Reforming Health Care in Alaska

Share

Mr. Chairman, Senators:

My name is Michael Tanner and I appreciate the invitation toappear today and the opportunity to share my perspective on thevital issue of reforming health care and what Alaska should andshould 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. Beforethat I served as legislative director for the Georgia Public PolicyFoundation and as legislative director for health & welfarewith the American Legislative Exchange Council. In all, I havespent more than 20 years studying the American health care systemand am the author of five books on health care reform, mostrecently Healthy Competition: What’s Holding Back AmericanHealth Care and How to Free It.

During my time studying this issue, I have concluded that, indeveloping health policy it is vital to keep in mind one pertinentfact: for all its problems, the United States offers the highestquality health care in the world. Most of the world’s top doctors,hospitals, and research facilities are located in the UnitedStates. Eighteen of the last 25 winners of the Nobel Prize inMedicine either are U.S. citizens or work in thiscountry.1 U.S. companies havedeveloped half of all the major new medicines introduced worldwideover the past 20 years.2 Infact, Americans played a key role in 80 percent of the mostimportant medical advances of the past 30 years.3 Nearly every type of advanced medicaltechnology or procedure is more available in the United States thanin any other country.4 Byalmost any measure, if you are diagnosed with a serious illness,the United States is the place you want to be. That is why tens ofthousands of patients from around the world come to this countryevery year for treatment.

Of course, I’m aware that, as critics of American health careoften point out, other countries have higher life expectancies andlower infant mortality rates, but those two indicators are not agood way to measure the quality of a nation’s health care sys​tem​.In the United States, very low‐​birth‐​weight infants have a muchgreater chance of being brought to term with the latest medicaltechnologies. Some of those low‐​birth‐​weight babies die soon afterbirth, which boosts our infant mortality rate, but in many otherWestern countries, those high‐​risk, low‐​birth‐​weight infants arenot 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 violentcrime, poverty, obesity, tobacco and drug use, and other issuesunrelated to health care. As the OECD explains, “It is difficult toestimate the relative contribution of the numerous non‐​medical andmedical factors that might affect variations in life expectancyacross countries and over time.“5 Consider the nearly three year disparity in lifeexpectancy between Utah (78.7 years) and Nevada (75.9 years),despite the fact that the have essentially the same health caresystems.6 In fact, theseexogenous factors are so distorting that if you correct forhomicides and accidents, the U.S. rises to the top of the list forlife expectancy.7

On the other hand, when you compare the outcome for specificdiseases like cancer or heart disease, the United States clearlyoutperforms the rest of the world. Take prostate cancer, forexample. Even though American men are more likely to be diagnosedwith prostate cancer than their counterparts in other countries, weare less likely to die from the disease. Less than one out of fiveAmerican men with prostate cancer will die from it, but 57 percentof British men and nearly half of French and German men will. Evenin Canada, a quarter of men diagnosed with prostate cancer, diefrom the disease.

Similar results can be found for other forms of cancer. Forinstance, just 30 percent of U.S. citizens diagnosed with coloncancer die from it, compared to fully 74 percent in Britain, 62percent in New Zealand, 58 percent in France, 57 percent inGermany, 53 percent in Australia, and 36 percent in Canada.Similarly, less than 25 percent of U.S. women die from breastcancer, but 46 percent of British women, 35 percent of Frenchwomen, 31 percent of German women, 28 percent of Canadian women, 28percent of Australian women, and 46 percent of women from NewZealand 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 difficultfor some people to afford the care they want or need. Moreover,while the number of uninsured Americans is often exaggerated, thereare far too many Americans without health insurance. And while theU.S. provides the world’s highest quality health care, that qualityis uneven and too often Americans don’t receive the standard ofcare that they should.

It is important, therefore, that any reform of the health caresystem, either nationally or here in Alaska, not destroy thosethings that make our health care system so effective‐​individualchoice and free markets. In particular, you should avoid thetemptation to increase government regulation and control over thestate’s health care system. I am concerned, therefore, that SB 160is headed down the wrong road to reform.

Let me start, though, by mentioning something important that SB160 gets right. SB 160 is not a single‐​payer plan. For this, thepeople of Alaska can be profoundly grateful. After all, the onecommon characteristic of single‐​payer health care systems is thatthey ration care. Indeed, recently the Canadian Supreme Courtstruck down a portion of that country’s national health caresystem, noting that, “Access to a waiting list is not access tohealth care…there is unchallenged evidence that in someserious cases people die as a result of waiting lists for publichealth care.“9

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

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

Employer Mandate: SB 160 requires employers toprovide workers with health insurance or pay 1 – 2 percent of payrollinto the Alaska Health Fund, a “play or pay” mandate onbusinesses.10 There are twomajor problems with such an approach. First, the net result of ahealth care mandate on businesses will be to hurt the workers thatthe mandate was designed to help. It is simple economics. Theamount of compensation each worker receives is a function of his orher productivity. The employer is indifferent to the makeup of thatcompensation between wages, taxes, insurance premiums, or othercosts associated with that worker’s employment. Mandating anincrease in a worker’s compensation (through the provision ofhealth insurance) increases the worker’s operating costs withoutincreasing the worker’s productivity. Employers must therefore findways to offset the added costs imposed by the mandate. Optionsinclude raising prices (which is unlikely in a competitive market),lowering wages, reducing wage increases, reducing other healthcosts (such as drug coverage or retiree health benefits), reducingother benefits (such as pensions), instituting layoffs, replacingworkers with automation, reducing hiring, hiring ineligible workersincluding undocumented aliens, out‐​sourcing work overseas, or evenmoving 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 furtherlock us into our current‐​employer based health care system.Employer-based health insurance is an historical accident, stemmingfrom a combination of labor shortages and wage‐​price controlsduring World War II. It limits consumer choice by giving decisionsover insurance coverage to employers rather than workers. It meansthat workers who lose their jobs lose their insurance, the primarydriver for the lack of insurance coverage. And it means thatindividuals who do not receive employer‐​provided insurance face anincreased financial burden when they try to purchase insurance ontheir own.

Health care reform should move us away from employer‐​basedinsurance, not extend it.

Individual Mandate: On top of its mandate onbusiness, SB 160 would also impose an individual mandate. AllAlaskans who do not already have insurance meeting certain minimumstandards would be required to participate in the Alaska HealthCare Program.11 As I readthis bill’s language, the mandate for participation does not applyjust to those below 300 percent of the poverty level, who willreceive vouchers under the plan, but to all Alaskans. Thisrepresents a significant expansion of government power andintrusion into the personal health decisions of Alaskans.

In fact, until Massachusetts passed an individual mandate lastyear, no state had ever required that an individual, simply byvirtue of living in a state and for no other reason, purchase aspecific government‐​defined product. As the Congressional BudgetOffice has noted, such a mandate is an “unprecedented” level ofstate intervention in personal decision‐​making. 12

It is of course understandable why legislators might wish torequire participation in the Alaska Health Plan. There is alegitimate‐​if overstated‐​issue, uncompensated care or “free riders“on the current health care system. When an individual withouthealth insurance becomes sick or injured, he or she still receivesmedical treatment. In fact hospitals have a legal requirement toprovide care regardless of ability to pay. Physicians do not facethe same legal requirement, but few are willing to deny treatmentbecause a patient lacks insurance. However, such treatment is notfree. The cost is simply shifted to others, those with insurance,or more often, taxpayers.

In addition, those most likely to go without health insuranceare the young and relatively healthy. For example, although 18 to24 year olds are only 10 percent of the U.S. population, they are21 percent of the long‐​term uninsured.13 For these young, healthy individuals, goingwithout health insurance is often a logical decision. However, thisbecomes a form of adverse selection. Removing the young and healthyfrom the insurance pool means that those remaining in the pool willbe older and sicker. This results in higher insurance premiums forthose who are insured.

And of course for many, universal insurance coverage is theprimary goal of health care reform. Currently, more than 650,000Alaskans, 16.5% of the state’s population, do not have healthinsurance coverage.14 getthe care they need or may face ruinous costs if they do. Anindividual mandate is seen as a way to achieve universal coveragewithout either the job‐​killing burden of an employer mandate or thehigh taxes and inevitable rationing associated with a single‐​payersystem.

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 paythrough higher taxes and/​or higher insurance premiums. Yet thosecosts are generally less than the hospital industry and othersoften portray. Therefore, it is important to distinguish betweenoften‐​cited hospital charges and actual costs. Nationally, actualuncompensated care costs account for approximately 2 – 5 percent oftotal health care spending. Even assuming Alaska is at the high endof the estimate, uncompensated care represents a problem, but not asufficient crisis to justify the very serious problems that stemfrom an individual mandate.

Second, the relative absence of the young and the healthy fromthe insurance pool is an issue only if there are cross subsidies inexisting pools. If everyone’s rates are actuarially fair, thenyoung people’s explicit or implicit premiums do not result in loweror higher premiums for anyone else. If Alaska is truly concernedwith bringing more young and healthy people into the insurancemarket, it should take steps to reduce the cost of insurance forthose people by, for instance, removing mandated benefits andencouraging young people to purchase catastrophic coverage.

Third and perhaps most significantly, there’s a big differencebetween universal coverage and actual access to care. Simply sayingthat people have insurance is meaningless. Many countries provideuniversal insurance but deny critical procedures to patients whoneed them. For example, at any given time, 850,000 Britons arewaiting for admission to National Health Service hospitals, andshortages force the NHS to cancel as many as 50,000 operations eachyear. Next door in Canada, more than 800,000 patients are currentlyon waiting lists for medical procedures.15 According to Canadian Supreme Court ChiefJustice Beverly McLaughlin, many of these individuals sufferchronic pain and some will die awaiting the treatment they’ve beenpromised.16 Trulyincreasing the number of insured is ultimately a product ofimplementing other reforms correctly. Simply giving people a pieceof paper that says they have insurance does nothing to increasetheir access to care.

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

However, auto insurance does provide a useful guide to howdifficult it will be to enforce the mandate. Alaska requires proofof auto insurance to register a car. If caught driving withoutcoverage, the driver’s license can be suspended from 90 days to ayear.17 Despite this,roughly 15 percent of all Alaska drivers remainuninsured.18 In fact, 47states currently require automobile insurance, yet roughly 14.5percent of drivers in those states are uninsured. In some stateslike Texas, the uninsured motorist rate runs as high as 18 percent,and as many as 25 – 30 percent of Los Angeles drivers are unin​sured​.By comparison, in the three states without mandatory autoinsurance, roughly 15 percent of drivers are uninsured, the samerate as Alaska despite the mandate. 19

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

But while an individual mandate is unlikely to achieve universalcoverage, or significantly reduce health care costs, the mandatecrosses an important line: accepting the principle that it is thegovernment’s responsibility to ensure that every Alaskan has healthinsurance. In doing so, it opens the door to further widespreadregulation of the health care industry and political interferencein personal health care decisions. The result will be a slow butsteady spiral downward toward a government‐​run health caresystem.

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

This brings me to my second concern with SB 160.

The Alaska Health Board: SB 160 creates anappointed body, the Alaska Health Board, to oversee theplan.21 This includesdetermining which insurers qualify as “accountable health careplans.” The exact powers of this Board are broad and undefined, butit is clear that it becomes a new regulatory body with the power tolimit what insurance can be sold in Alaska. At a time whenover‐​regulation of insurance is a serious problem, this seems likethe wrong road to follow.

As mentioned earlier, the Board is given the authority todetermine what constitutes “essential healthservices.“22 The Board isgiven no guidance as to what that entails, but we can presume fromsimilar definitions other states have applied, that any definitionof “essential” will be far from the simple catastrophic coveragethat is the purpose of insurance.

It is important to realize that the purpose of insurance is tospread catastrophic risk. That is, it takes an event that haslittle likelihood of occurring, but a high cost if it does occur,and spreads that risk and cost over a large pool of people. Takehome owners insurance for example. The odds of your home burningdown are quite small. But if it does happen, few people have theresources to rebuild on their own. Therefore, people purchaseinsurance to spread that risk across a large number ofhomeowners.

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

But whatever the Board’s initial definition, special interestsrepresenting various health care providers and diseaseconstituencies can certainly be expected to lobby for the inclusionof additional services or coverage under any mandated benefitspackage.

Public choice dynamics are such that providers (who would makemoney from the increased demand for their services) and diseaseconstituencies (whose members naturally have an urgent desire forcoverage of their illness or condition) will always have a strongincentive to lobby legislators for inclusion under any minimumbenefits package. The public at large will likely be unaware of thedebate or will see resisting the small premium increase caused byany particular additional benefit as unworthy of the effort. It isa simple case of concentrated benefits and diffused costs.

If more benefits were continuously added, the cost of themandate would increase. This will place legislators in a verydifficult position. If you increase the size of the vouchers tokeep pace with the rising cost of the mandate, the cost of theprogram will explode. On the other hand, if you hold the size ofthe vouchers steady, the increased cost will be borne by consumers,who would have no choice but to continue purchasing the ever moreexpensive insurance. Since the consumers would have little or noleverage over insurers (they can no longer refuse to buy theirproducts), they can eventually be expected to turn to thegovernment for relief.

This creates a second dilemma for lawmakers. Attempts to scaleback benefits would certainly meet political opposition frompowerful constituencies and complaints about “cuts.” The only otheralternative would be for the state to intervene directly by cappingpremiums. But, insurers unable to charge more for an increasinglyexpensive product can be expected to trim costs by cutting back ontheir reimbursement rates to hospitals and physicians. The resultwill ultimately be rationing, the lack of available health caregoods and services.

One should always be careful of “slippery slope” arguments. Yetin 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 drugcoverage and outlawed insurance policies with more than a $2,000deductible.

I would urge Senators to think very carefully before puttingsuch wide‐​ranging legislative power in the hands of an unelectedBoard.

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

There are two significant dangers to subsidies of thismagnitude. First, the expansion of subsidies will greatly increasethe number of people dependent on government. Given that the medianhousehold income in Alaska is $51,571, the subsidies under SB 160extend government welfare programs well into the middle class. Aswith all means‐​tested government programs, we can expect this newmiddle‐​class welfare benefit to discourage work, family formation,wealth accumulation, and self‐​sufficiency, while creating a votingconstituency for ever‐​expanding benefits.

Second, the subsidies are liable to squeeze out unsubsidizedcoverage. Many Alaskans receiving vouchers will already have healthinsurance, either provided by their employer or purchasedthemselves. This will create incentives for small businesses andothers employing large numbers of low‐​income workers to stopoffering coverage, allowing taxpayers to pick up the slack.Likewise, taxpayers will be forced to pay at least part of theinsurance bill for many people who are currently paying that billfor themselves.

This crowding‐​out phenomenon has been readily apparent with boththe traditional Medicaid and S‑CHIP programs. A Robert Wood JohnsonFoundation survey of 22 studies of the relationship betweengovernment insurance programs and private coverage concluded thatsubstitution of government for private coverage “seemsinevitable.“24 Otherstudies have shown that when government programs are cut back,private coverage increases.25 And, the Congressional Budget Office estimatesthat of every three children added to the S‑CHIP program, one wasalready covered by private health insurance.

This last issue highlights yet another problem with the proposedsubsidies under SB 160‐​they are poorly targeted. Many of thoseeligible for coverage already have health insurance. Therefore thesubsidies should not be seen just as a method of increasingcoverage, but as a way of shifting a large portion of insurancecosts from individuals to the tax system. It becomes simply anotherform of income redistribution. While many taxpayers may accept suchredistribution to the truly poor, how will they feel aboutfinancing transfers to the middle class?

Managed Competition: Essentially SB 160 sets upa system of managed competition. Managed competition, which was theunderlying theory behind both the 1983 Clinton health care plan andMitt Romney’s reforms in Massachusetts is designed to takeadvantage of market competition, but within an artificial andcarefully regulated marketplace.26

But any competition would take place on a very constrainedbasis. Since all plans are required to offer the same core benefitspackage, there will be no more than marginal competition based onbenefit design. In addition, the ability of insurers to manage riskis constrained by the bill’s guaranteed‐​issuerequirements27 (and sinceguaranteed issue is meaningless in the absence of some kind ofcommunity rating, we should assume that restriction will follow).This situation is particularly problematic since an inability toprice according to risk generally causes insurers to retreat towardthe mean, resulting in overprovision of care to the healthy andunder provision to the sick.28 Some limited price competition is likely tooccur, but because plans cannot reduce costs by managing risks orthrough benefit design, even that will be marginal.

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

Supporters of the managed competition liken it to something likeCarMax. “There are many different kinds of cars to choose from, alloffered through one giant dealership.“30 However, CarMax is not the only dealership. Ifyou 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 suchoptions would be available under the Alaska Health plan.

As University of Chicago law professor Richard Epstein haspointed out, “Managed competition is not so much a coherentgovernment plan as an oxymoron. It is possible to have eithermanaged health care or competition in health care services. It isnot possible to have both simultaneously.“31 Even Alain Enthoven, the father of managedcompetition, agrees that “managed competition is not a freemarket.“32

A Better Approach: If the Alaska Health Plan isnot the answer, what can Alaska do to improve its health caresystem? The unfortunate reality is that the state’s options arelimited because both the real villains and solutions to America’shealth care problems lie in Washington, and specifically with thefederal tax code, beyond the reach of state lawmakers. However,there are some important steps that this state can take that willreduce the cost of health care and increase the number of peoplewho are insured, while preserving‐​and even improving‐​the quality ofthe current system.

First, Alaska should do what it can to reduce the cost of healthinsurance. After all, the number one reason that people give fornot purchasing insurance is cost.33 This is particularly true for young and healthyindividuals; precisely the people who should be encouraged to enterthe insurance market before they become older and sicker. Yetcurrent state regulations drive up the cost of health insurance andmake it a reasonably logical decision for these young, healthyindividuals to remain uninsured.

For example, Alaska currently has 28 mandated benefits. Theseinclude alcoholism treatment, breast reconstruction, cervical andprostate cancer screening, diabetes treatment, mammographyscreening, and treatment for phenylketonuria.34

These mandates in total add significantly to the cost ofinsurance. Many of the other mandates add 1 – 3 percent each toinsurance costs.35 Clearly,people should be able to purchase coverage for such conditions andproviders if they desire it. But just as clearly, those who wish topurchase a less inclusive but also less expensive policy should beable to do so. Repealing such mandates would be one of the mosteffective steps that Alaska could take to reduce the cost of healthinsurance and thereby increase the number of people withinsurance.

Of course repealing such mandates will encounter fierceresistance from special interests and may prove politicallydifficult. There is a potentially easier step that Alaska couldtake to achieve similar, indeed possibly more comprehensive,results. The state could amend its insurance laws to allow the saleof any health insurance plan approved for sale byany state.

Currently, health insurance consumers are stuck with theregulatory regime of the state in which they reside. Alaskanbusinesses and individuals are held hostage by the state’sinsurance regulation. But if free to purchase health insuranceregulated by states other than their own, customers could avoidregulations that added unwanted costs. They could in effect,“purchase” another state’s set of regulations by purchasinginsurance from an insurer chartered in that state. If Alaskans donot wish to purchase all 28 required coverage mandates, they couldpurchase insurance from, say, Idaho, where there are only 14, orfrom any state whose laws are more closely aligned with their ownpreferences.

Not only would such a simple change to your state’s insurancelaws benefit consumers, reduce costs, and increase the number ofpeople with insurance, but the same competitive process that drivesproducers to improve quality and reduce costs in other productscould help produce higher quality regulations. Alaska would have tocompete for the best regulatory environment in the same way itcurrently competes with other states for the best taxenvironment.

Secondly, the state should institute a thorough review of how itcan reduce the cost of providing health care. In particular itshould look at such issues as expanding the scope of practice fornon physician professionals, and removing barriers to hospitalcompetition.

Third, the state should continue to do all it can to expand theuse of consumer‐​oriented health plans such as Health SavingsAccounts.

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

It is understandable that Alaskans are frustrated by theinability of Congress to address the undeniable need for healthcare reform. Yet it is sadly true that the keys to health carereform lie in federal, not state, legislation. There are limitedsteps that Alaska can take to make the situation better. But, inthe end, you should be extremely careful to make sure thatimpatience does not push you into taking steps that will ultimatelymake 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 wouldbe happy to answer any questions.


1“Nobel Prize inPhysiology or Medicine Winners 2006 – 1901,” The Nobel Prize InternetArchive, http://​almaz​.com/​n​o​b​e​l​/​m​e​d​i​c​i​n​e​/​m​e​d​i​c​i​n​e​.html.

2PharmaceuticalManufacturers Association, “Facts about the U.S. PharmaceuticalIndustry,” 2002.

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

4Gerard Anderson et al.,“It’s the Prices Stupid: Why the United States Is So Different fromOther Countries,” Health Affairs 22, no. 3 (May/​June2003): 99.

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

6U.S. Census Bureau, 2000Census.

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

8Varduhi Petrosyan, andPeter Hussey, Multinational Comparisons of Health Systems Data,2002 (New York: The Commonwealth Fund, 2002), pp. 55 – 62;Gerard Anderson and Peter Hussey, Multinational Comparisons ofHealth Data Systems Data, 2000 (New York: The CommonwealthFund, 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 BudgetaryTreatment of an Individual Mandate to Buy Health Insurance,“Congressional Budget Office Memorandum, August 1994.

13Rob Stewart andJeffrey Rhoades, “The Long‐​Term Uninsured,” Research Note, U.S.Census Bureau, http://​aspe​.hhs​.gov/​h​e​a​l​t​h​/​l​o​n​g​-​t​e​r​m​-​u​n​i​n​s​u​r​e​d​0​4​/​r​e​p​o​r​t.pdf.

14“Income, Poverty andHealth Insurance Coverage in the United States: 2006.” US CensusBureau, Housing and Household Economic Statistics Division, August2007.

15Nadeem Esmail, MichaelWalker, 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 InsuranceRequirements,” Department of Motor Vehicles,www​.dmv​.org/​a​s​-​a​l​a​s​k​a​/​c​a​r​-​i​n​s​u​r​a​n​c​e.php. last visited August 29,2007

18Insurance ResearchCouncil, “Uninsured Motorists, 2000 Edition,” December 2000.

19Stephanie Jones,“Uninsured Drivers Travel Under the Radar,” InsuranceJournal, 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 etal., “Public Program Crowd‐​Out of Private Coverage: What Are TheIssues?” Robert Woods Johnson Foundation Research Synthesis Reportno. 5, June 2004.

25George Borjas,“Welfare Reform, Labor Supply, and Health Insurance in theImmigrant 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,” HealthAffairs, supplement (1993).

28John Goodman andGerald Musgrave, “A Primer on Managed Competition,” National Centerfor Policy Analysis Policy Report no. 183, April 1994.

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

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

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

32Alain Enthoven, “TheHistory and Principles of Managed Competition,” HealthAffairs, supplement (1993), p. 44.

33“The Uninsured: APrimer, Key Facts About Americans Without Health Insurance,” KaiserFamily Foundation, December 2003

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

35Ibid.