Reforming Health Care in Kansas

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Mr. Chairman:

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 Kansas can and cannotdo 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. 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. The University of Kansas Hospital, for example, isconsidered a center of excellence in cancer treatment. Eighteen ofthe 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 themajor new medicines introduced worldwide over the past 20years.2 In fact, Americansplayed a key role in 80 percent of the most important medicaladvances of the past 30 years.3 Nearly every type of advanced medical technologyor procedure is more available in the United States than in anyother country.4 By almost anymeasure, if you are diagnosed with a serious illness, the UnitedStates is the place you want to be. That is why tens of thousandsof patients from around the world come to this country every yearfor 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 system.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 lifeexpectancies are affected by exogenous factors like violent crime,poverty, obesity, tobacco and drug use, and other issues unrelatedto health care. In contrast, when you compare the outcome forspecific diseases like cancer or heart disease, the United Statesclearly outperforms the rest of the world.5

Take prostate cancer, for example. Even though American men aremore likely to be diagnosed with prostate cancer than theircounterparts in other countries, we are less likely to die from thedisease. Less than one out of five American men with prostatecancer will die from it, but 57 percent of British men and nearlyhalf of French and German men will. Even in Canada, a quarter ofmen diagnosed with prostate cancer, die from 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.6

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

After all, the one common characteristic of all national healthcare systems is that they ration care. Sometimes they ration itexplicitly, denying certain types of treatment altogether. Moreoften, they ration more indirectly, imposing global budgets orother cost constraints that limit the availability of high-techmedical equipment or imposes long waits on patients seekingtreatment. For example, one million Britons are waiting foradmission to National Health Service hospitals at any given time,and shortages force the NHS to cancel as many as 100,000 operationseach 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 ayear. And, in Canada more than 800,000 patients are currently onwaiting lists for medical procedures.7

Still, there are clearly problems with the US and Kansas healthcare systems that need to be addressed. For example, too manyKansans lack health insurance. Some 300,000 Kansas citizens wereuninsured for at least part of 2005, roughly 10.9 percent of thestate's population.8 Whilethis is considerably less than the national uninsurance rate, itnonetheless represents a problem for the state for severalreasons.

First, while we should be careful about equating insurancecoverage with access to health care and access to better health, weshould be concerned about whether uninsured Kansans are receivingthe health care they need. The academic evidence is quite mixedabout whether being uninsured results in poorer health outcomes.However, there appears to be some evidence that those withouthealth insurance may delay receiving treatment or receive lesspreventive care. Certainly, you have all encountered anecdotalevidence of hardships encountered by the uninsured. These hardshipsshould not be discounted.

In addition, we should understand that when an individualwithout health insurance becomes sick or injured, he or she stillreceives medical treatment. In fact hospitals have a legalrequirement to provide care regardless of ability to pay.Physicians do not face the same legal requirement, but few arewilling to deny treatment because a patient lacks insurance.However, such treatment is not free. The cost is simply shifted toothers, those with insurance, or more often, taxpayers. Thus, to alarge 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 percentof total health care spending.9 This is a problem, to be sure, but not acrisis.

We should also be aware that those most likely to go withouthealth 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-termuninsured.10 For theseyoung, healthy individuals, going without health insurance is oftena logical decision. However, this becomes a form of adverseselection. Removing the young and healthy from the insurance poolmeans that those remaining in the pool will be older and sicker.This results in higher insurance premiums for those who areinsured, at least to the degree that 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.)

Generally, states are exploring three possible-and equallyproblematic--avenues toward achieving universal coverage.

The first is to have the government pay for health care. At itsmost radical, this means embracing a single-payer health caresystem such as those in Canada or Europe. However, as I mentionedat the beginning of my remarks, the one common characteristic ofsuch government-run health care systems is that they ration care.Indeed, recently the Canadian Supreme Court struck down a portionof that country's national health care system, noting that, "Accessto a waiting list is not access to health care...there isunchallenged evidence that in some serious cases people die as aresult of waiting lists for public health care."11

Less radical proposals would leave the basic health care systemintact while expanding government subsidies to low-incomeindividuals and other groups, by increasing eligibility forMedicaid, SCHIP, and other programs. Expansion of these subsidiesseem particularly popular with state legislatures since it enablesstates to maximize their receipt of federal funds, shifting atleast a portion of the cost to out-of-state taxpayers.

However, while some level of subsidy may indeed be necessary forthe poorest Kansans, the state should proceed cautiously in thisregard. 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-outphenomenon has been readily apparent with both the traditionalMedicaid and SCHIP programs. A Robert Wood Johnson Foundationsurvey of 22 studies of the relationship between governmentinsurance programs and private coverage concluded that substitutionof government for private coverage "seems inevitable."12 Other studies have shown that whengovernment programs are cut back, private coverageincreases.13

Even Medicaid reforms that are otherwise appealing should beapproached cautiously. For example, vouchers and health savingsaccounts may actually make Medicaid compared more attractivecompared to private insurance, increasing the likelihood thatemployers and individuals will abandon traditional insurance forthe program, especially if Medicaid eligibility is extended up theincome range as part of the reform.

It should be remembered that health care subsidies to thelow-income are essentially a form of welfare. In fact, Medicaidprovides average benefits twice as valuable as those availableunder federal cash assistance programs. Unsurprisingly, studieshave found that Medicaid increases dependence and discouragesself-reliance in the same way that other welfare programsdo.14 Therefore, inreforming Medicaid, states should apply many of the lessons ofwelfare reform, imposing eligibility restrictions, workrequirements, and other welfare-reform-style barriers to discouragepeople from becoming dependent on the program.

If government is not to pay for universal health insurance, asecond approach considered by many states is to impose a mandate onemployers. Under most designs, such an approach would require allemployers over a certain size to either provide their workers withhealth insurance or pay taxes to a government program that willinsure those workers. Attempts to impose such employer mandateshave generally run afoul of ERISSA and been struck down by thecourts. But that has not prevented states from continuing totry.

The drawbacks of an employer mandate are obvious. The amount ofcompensation each worker receives is a function of his or herproductivity. 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. Inalmost all these cases, the net result will be to hurt the workersthat the mandate was designed to help.

If an employer mandate will not work, what about a mandate onindividuals? Recently, there has been a great deal of interest insuch an approach, a legal requirement that every resident of astate obtain adequate private health insurance coverage. Those whodon't receive such coverage through their employer or some othergroup would be required to purchase individual coverage. Failure tocomply would result in some form of penalty, financial orotherwise. Such a mandate was a key component of last year'sMassachusetts health reform that has received widespread nationalattention.

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

It is import to recognize that such a mandate would represent asignificant infringement on individual liberty and decision making.As the Congressional Budget Office has noted, "The government hasnever required people to buy any good or service as a condition oflawful residence in the United States."15 And prior to Massachusetts enactment of anindividual mandate last year, neither had any state. Some havecompared an individual health insurance mandate to the currentstate mandate for automobile insurance. This is an imperfectanalogy, however. First, it has long been recognized that drivingis a privilege, subject to all manner of regulatory requirements.If one does not like the regulations, including an insurancemandate, one can choose not to drive. A health insurance mandatewould not generally give people such a choice. Second, the reasonstates mandate auto insurance is for the protection ofothers rather than oneself. Most states do not mandate youcarry insurance for your own injury or repair costs.

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

For example, to enforce a health insurance mandate, some agencyof the Kansas government would need some way to determine whetherKansans are insured or not and to penalize those who have notcomplied with the mandate. But government's record of enforcinginsurance mandates has not been an overwhelming success. Forexample, 47 states have laws mandating that drivers purchaseautomobile liability insurance. Yet, roughly 14.5 percent ofdrivers in those states are uninsured.16 Here in Kansas roughly 10 percent of driversdon't have the required coverage, barely better than the rate ofKansans without health insurance. Clearly an automobile insurancemandate, with fines as high as $1,000 has failed to force Kansansto buy insurance. There is no reason to believe that a healthinsurance mandate will be more successful.

The most common solution is to require that Kansans submit proofof insurance when they file their state income taxes. But thousandsof Kansans are either not currently required to file tax returns orfail to file despite being required to. Some of these nonfilers areelderly, homeless, the mentally ill, and illegal aliens. Otherswill have changed their address, perhaps multiple times. Doesanyone truly believe that it will be possible to track down everylast person in the state and determine whether or not they havehealth insurance?

Moreover, only about 30 percent of uninsured Americans have beenuninsured for a full year. In fact nearly 45 percent will regaininsurance within four months.17 Therefore many Kansans who lack health insuranceat some point throughout the year, will in fact be insured at thetime 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 proceduresconsiderably. It would also increase the incentive to lie.

If the government were able to determine that someone has notpurchased health insurance, what penalty would apply? Ideas havebeen suggested ranging from loss of drivers licenses to directfines to some sort of tax penalty. Again, as a practical measure,all these approaches are problematic in dealing with low-incomeindividuals, people who don't file income taxes, transients, andothers who are likely to be uninsured. It is unrealistic,therefore, to believe that an individual mandate likely to achieveanything close to universal coverage or significantly reduce healthcare costs.

On the other hand, the mandate crosses an important line,accepting the principle that it is the government's responsibilityto assure that every American has health insurance. In doing so, itopens the door to further widespread regulation of the health careindustry and political interference in personal health caredecisions. The result will be a slow but steady spiral downwardtoward a government-run health care system.

Whatever the initial minimum benefits package consists of,special interests representing various health care providers anddisease constituencies can certainly be expected to lobby for theinclusion of additional services or coverage under any mandatedbenefits package.

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 lawmakers for inclusion under any minimumbenefits package. The public at large will likely be unaware of thedebate or see resisting the small premium increase caused by anyparticular additional benefit as unworthy of a similar effort. Itis a simple case of concentrated benefits and diffuse costs.

As more benefits were added, the cost of the mandate wouldincrease. That will place legislators in a very difficult position.If they increase subsidies to keep pace with the rising cost of themandate, the cost of the program will explode. On the other hand,if they hold subsidies steady, the increased cost will be borne byconsumers, who would have no choice but to continue purchasing theever more expensive insurance. Since the consumers would havelittle or no leverage over insurers (they can no longer refuse tobuy their products), they can eventually be expected to turn to thegovernment for relief.

Attempts to scale back benefits would certainly meet politicalopposition from powerful constituencies and complaints about"cuts." The only other alternative would be for the government tointervene directly by capping premiums. Insurers unable to chargemore for an increasingly expensive product can be expected to trimcosts by cutting back on their reimbursement rates to hospitals andphysicians. The result will ultimately be rationing, the lack ofavailable health care goods and services.

An individual mandate, therefore, should not be seen in avacuum. It is more akin to the first in a series of dominoes. "Ifyou want to go down the road of an individual mandate, it'snecessary to reform the entire health insurance system to make surehealthy people can get affordable coverage and sick people are notpriced out of the market," says Gail Shearer of ConsumersUnion.18 By distorting thehealth care marketplace, an individual mandate sets in place acascading 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 thedysfunction of its individual and small group insurance markets.Both of these markets are highly regulated in Kansas, as in mostother states, making them inefficient and leading to higher costs.Other states have attempted to solve this problem by combining thetwo markets and establishing a single regulatory system with theexpectation that individual and small group insurance would becomemore available and affordable. This is the approach that led to thedevelopment of "The Connector" in Massachusetts. Several otherstates are also considering the "connector" model, and I understandKansas to also be looking at this approach. However, I believe itwould be a tremendous mistake for your state to go down thisroad.

As generally conceived, a Connector would allow individuals andworkers in small companies to take advantage of the economies ofscale, both in terms of administration and risk pooling, which arecurrently enjoyed by large employers. Multiple employers would beable to pay into the Connector on behalf of a single employee. And,most importantly, a Connector would allow workers to use pre-taxdollars to purchase individual insurance. This would make insurancepersonal and portable, rather than tying it to an employer, allvery desirable things.

Again, as conceived, a Connector would not actually be aninsurer. Insurance would still be provided by the private sector.Rather, a Connector would function as a clearinghouse, a sort ofwholesaler or middleman, matching customers with providers andproducts. Most promisingly, when offered as an option under Section125 plans, it provides a way around the federal tax preference foremployer-provided insurance. If that is all it did, the Connectorwould be modestly useful tool.

However, in practice, at least as demonstrated in Massachusetts,the Connector can quickly devolve into a regulatory body. Forexample, in Massachusetts, the Connector has wide-ranging authorityto determine what insurance products it will offer. The connectoris authorized to offer a "connector seal of approval" to productsthat provide "high quality and good value." The connector itself isleft to define what constitutes high quality and a good value, butsignificantly, that phrase frequently appears in legislation asjustification for mandated benefits. The connector may choose tosell products that do not receive its seal of approval, but theyare not required to do so. In addition, the maximum deductibleallowed is $2,700 for an individual and $5,450 for a family. Whilethis conforms to current federal law, it locks in the status quo ata time when attempts are being made to change federal HealthSavings Account restrictions. Moreover, individuals choosing ahigh-deductible policy must combine it with a Health SavingsAccount. And policies must be community-rating and meet otherrestrictions designed to limit the ability of insurers to segmentthe market according to risk.19

As a result of these Connector-imposed restrictions the price ofpolicies it will offer has risen dramatically even before theprogram becomes operational. Originally estimated by GovernorRomney to cost around $250 per month, the cheapest available policyis now expected to cost more than $380 per month. No actualprohibition exists on selling small group or individual insuranceoutside the Connector. However, because the subsidies and taxadvantages are available only within the connector, and because ofits competitive advantage in terms of pooling costs and risk, theconnector will eventually squeeze out any outside market. In theend, the connector can be expected to become a monopsony purchaserof health insurance.

In practice, the Connector appears to be a form of managedcompetition. Managed competition, which was the centerpiece of thefailed 1993 Clinton health plan, is a scheme under which insuranceis provided by the private sector but within an artificialgovernment designed and controlled marketplace. Managed competitionis meant to spur competition between health plans, yet competitiontakes place on a very limited basis. Some limited price competitionis likely to occur, but because plans cannot reduce costs bymanaging risks or through benefit design, even that will bemarginal. This situation is particularly problematic since aninability to price according to risk generally causes insurers toretreat toward the mean. This step results in an overprovision ofservices to the healthy and an underprovision to the sick.

Managed competition is an attempt to be a little bit pregnant onthe question of markets versus government control. Or, asUniversity of Chicago Law Professor Richard Epstein says, managedcompetition is "an oxymoron. One can either have managed healthcare or competition in health care services. It is not possible tohave both simultaneously."20

The dangers inherent with creating a potential new regulatorybody such as a Connector would appear to substantially outweigh anyadvantages, particularly given other options for reforming theindividual and small group insurance markets that I will discussshortly. However, at the very least, should you decide to create aConnector, it should not only be prohibited from regulatinginsurance, it should be specifically required to offer any healthinsurance product otherwise approved for sale in the state.

What, then, can Kansas do to improve its health care system? Theunfortunate reality is that the state's options are limited becausethe real villains and solutions to America's health care ills liein Washington, and specifically with the federal tax code, beyondthe reach of state lawmakers. However, there are some importantsteps that this state can take that will reduce the cost of healthcare and increase the number of people who are insured, whilepreserving-and even improving-the quality of the currentsystem.

First, Kansas should do what it can to reduce the cost of healthinsurance. After all, the number one reason that people give fornot purchasing insurance is that they cannot affordit.21 This is particularlytrue for young and healthy individuals that precisely the peoplewho we should be encouraging to enter the insurance market beforethey become older and sicker. Yet, current state regulations driveup the cost of health insurance and make it a reasonably logicaldecision for these young healthy individuals to remainuninsured.

For example, Kansas currently has some 37 mandated benefits,putting Kansas in the worst half of states for the number ofmandates. These include mandates that all insurance policies soldin the state include coverage for Alzheimer's disease, bone massmeasurement, cancer pain medications, dental anesthesia, diabetesself-management, diabetic supplies, drug abuse treatment,mammograms, mastectomies and extended mastectomy stays, mentalhealth-including a requirement for mental health parity, off-labeldrug use, prostate screening, well-child care, chiropractors,dentists, nurse anesthesiologists, nurse practitioners,optometrists, oral surgeons, osteopaths, pain managementspecialists, psychologists, pharmacists, physical therapists,physicians assistants, podiatrists, and socialworkers.22

These mandates add significantly to the cost of insurance. Therequirement for mental health parity alone adds as much as 10percent to the cost of an insurance policy. Many of the othermandates add 1-3 percent each to insurance costs.23 Clearly, people should be able to purchasecoverage for such conditions and providers if they desire it. Butjust as clearly, those who wish to purchase a less inclusive butalso less expensive policy should be able to do so. Repealing suchmandates would be one of the most effective steps that Kansas couldtake to reduce the cost of health insurance and thereby increasethe number of people with insurance.

Of course repealing such mandates will encounter fierceresistance from special interests and may prove politicallydifficult. There is therefore a potentially easier step that Kansascould take 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 purchasers are essentially stuck withthe regulatory regime of the state in which they reside. Kansasbusinesses and individuals are held hostage by Kansas insuranceregulation. But if free to purchase health insurance regulated bystates other than their own, customers could avoid regulations thatadded unwanted costs. They could, in effect, "purchase" anotherstate's set of regulations by purchasing insurance from an insurerchartered in that state. If Kansans do not wish to purchase all 37types of coverage mandates that your state requires, they couldpurchase insurance from, say, Idaho, where there are only 13, orany 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. Kansas would have tocompete for the best regulatory environment in the same way itcurrently competes with other states for a better 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 fornonphysician professionals, and removing barriers to hospitalcompetition.

Third, the state should remove roadblocks to association healthplans and other mechanisms for allowing small businesses to bandtogether for the purposes of insurance pooling. The plans currentlyoffered by the Wichita Independent Business Association, the TopekaIndependent Business association, and the Kansas restaurant andHospitality Association offer models for what such plans might looklike.

And fourth, the state should continue to do all it can to expandthe use of consumer-oriented health plans such as Health SavingsAccount. Here Kansas should be commended as a leader in removingbarriers to HSAs and encouraging their use by state employees andothers. I encourage you to continue those efforts and to remainvigilant against proposals that would restrict or limit suchplans.

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

It is understandable that Kansans 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 Kansas 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 Kansas 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/nobel/medicine/medicine.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.

5Miranda Mugford, "AComparison of Reported Differences in Definitions of Vital Eventsand Statistics," World Health Statistics Quarterly 36 (1983),cited in Nicholas Eberstadt, The Tyrany of Numbers: Measurements& Misrule (Washington: American Enterprise Institutepress, 1995), p. 50.

6Varduhi Petrosyan, andPeter Hussey, Multinational Comparisons of Health SystemsData, 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).

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

8AARP, State HealthProfiles 2006.

9Greg Scandlen, "ThePitfalls of Mandating Health Insurance," Council for AffordableHealth Insurance's Issues & Answers, no. 135 (April2006).

10Rob Stewart andJeffrey 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 etal., "Public Program Crowd-Out of Private Coverage: What Are TheIssues?" Robert Woods Johnson Foundation Research Synthesis Reportno. 5, June 2004.

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

14See, for example,Aaron Yelowitz, "Evaluating the Effects of Medicaid on Welfare andWork: Evidence from the Past Decade," Employment PoliciesInstitute, December 2000.

15Robert Hartman andPaul van de Water, "The Budgetary Treatment of an IndividualMandate to Buy Health Insurance," Congressional Budget OfficeMemorandum, August 1994.

16Greg Kelly, "CanGovernment Force People to Buy Insurance?" Issues & Answers No.123, Council for Affordable Health Insurance, March 2004, citingdata from the Insurance Research Council.http://www.cahi.org/cahi_contents/resources/pdf/n123GovernmentMandate.p….

17Lyle Nelson, "How ManyPeople Lack Health Insurance and for How Long?" CongressionalBudget Office, May 12, 2003.

18Quoted in JulieAppleby, "Mass. Gov. Romney's Health Care Plan Says Everyone Pays,"USA Today, July 4, 2005.

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

20Richard Epstein,"Unmanageable care," Reason, May 1993.

21"The Uninsured: APrimer, Key Facts About Americans Without Health Insurance," KaiserFamily Foundation, December 2003.

22Victoria Craig Bunce,JP Wieske, and Vlasta Prikazky, "Health Insurance Mandates in theStates, 2006," Council for Affordable Health Insurance, March2006.

23Ibid.