such government-run 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.”11

Less radical proposals would leave the basic health care system intact while expanding government subsidies to low-income individuals and other groups, by increasing eligibility for Medicaid, SCHIP, and other programs. Expansion of these subsidies seem particularly popular with state legislatures since it enables states to maximize their receipt of federal funds, shifting at least a portion of the cost to out-of-state taxpayers.

However, while some level of subsidy may indeed be necessary for the poorest Kansans, the state should proceed cautiously in this regard. Subsidies are liable to squeeze out unsubsidized coverage, encouraging businesses to cease offering employer provided plans, shifting the cost of insurance to taxpayers. This crowding-out phenomenon has been readily apparent with both the traditional Medicaid and SCHIP 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.”12 Other studies have shown that when government programs are cut back, private coverage increases.13

Even Medicaid reforms that are otherwise appealing should be approached cautiously. For example, vouchers and health savings accounts may actually make Medicaid compared more attractive compared to private insurance, increasing the likelihood that employers and individuals will abandon traditional insurance for the program, especially if Medicaid eligibility is extended up the income range as part of the reform.

It should be remembered that health care subsidies to the low-income are essentially a form of welfare. In fact, Medicaid provides average benefits twice as valuable as those available under federal cash assistance programs. Unsurprisingly, studies have found that Medicaid increases dependence and discourages self-reliance in the same way that other welfare programs do.14 Therefore, in reforming Medicaid, states should apply many of the lessons of welfare reform, imposing eligibility restrictions, work requirements, and other welfare-reform-style barriers to discourage people from becoming dependent on the program.

If government is not to pay for universal health insurance, a second approach considered by many states is to impose a mandate on employers. Under most designs, such an approach would require all employers over a certain size to either provide their workers with health insurance or pay taxes to a government program that will insure those workers. Attempts to impose such employer mandates have generally run afoul of ERISSA and been struck down by the courts. But that has not prevented states from continuing to try.

The drawbacks of an employer mandate are obvious. 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. In almost all these cases, the net result will be to hurt the workers that the mandate was designed to help.

If an employer mandate will not work, what about a mandate on individuals? Recently, there has been a great deal of interest in such an approach, a legal requirement that every resident of a state obtain adequate private health insurance coverage. Those who don’t receive such coverage through their employer or some other group would be required to purchase individual coverage. Failure to comply would result in some form of penalty, financial or otherwise. Such a mandate was a key component of last year’s Massachusetts health reform that has received widespread national attention.

Because, unlike single-payer or employer mandates, an individual mandate has received substantial support from organizations and individuals otherwise disposed towards a free market approach to health care reform, I would like to take a little extra time to explain why I believe that this is a very bad idea.

It is import to recognize that such a mandate would represent a significant infringement on individual liberty and decision making. As the Congressional Budget Office has noted, “The government has never required people to buy any good or service as a condition of lawful residence in the United States.”15 And prior to Massachusetts enactment of an individual mandate last year, neither had any state. Some have compared an individual health insurance mandate to the current state mandate for automobile insurance. This is an imperfect analogy, however. 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 would not generally give people such a choice. Second, the reason states mandate auto insurance is for the protection of others rather than oneself. Most states do not mandate you carry insurance for your own injury or repair costs.

Beyond questions of individual liberty, however, there are serious practical questions about an individual mandate.

For example, to enforce a health insurance mandate, some agency of the Kansas government would need some way to determine whether Kansans are insured or not and to penalize those who have not complied with the mandate. But government’s record of enforcing insurance mandates has not been an overwhelming success. For example, 47 states have laws mandating that drivers purchase automobile liability insurance. Yet, roughly 14.5 percent of drivers in those states are uninsured.16 Here in Kansas roughly 10 percent of drivers don’t have the required coverage, barely better than the rate of Kansans without health insurance. Clearly an automobile insurance mandate, with fines as high as $1,000 has failed to force Kansans to buy insurance. There is no reason to believe that a health insurance mandate will be more successful.

The most common solution is to require that Kansans submit proof of insurance when they file their state income taxes. But thousands of Kansans are either not currently required to file tax returns or fail to file despite being required to. Some of these nonfilers are elderly, homeless, the mentally ill, and illegal aliens. Others will have changed their address, perhaps multiple times. Does anyone truly believe that it will be possible to track down every last person in the state and determine whether or not they have health insurance?

Moreover, only about 30 percent of uninsured Americans have been uninsured for a full year. In fact nearly 45 percent will regain insurance within four months.17 Therefore many Kansans who lack health insurance at some point throughout the year, will in fact be insured at the time they file their taxes. Presumably, the “proof of insurance” could include of the length of time that the person was insured, but that would raise the complexity of compliance procedures considerably. It would also increase the incentive to lie.

If the government were able to determine that someone has not purchased health insurance, what penalty would apply? Ideas have been suggested ranging from loss of drivers licenses to direct fines to some sort of tax penalty. Again, as a practical measure, all these approaches are problematic in dealing with low-income individuals, people who don’t file income taxes, transients, and others who are likely to be uninsured. It is unrealistic, therefore, to believe that an individual mandate likely to achieve anything close to universal coverage or significantly reduce health care costs.

On the other hand, the mandate crosses an important line, accepting the principle that it is the government’s responsibility to assure that every American 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.

Whatever the initial minimum benefits package consists of, 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 lawmakers for inclusion under any minimum benefits package. The public at large will likely be unaware of the debate or see resisting the small premium increase caused by any particular additional benefit as unworthy of a similar effort. It is a simple case of concentrated benefits and diffuse costs.

As more benefits were added, the cost of the mandate would increase. That will place legislators in a very difficult position. If they increase subsidies to keep pace with the rising cost of the mandate, the cost of the program will explode. On the other hand, if they hold subsidies 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.

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 government to intervene directly by capping premiums. 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.

An individual mandate, therefore, should not be seen in a vacuum. It is more akin to the first in a series of dominoes. “If you want to go down the road of an individual mandate, it’s necessary to reform the entire health insurance system to make sure healthy people can get affordable coverage and sick people are not priced out of the market,” says Gail Shearer of Consumers Union.18 By distorting the health care marketplace, an individual mandate sets in place a cascading series of additional mandates and regulations resulting, ultimately, in a government-run health care system.

A second problem with Kansas’ health care system lies in the dysfunction of its individual and small group insurance markets. Both of these markets are highly regulated in Kansas, as in most other states, making them inefficient and leading to higher costs. Other states have attempted to solve this problem by combining the two markets and establishing a single regulatory system with the expectation that individual and small group insurance would become more available and affordable. This is the approach that led to the development of “The Connector” in Massachusetts. Several other states are also considering the “connector” model, and I understand Kansas to also be looking at this approach. However, I believe it would be a tremendous mistake for your state to go down this road.

As generally conceived, a Connector would allow individuals and workers in small companies to take advantage of the economies of scale, both in terms of administration and risk pooling, which are currently enjoyed by large employers. Multiple employers would be able to pay into the Connector on behalf of a single employee. And, most importantly, a Connector would allow workers to use pre-tax dollars to purchase individual insurance. This would make insurance personal and portable, rather than tying it to an employer, all very desirable things.

Again, as conceived, a Connector would not actually be an insurer. Insurance would still be provided by the private sector. Rather, a Connector would function as a clearinghouse, a sort of wholesaler or middleman, matching customers with providers and products. Most promisingly, when offered as an option under Section 125 plans, it provides a way around the federal tax preference for employer-provided insurance. If that is all it did, the Connector would be modestly useful tool.

However, in practice, at least as demonstrated in Massachusetts, the Connector can quickly devolve into a regulatory body. For example, in Massachusetts, the Connector has wide-ranging authority to determine what insurance products it will offer. The connector is authorized to offer a “connector seal of approval” to products that provide “high quality and good value.” The connector itself is left to define what constitutes high quality and a good value, but significantly, that phrase frequently appears in legislation as justification for mandated benefits. The connector may choose to sell products that do not receive its seal of approval, but they are not required to do so. In addition, the maximum deductible allowed is $2,700 for an individual and $5,450 for a family. While this conforms to current federal law, it locks in the status quo at a time when attempts are being made to change federal Health Savings Account restrictions. Moreover, individuals choosing a high-deductible policy must combine it with a Health Savings Account. And policies must be community-rating and meet other restrictions designed to limit the ability of insurers to segment the market according to risk.19

As a result of these Connector-imposed restrictions the price of policies it will offer has risen dramatically even before the program becomes operational. Originally estimated by Governor Romney to cost around $250 per month, the cheapest available policy is now expected to cost more than $380 per month. No actual prohibition exists on selling small group or individual insurance outside the Connector. However, because the subsidies and tax advantages are available only within the connector, and because of its competitive advantage in terms of pooling costs and risk, the connector will eventually squeeze out any outside market. In the end, the connector can be expected to become a monopsony purchaser of health insurance.

In practice, the Connector appears to be a form of managed competition. Managed competition, which was the centerpiece of the failed 1993 Clinton health plan, is a scheme under which insurance is provided by the private sector but within an artificial government designed and controlled marketplace. Managed competition is meant to spur competition between health plans, yet competition takes place on a very limited basis. 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. This situation is particularly problematic since an inability to price according to risk generally causes insurers to retreat toward the mean. This step results in an overprovision of services to the healthy and an underprovision to the sick.

Managed competition is an attempt to be a little bit pregnant on the question of markets versus government control. Or, as University of Chicago Law Professor Richard Epstein says, managed competition is “an oxymoron. One can either have managed health care or competition in health care services. It is not possible to have both simultaneously.”20

The dangers inherent with creating a potential new regulatory body such as a Connector would appear to substantially outweigh any advantages, particularly given other options for reforming the individual and small group insurance markets that I will discuss shortly. However, at the very least, should you decide to create a Connector, it should not only be prohibited from regulating insurance, it should be specifically required to offer any health insurance product otherwise approved for sale in the state.

What, then, can Kansas do to improve its health care system? The unfortunate reality is that the state’s options are limited because the real villains and solutions to America’s health care ills 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, Kansas 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 that they cannot afford it.21 This is particularly true for young and healthy individuals that precisely the people who we should be encouraging 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, Kansas currently has some 37 mandated benefits, putting Kansas in the worst half of states for the number of mandates. These include mandates that all insurance policies sold in the state include coverage for Alzheimer’s disease, bone mass measurement, cancer pain medications, dental anesthesia, diabetes self-management, diabetic supplies, drug abuse treatment, mammograms, mastectomies and extended mastectomy stays, mental health-including a requirement for mental health parity, off-label drug use, prostate screening, well-child care, chiropractors, dentists, nurse anesthesiologists, nurse practitioners, optometrists, oral surgeons, osteopaths, pain management specialists, psychologists, pharmacists, physical therapists, physicians assistants, podiatrists, and social workers.22

These mandates add significantly to the cost of insurance. The requirement for mental health parity alone adds as much as 10 percent to the cost of an insurance policy. Many of the other mandates add 1-3 percent each to insurance costs.23 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 Kansas 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 therefore a potentially easier step that Kansas 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 purchasers are essentially stuck with the regulatory regime of the state in which they reside. Kansas businesses and individuals are held hostage by Kansas 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 Kansans do not wish to purchase all 37 types of coverage mandates that your state requires, they could purchase insurance from, say, Idaho, where there are only 13, or 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. Kansas would have to compete for the best regulatory environment in the same way it currently competes with other states for a better 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 nonphysician professionals, and removing barriers to hospital competition.

Third, the state should remove roadblocks to association health plans and other mechanisms for allowing small businesses to band together for the purposes of insurance pooling. The plans currently offered by the Wichita Independent Business Association, the Topeka Independent Business association, and the Kansas restaurant and Hospitality Association offer models for what such plans might look like.

And fourth, the state should continue to do all it can to expand the use of consumer-oriented health plans such as Health Savings Account. Here Kansas should be commended as a leader in removing barriers to HSAs and encouraging their use by state employees and others. I encourage you to continue those efforts and to remain vigilant against proposals that would restrict or limit such plans.

I regret that I have not been able to come here and offer a silver bullet to fix the problems with Kansas health system. Indeed, some may be disappointed that so much of my advice is in the form of what not to do. That 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 Kansans 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 Kansas 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 Kansas 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.

5Miranda Mugford, “A Comparison of Reported Differences in Definitions of Vital Events and Statistics,” World Health Statistics Quarterly 36 (1983), cited in Nicholas Eberstadt, The Tyrany of Numbers: Measurements & Misrule (Washington: American Enterprise Institute press, 1995), p. 50.

6Varduhi 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).

7See Michael Cannon and Michael Tanner, Healthy Competition: What’s Holding Back Health Care and How to Free It (Washington: Cato Institute: 2005), pp. 36-37.

8AARP, State Health Profiles 2006.

9Greg Scandlen, “The Pitfalls of Mandating Health Insurance,” Council for Affordable Health Insurance’s Issues & Answers, no. 135 (April 2006).

10Rob Stewart and Jeffrey Rhoades, “The Long-Term Uninsured,” Research Note, U.S. Census Bureau, http://aspe.hhs.gov/health/long-term-uninsured04/report.pdf.

11Chaoulli v. Quebec (Attorney General), 2005 SCC 35, p. 4.

12Getsur 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.

13George Borjas, “Welfare Reform, Labor Supply, and Health Insurance in the Immigrant Population,” Journal of Health Economics.22 (2003): 956-957.

14See, for example, Aaron Yelowitz, “Evaluating the Effects of Medicaid on Welfare and Work: Evidence from the Past Decade,” Employment Policies Institute, December 2000.

15Robert Hartman and Paul van de Water, “The Budgetary Treatment of an Individual Mandate to Buy Health Insurance,” Congressional Budget Office Memorandum, August 1994.

16Greg Kelly, “Can Government Force People to Buy Insurance?” Issues & Answers No. 123, Council for Affordable Health Insurance, March 2004, citing data from the Insurance Research Council. http://www.cahi.org/cahi_contents/resources/pdf/n123GovernmentMandate.pdf.

17Lyle Nelson, “How Many People Lack Health Insurance and for How Long?” Congressional Budget Office, May 12, 2003.

18Quoted in Julie Appleby, “Mass. Gov. Romney’s Health Care Plan Says Everyone Pays,” USA Today, July 4, 2005.

19Chapter 58 of the Acts of 2006, sections 101 and 76.

20Richard Epstein, “Unmanageable care,” Reason, May 1993.

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

22Victoria Craig Bunce, JP Wieske, and Vlasta Prikazky, “Health Insurance Mandates in the States, 2006,” Council for Affordable Health Insurance, March 2006.