As the old saying goes, you can’t beat something with nothing. If conservatives want to stave off a full government takeover of health care, they need to articulate practical, better solutions that the American people can understand and accept.
Unfortunately, 2017 and 2018 saw Republicans in Congress fritter away a prime opportunity to articulate this type of vision. Predictably, the slogan “repeal-and-replace”—invented by staff for then-Senate Minority Leader Mitch McConnell (R-KY) at the time of Obamacare’s passage—turned into “repeal-vs.-replace.”1 Conservative Republicans focused on repealing the law “root-and-branch,” as McConnell himself famously proclaimed in a 2013 speech, while moderates wanted to replace Obamacare with something that retained most, if not all, of its supposed benefits.2
The debate very quickly bogged down to where congressional Republicans fought over how much of Obamacare to keep. They ended up in a political “no-man’s-land,” with the worst of both worlds: Keeping enough of Obamacare to ensure premiums would remain high, and require massive subsidies to make coverage “affordable,” while repealing enough of the law to allow Democrats to claim that they had “gutted” its preexisting condition provisions.3
Conservatives can only reframe the debate on health care by seizing it. As Margaret Thatcher famously observed, “First you win the argument—then you win the vote.” But one can only win the argument—and the vote—by making it.
Unfortunately, many conservative lawmakers tend not to prioritize health care as an issue: They don’t understand it, don’t feel comfortable discussing the nuances of health policy, and only take a strong stand by outlining what they oppose—whether Obamacare, “Hillarycare,” or single payer—rather than what they support.
But health-care entitlements represent a large, and growing, share of both federal and state budgets. That growth impedes the nation’s ability to keep taxes low and maintain a strong national defense. On the state level, rising health-care spending means that Medicaid has tripled in size over the past three decades—growing from 9.7% of the average state budget in 1985 to 29.7% in 2018—crowding out other priorities like education, transportation, and law enforcement.4
Conservatives who care about any of these issues—from national security to transportation to state and federal taxes—must take an interest in health policy. Not only do their policy preferences depend on it—ordinary voters frustrated by the ever-rising cost of care will demand it. The principles outlined below provide a way forward for conservatives interested in outlining better solutions, ones that put the power to make health decisions back in the hands of doctors and patients, rather than bureaucrats.
After the 2018 campaign, discussion of almost any conservative health-care plan immediately comes back to one issue: What will you do about pre-existing conditions? To say that Republicans botched this issue in the midterm elections would put it mildly. Some failed to grasp the underlying policy, while many thought that repeating their support for pre-existing conditions would neutralize the issue.
But the legislative proposals Congress considered in 2017 and 2018 helped put Republican lawmakers in a box of their own creation.5 Those bills by and large retained two of Obamacare’s pre-existing condition provisions—guaranteed issue, which requires insurers to accept all applicants regardless of health status, and community rating, which requires insurers to charge everyone the same premiums except for a few limited factors (age, family size, geography, and tobacco use). But the bills would have repealed, or allowed states to waive, two other provisions—essential health benefits, which tell insurers what types of treatments to include in their plans, and actuarial value, which tells insurers how much of the average person’s health expenses their policies must cover.
Unfortunately, Republicans failed to understand two key points: one rooted in policy, the other in politics. First, the guaranteed issue and community rating provisions, and not the essential health benefits and actuarial value requirements, represented the “largest share of premium increases due to Obamacare.”6
That conclusion comes from a March 2018 Heritage Foundation study. It analyzed the reasons premiums more than doubled for individual health insurance from 2013 (the year before Obamacare’s major provisions took effect) to 2017.7 Repealing, or allowing states to waive, other regulations, like essential health benefits and actuarial value, without also repealing the guaranteed issue and community rating requirements would bring only minor premium relief to insurance markets.8
Second, on pre-existing conditions, Democrats have no interest in splitting hairs over policy nuances. Particularly after their 2018 midterm election victories, which they attribute in large part to health care, they will attack any change to Obamacare’s regulatory regime as “gutting” the pre-existing condition provisions. In May 2019, as Republicans noted, Democrats brought to the House floor legislation, entitled the Protecting Americans with Pre-Existing Conditions Act, that had at best a tangential relationship to pre-existing conditions.9
Liberals engaged in similar political gamesmanship over pre-existing conditions during the 2018 campaign, attacking Republican proposals to repeal or waive the essential health benefits and actuarial value provisions. As the Washington Post noted, Democrats even attacked one lawmaker, Rep. Brian Fitzpatrick (R-PA), who opposed “repeal-and-replace” legislation because he thought it undermined individuals with preexisting conditions:
The [Democratic Congressional Campaign Committee] really crosses the line here. Fitzpatrick bucked his party to vote against one of the President’s top priorities, the repeal of Obamacare, specifically because he was concerned about the impact on people with pre-existing conditions. His reward? Being attacked for selling his constituents out on the issue because of his minor procedural votes….You would think Democrats would at least applaud him for his courage, but apparently that’s not how the game is played these days.10
Accepting the leftist position didn’t spare Fitzpatrick from Democratic attacks in 2018—and abject surrender won’t spare other Republicans from similar attacks on pre-existing conditions either.
As with prior messaging campaigns from the Left, such as the “Mediscare” ads charging that House Budget Committee Chairman Paul Ryan (R-WI) wanted to throw seniors off a cliff, or the “War on Women” attacks about contraception coverage, when Democrats think they have a winning political issue, they won’t give an inch.
To parry those attacks, conservatives should not expect that claiming support for Obamacare’s pre-existing condition provisions will let them off the proverbial hook. Instead, recognizing that they will get attacked regardless, they should put forward their own better vision, consistent with common sense and human experience.
Conservative messaging on pre-existing conditions went off track when it neglected Obamacare’s biggest victims.11 Who can forget the 4.7 million individuals who received cancellation notices in fall 2013?12 Many lost the health insurance they had and liked, leaving them without coverage when they developed pre-existing conditions.
I know one such individual, the father of a friend and former colleague. He and his wife lost their coverage in the fall of 2013, and when he was diagnosed with colon cancer, the consequences proved devastating:
We turned to a Christian [health care] sharing ministry after Obamacare canceled our Blue Cross Blue Shield plan because it was the only affordable option we had. And we prayed we’d make it to 65 without getting sick. Unfortunately, that didn’t happen. When we realized that I needed to get treatment at M.D. Anderson [Cancer Center] because of the tricky location of the tumor, the cost of entry was prohibitive because our sharing ministry plan was considered “self-pay” by the hospital. That’s when my son started up a GoFundMe to get me in the door to get the care I needed.13
God worked a miracle in that operating room. I’m cancer-free and back to a normal life. But the stress of the financial burden, which would’ve been greatly diminished if we had still had our previous plan, was overwhelming in the face of the diagnosis. That was pain inflicted on our family because of decisions made by politicians and bureaucrats in a distant city. That’s not how things are supposed to be.14
The next time any liberal wants to lecture conservatives about helping people with pre-existing conditions, let him or her read this story. For that matter, let that person contribute to this GoFundMe page, which represents the only “coverage” one individual had after Obamacare bureaucrats snatched his insurance away.
Unfortunately, this story does not represent an isolated incident, as Obamacare’s pre-existing condition provisions have literally priced millions out of coverage. The Kaiser Family Foundation noted that, from the first quarter of 2017 to the first quarter of 2018, more than 2.5 million individuals who do not qualify for Obamacare subsidies dropped their coverage.15 Enrollment outside of the Obamacare exchanges dropped by 38%.16 After a more than doubling of premiums from 2013 through 2017, a nearly 40% increase in rates for 2018 proved the last straw for many, and they dropped their coverage entirely.17
Despite all the political focus on pre-existing conditions, Americans care more about ensuring the affordability of their health-care coverage. Cato Institute polling demonstrates that the popularity of Obamacare’s pre-existing condition provisions drops by 16 points when individuals are told that the provisions will increase premiums.18 And a November 2018 Gallup survey found that, by double-digit margins, Americans care more about premium increases than whether they, or someone in their family, “will be denied health insurance coverage for a pre-existing medical condition.”19 Of course, liberal think-tanks won’t conduct surveys asking whether the American people think the pre-existing condition provisions are worth higher premiums.20
But the more than 2.5 million individuals who dropped their insurance in a single year, likely because Obamacare’s pre-existing condition provisions raised their premiums, have no coverage whatsoever should they suddenly develop a preexisting condition. Therein lies the opportunity for conservatives. Whereas liberals want to ensure individuals have coverage after they develop a pre-existing condition, conservatives should focus on ensuring that people have coverage they can afford before they come down with a pre-existing condition, and can maintain after their diagnosis.
Obamacare articulates a one-size-fits-all approach to preexisting conditions, requiring insurers to provide everyone with the same coverage. But that approach has literally priced millions out of the marketplace, leaving them to fend for themselves. Only repealing these regulations can relieve the millions of Americans struggling to afford coverage.
Instead of the sledgehammer that Obamacare took to insurance markets, conservatives should offer the proverbial scalpel, proposing a series of tailored solutions and options for patients regarding pre-existing conditions.21 Those tailored solutions should focus on the first key principle of any sensible health reform.22
Liberal rhetoric about pre-existing conditions focuses on the symptoms—people unable to obtain coverage after they are diagnosed with serious, and costly, diseases—but ignores the underlying problem: Most Americans do not currently own their own health insurance. If individuals could buy, hold, and keep a policy for many years, if not their whole lifetime, then many fewer people would need to purchase coverage after developing a health condition.
Making insurance personally owned would not only reduce the pre-existing condition problem over time, it would also allow individuals, rather than their employers, to exercise greater control over their health coverage and health care. Of course, it would also mean that government bureaucrats would have less of a role in health care, which might explain why the left spends most of its time micromanaging the symptoms rather than fixing the underlying problem.
These reforms would help to stave off the liberal march to single payer, by fixing the pre-existing condition problem in ways that put patients back in control.
Health Reimbursement Arrangements: A regulation the Trump administration proposed in 2018 could help to revolutionize the current health insurance system.23 The proposed rule would allow employers to contribute money to Health Reimbursement Arrangements (HRAs), which individuals could use to fund their own health insurance tax-free.24
If adopted, this proposed rule would make health coverage individual and portable. Workers could purchase one health insurance policy, and keep it from job to job. Their employers would make a defined contribution—say, $500 per month—toward that policy through the HRA, and workers would pay any premium balance over and above the employer’s contribution on a pre-tax basis.
Likewise, businesses would find this mechanism much simpler than the current menagerie of employer-provided health coverage. Firms could make predictable contributions to their workers’ HRAs each month, making their costs easier to quantify. Employers could also forgo the administrative burden and expense of maintaining their own health plan, even as their workers would have many more insurance choices than most companies (particularly small businesses) can offer.
Health Status Insurance: Whereas HRAs could supplant the current system of employer-provided health insurance, health status insurance would complement it. Status insurance refers to the option for individuals to purchase coverage at some point in the future, should they need it. Put another way, these policies function as “health insurance insurance,” guarding against a future pre-existing condition that might make an individual uninsurable.
Status insurance would guard against the classic pre-existing condition problem, whereby someone changes his job and can no longer obtain health coverage—or, worse yet, has to leave his job because of a health condition and loses his employment and coverage at the same time. At the time of their rollout just over a decade ago, status insurance policies cost one-fifth the amount of health insurance coverage.25 At those prices, individuals could pay a few hundred dollars annually for the reassurance that, if they left their job, they would still have the ability to access quality, affordable coverage, by converting their status insurance into a full-fledged health plan.
Unfortunately, however, Obamacare’s enactment made health status coverage obsolete. Reforming the federal insurance regulations to make status insurance a viable concept would provide protections for individuals who fear the diagnosis of a pre-existing condition—potentially at more affordable rates than the Obamacare status quo.
Other Reforms: Making health coverage portable would reduce the pre-existing condition problem over time. However, it would obviously not help those who already have pre-existing conditions, or individuals who develop pre-existing conditions early in life (e.g., congenital diseases). In those cases, state-based high-risk pools, with appropriate funding from the federal government, would provide coverage.
Policies about pre-existing conditions should also ensure that individuals can access quality care. For instance, direct primary care arrangements, which have grown in popularity in recent years, allow individuals to have frequent interactions with primary care doctors for a set monthly fee.26 These arrangements could prove invaluable for individuals with chronic conditions, to help them to manage their care better.
Likewise, Harvard University professor Regina Herzlinger has promoted the concept of centers of excellence, which she called “focused factories,” as a way to provide high-quality care to individuals with chronic conditions.27 Because quality improves and cost often declines as hospitals perform more of a given type of procedure (e.g., heart bypass, knee replacement), patients would benefit by visiting high-volume facilities.
Walmart and other large employers have adopted this model for certain procedures, and have saved money while doing so, even after paying for patients’ travel costs to visit the centers of excellence.28 High-risk pools could provide a similar service for individuals with pre-existing conditions outside the employer marketplace.
At present, Obamacare does a disservice to individuals with pre-existing conditions. Because it requires insurers to accept all applicants, and charge applicants the same price regardless of health status, it encourages insurers to discriminate against sick patients. Small wonder then that few Obamacare insurers include prominent hospitals like the Mayo Clinic in their networks, because the law gives them every reason to avoid attracting sick patients.29 Likewise, in 2014 a group of HIV patients filed a complaint against several Florida health insurers for failing to cover HIV drugs. The insurers placed all HIV/AIDS drugs, including generics, in the highest-cost tier, to discourage HIV-positive patients from applying for coverage.30
Reforms like high-risk pools, direct primary care, and centers of excellence would allow patients to receive quality care—and hopefully in ways that can lower the cost of care as well. They would help transform our current insurance system to focus on providing more personalized options to patients.
The reasons for this reform principle seem obvious: $22 trillion in federal debt, and rising.31 A Medicare program that needs shoring up, due to the retirement of 10,000 Baby Boomers each day.32 More than $42 trillion in unfunded liabilities for the Medicare program over the next 75 years—more if one disregards the accounting gimmicks, and unrealistic payment reductions, included in Obamacare.33
Unfortunately, during the last presidential election, both major-party candidates saw fit to ignore the looming problems of America’s entitlement system.34 But politicians should not slough off the impending fiscal crisis, not least because financial markets may not allow them to do so.
At the heart of this reform principle lies the sentiment House Majority Leader Steny Hoyer (D-MD) expressed in 2009, and cited earlier in this book: “If we take care of everybody, we won’t be able to take care of those who need us most.”35
Liberals at times try to attack conservatives as uncaring, for wanting to set limits on government spending and intervention. But as Hoyer noted, trying to provide benefits to everybody could end up giving benefits to nobody—one of the prime downsides of a single-payer system. This principle understands the need for a safety net to protect the most vulnerable, but also sets clear priorities for that safety net, to make sure it can last for those truly in need.
Medicaid Reform: Obamacare’s expansion of Medicaid coverage to the able-bodied has strained state and federal budgets alike. For states participating in expansion, enrollment has on average more than doubled beyond states’ original projections.36 The enrollment explosion has placed states under fiscal strain, as Medicaid continues to consume a larger and larger portion of their budgets.37 One Democratic lawmaker in New Mexico admitted that, due to the rising cost of Medicaid expansion, “the most vulnerable of our citizens—the children, our senior citizens, our veterans, individuals with disabilities”—could “get hit.”38
Just as important, Medicaid expansion places able-bodied adults ahead of the most vulnerable in our society, effectively discriminating against individuals with disabilities.39 Obamacare gave states a 90% match to cover able-bodied adults, compared to only a 50-76% match to provide home care to individuals with disabilities.40
The 707,000 individuals with disabilities currently on Medicaid waiting lists for home and community-based care should have priority over subsidies for able-bodied adults.41 Sadly, however, since Obamacare’s Medicaid expansion took effect, at least 21,904 individuals with disabilities in states that expanded Medicaid have died while on waiting lists for care.42
To right-size their budgets, and to end Obamacare’s discrimination against individuals with disabilities, states and the federal government should freeze enrollment in Medicaid expansion.43 Such a change would allow individuals currently on expansion to remain until they become ineligible, but states could not add any new individuals to the Medicaid rolls. In such a manner, states could reduce their rolls over time, as people move off public assistance and into work. This simple change would also save the federal government at least $525-$603 billion, and states at least $56-64 billion, over a decade.44
Once they have begun phasing out expansion, Congress should work with the states to provide additional flexibility for their Medicaid populations in exchange for a fixed-sum block grant. Rhode Island agreed to a similar arrangement under the Bush administration in January 2009, in which the state received expanded waiver authority from federal regulations in exchange for a capped level of federal funding.
The success of Rhode Island’s Medicaid reform provides a way forward for other states. In Rhode Island, per-beneficiary spending declined over a five-year period, and overall spending in Medicaid remained flat for four years, even as enrollment in the program increased during the Great Recession.45 Rhode Island lowered spending on Medicaid not by stinting on care, but providing more of it—better coordinating care and providing more primary care, particularly for vulnerable patients.46 The Rhode Island model provides a clear example of how Medicaid reform can present a “win-win” opportunity, in which taxpayers can save money and patients can receive better care—with the former occurring because of the latter.
Medicare Reform: Absent Obamacare’s deceptive double-counting, whereby Democrats credited provisions as both funding the law’s coverage expansions and extending Medicare’s solvency, the Part A (Hospital Insurance) Trust Fund would likely have faced insolvency.47 Put another way, the current Medicare program is already functionally insolvent; Obamacare’s accounting gimmicks merely masked the problem from the public, and allowed Washington politicians to avoid the issue. While the program desperately needs reform, two solutions could go a long way toward solving Medicare’s shortfalls—if politicians have the courage to act.
First, lawmakers should reform the Medicare benefit, introducing a combined deductible for Part A (hospital coverage) and Part B (physician coverage) of traditional Medicare, while reforming Medigap supplemental coverage. This reform would create a cap on out-of-pocket expenses, which does not currently exist in traditional Medicare. It would also save four out of five Medigap policy-holders an average of $415 per year, by reducing the need for seniors to spend money on expensive supplemental insurance coverage.48
Congress should also convert Medicare into a system that provides seniors a generous contribution to purchase an insurance plan of their choosing—whether a private plan or traditional Medicare—to deliver their benefits. The Congressional Budget Office concluded in 2017 that one such mechanism would save the federal government $184 billion, while also reducing seniors’ premiums by 7%, and their total out-of-pocket spending by 5%.49
This premium support system represents the ultimate “winwin” proposition, in which both seniors and taxpayers benefit. It can do so by unleashing the benefits of competition among private plans and traditional Medicare. It will help make our current Medicare system more sustainable by properly aligning incentives within one key portion of our health-care system.
The ongoing discussion about whether our country spends too much, or too little, on health care misses one key point. At present, our health-care system costs so much because it contains skewed incentives. To put it bluntly, Americans do a good job of spending everyone else’s money, which helps to explain why costs continue to rise ever higher.
A better system would focus on making it possible for Americans to spend more of their own money, which would promote both transparency and efficiency throughout health care markets. If Americans had more properly aligned incentives, and chose to increase their spending on health care, that will represent millions of rational choices by individuals. On the other hand, aligning the incentives correctly could result in lower health costs, if it makes waste in the system more readily apparent.
Tax Treatment of Health Insurance: The current tax treatment of health insurance creates several problems. First, because the federal tax code excludes employer-sponsored coverage, but not individually purchased insurance, from both payroll and income taxes, workers have a strong incentive to obtain coverage from their employers. That employer-based coverage creates the portability problems—and the pre-existing condition problems—outlined above.
Second, the federal tax code provides no limit to the exclusion for employer-sponsored health coverage. Under current law, individuals pay anywhere from 30-50% of their wages in federal and state income and payroll taxes, but no tax at all on health coverage, no matter how generous. Most economists agree that this provision encourages individuals to over-consume health insurance, and ultimately health care.50
A better solution would impose a standard deduction for health coverage, available to those with employer-sponsored coverage and who buy health insurance on their own. If households purchase coverage valued below the amount of the standard deduction, they would receive an added tax benefit compared to current law.
For instance, assume this proposal sets the standard deduction set at $20,000 for family coverage. If a family buys a plan with a premium of only $15,000 per year, they would still get to write off the full $20,000 standard deduction for health coverage on their taxes, whereas at present, they would only receive a tax benefit based on the $15,000 value of their plan.
The standard deduction would better align incentives in two respects. The prospect of an added tax benefit would encourage individuals to spend wisely when shopping for health coverage in the short term. In the longer term, growing the value of the deduction at a slower rate—for instance, the rate of overall inflation, rather than the (higher) rate of health-care inflation—would help reverse rising health-care costs.
Health Savings Accounts: HSAs represent one way to change the tax treatment of health insurance, by encouraging individuals to save for medical expenses in a pre-tax account. They have proven popular with many American families, with at least 21.8 million individuals purchasing HSA-eligible coverage, and HSA account balances set to hit $75 billion by the end of 2020.51
Ideal reforms would increase the annual limit on contributions to an HSA, and allow HSA funds to pay for health insurance premiums. Like the Health Reimbursement Arrangement provision discussed above, this change would make health coverage more portable, by allowing employers to make contributions to workers’ accounts that workers can then use to purchase health insurance. Unlike HRAs, however, HSA funds belong to individuals and not employers, so allowing HSAs to pay for premiums would make both the insurance coverage and leftover fund balances portable to employees.
Scope of Practice: States also have a role to play in aligning incentives properly. They can start by ensuring that medical professionals, like nurse practitioners, can work to the highest scope of their medical training. Currently, some states impose additional restrictions on practitioners—requiring direct supervision by physicians, for instance—that many experts consider unnecessary.52
With our nation facing a physician shortage, reforming scope of practice laws can improve access to care, particularly in rural and underserved areas.53 Scope of practice can also help control the growth of health-care costs, both by expanding available supply and by providing more appropriate service venues—for instance, treating a knee sprain at an urgent care center rather than the emergency room.
Certificate of Need: Here again, state reforms can help improve access to care. Many states have laws that require entities seeking to construct new facilities—from hospitals to MRI clinics to nursing homes—to obtain approval from a government board (i.e., a certificate of need) before doing so. Of course, these boards provide an opportunity for existing providers to keep out potential competition by urging the boards to deny any newcomers the certificate they need to operate.
Certificate of need laws have their roots in a 1970s-style approach to health care that uses centralized planning by bureaucrats to substitute for the judgment of individual patients and doctors. However, research indicates that these laws do not restrain health costs or improve quality.54 Rather than using the edicts of a government board to control health costs, states should instead repeal their certificate of need laws, and focus on reforming other incentives in the health-care system to make it function more efficiently.
The above concepts represent just some of the better alternatives to our current health-care problems and to a government-run, single-payer health system. Most importantly, they put patients at the center of the system, rather than constructing a new bureaucratic apparatus and hoping patients ultimately benefit from it.
Conservatives need to make the case for these better ideas, even as they make the case against single payer. The American people deserve better than the broken status quo, and than single payer. By making sound arguments on both fronts, conservatives can deliver on the former, and prevent the latter.
1 Carl Hulse, “‘Repeal and Replace:’ Words Still Hanging over G.O.P.’s Health Care Strategy,” New York Times, January 15, 2017, https://www.nytimes.com/2017/01/15/us/politics/affordable-care-act-republicans-health-care.html; Chris Jacobs, “‘Repeal and Replace’ Becomes ‘Repeal versus Replace,’” National Review, February 23, 2017, https://www.nationalreview.com/2017/02/repeal-obamacare-replace-obamacare-republicans-disagree/.
2 Jillian Rayfield, “Mitch McConnell at CPAC: Repeal Obamacare ‘Root and Branch,’” Salon, March 15, 2013, https://www.salon.com/2013/03/15/mcconnell_at_cpac_repeal_obamacare_root_and_branch/.
3 Chris Jacobs, “How Republicans Shot Themselves in the Feet on Pre-Existing Conditions,” Federalist, November 12, 2018, https://thefederalist.com/2018/11/12/republicans-shot-feet-pre-existing-conditions/.
4 National Association of State Budget Officers, “The State Expenditure Report,” July 1987, https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/ER_1987.PDF, “Medicaid Expenditures as a Percentage of Total Expenditures,” p. 30; National Association of State Budget Officers, “2018 State Expenditure Report,” November 2018, https://higherlogicdownload.s3.amazonaws.com/NASBO/9d2d2db1-c943-4f1b-b750-0fca152d64c2/UploadedImages/SER%20Archive/2018_State_Expenditure_Report_S.pdf, Table 29, Medicaid Expenditures as a Percentage of Total Expenditures, p. 56.
5 Jacobs, “How Republicans Shot Themselves in the Feet.”
6 Edmund Haislmaier and Doug Badger, “How Obamacare Raised Premiums,” Heritage Foundation Backgrounder No. 3291, March 5, 2018, https://www.heritage.org/sites/default/files/2018-03/BG3291.pdf.
7 Department of Health and Human Services Office of Planning and Evaluation, “ASPE Data Point: Individual Market Premium Changes: 2013-2017,” May 23, 2017, https://aspe.hhs.gov/system/files/pdf/256751/IndividualMarketPremiumChanges.pdf.
8 Chris Jacobs, “Americans Do Have ‘Binary Choices’ About Replacing Obamacare, But Not the Ones Paul Ryan Says,” Federalist, April 4, 2017, https://thefederalist.com/2017/04/04/americans-binary-choices-replacing-obamacare-not-ones-paul-ryan-says/.
9 Juliegrace Brufke, “Republicans Troll Democrats with Proposals to Rename Upcoming Health Care Bill,” The Hill, May 6, 2019, https://thehill.com/homenews/house/442418-republicans-troll-democrats-with-proposals-to-rename-upcoming-health-care-bill; H.R. 986, Protecting Americans with Pre-Existing Conditions Act of 2019.
10 Glenn Kessler, “Democratic Attack Ad Falsely Knocks Republican on Pre-Existing Conditions,” Washington Post Fact Checker blog, October 15, 2018, https://www.washingtonpost.com/politics/2018/10/15/democratic-attack-ad-falsely-knocks-republican-preexisting-conditions/?utm_term=.2ea54de07ccc.
11 Chris Jacobs, “What the Press Isn’t Telling You About the Politics of Pre-Existing Conditions,” Federalist, November 5, 2018, https://thefederalist.com/2018/11/05/press-isnt-telling-politics-pre-existing-conditions/.
12 Associated Press, “Policy Notifications and Current Status, by State,” December 26, 2013, https://finance.yahoo.com/news/policy-notifications-current-status-state-204701399.html.
13 https://www.gofundme.com/coachwhite.
14 Jim White, personal communication, May 8, 2019.
15 Ashley Semanskee, Larry Levitt, and Cynthia Cox, “Data Note: Changes in Enrollment in the Individual Health Insurance Market,” Kaiser Family Foundation, July 31, 2018, https://www.kff.org/health-reform/issue-brief/data-note-changes-in-enrollment-in-the-individual-health-insurance-market/.
16 Ibid.
17 HHS, “Data Point”; Department of Health and Human Services Office of Planning and Evaluation, “ASPE Research Brief: Health Plan Choice and Coverage in the 2018 Federal Health Insurance Exchange,” October 30, 2017, https://aspe.hhs.gov/system/files/pdf/258456/Landscape_Master2018_1.pdf.
18 Emily Ekins, “The ACA’s Pre-Existing Condition Regulations Lose Support When the Public Learns the Cost,” Cato Institute, November 5, 2018, https://www.cato.org/survey-reports/acas-pre-existing-condition-regulations-lose-support-when-public-learns-cost.
19 Justin McCarthy, “Six in Ten Americans Worry About Higher Health Insurance Premiums,” Gallup, December 10, 2018, https://news.gallup.com/poll/245312/six-americans-worry-higher-healthcare-premiums.aspx.
20 Jacobs, “What Liberals Won’t Tell You About Pre-Existing Conditions,” The Federalist June 28, 2018, https://thefederalist.com/2018/06/28/liberals-wont-tell-preexisting-conditions/.
21 Chris Jacobs, “Four Better Ways to Address Pre-Existing Conditions Than Obamacare,” Federalist, November 13, 2018, https://thefederalist.com/2018/11/13/4-better-ways-address-pre-existing-conditions-obamacare/.
22 Chris Jacobs, “Three Health Care Reforms Conservatives Should Rally Around,” Federalist, December 4, 2018, https://thefederalist.com/2018/12/04/3-key-health-care-reforms-conservatives-rally-around/.
23 Chris Jacobs, “How an Obscure Regulatory Change Could Transform American Health Insurance,” The Federalist, October 30, 2018, https://thefederalist.com/2018/10/30/how-an-obscure-regulatory-change-could-transform-american-health-insurance/.
24 Departments of the Treasury, Labor, and Health and Human Services, Proposed rule regarding “Health Reimbursement Arrangements and Other Account-Based Group Health Plans: A Proposed Rule” Federal Register, October 29, 2018, https://www.federalregister.gov/documents/2018/10/29/2018-23183/health-reimbursement-arrangements-and-other-account-based-group-health-plans pp. 54420–77.
25 Reed Abelson, “United to Insure the Right to Insurance,” New York Times, December 2, 2008, https://www.nytimes.com/2008/12/03/business/03insure.html.
26 Lydia Ramsey, “A New Kind of Doctor’s Office Charges a Monthly Fee and Doesn’t Take Insurance—And It Could Be the Future of Medicine,” Business Insider, March 19, 2017, https://www.businessinsider.com/direct-primary-care-a-no-insurance-healthcare-model-2017-3.
27 Regina Herzlinger, Who Killed Health Care? America’s $2 Trillion Medical Problem—And the Consumer-Driven Cure (New York: McGraw-Hill, 2007), pp. 168-72.
28 Lisa Woods, Jonathan Slotkin, and Ruth Coleman, “How Employers Are Fixing Health Care,” Harvard Business Review, March 19, 2019, https://hbr.org/cover-story/2019/03/how-employers-are-fixing-health-care.
29 John Goodman, “Obamacare Can Be Worse Than Medicaid,” Wall Street Journal, June 27, 2018, https://www.wsj.com/articles/obamacare-can-be-worse-than-medicaid-1530052891.
30 Michelle Andrews, “Complaint Says Insurance Plans Discriminate Against HIV Patients,” NPR, July 8, 2014, https://www.npr.org/sections/health-shots/2014/07/08/329591574/complaint-says-insurance-plans-discriminate-against-hiv-patients.
31 Department of the Treasury, “The Debt to the Penny and Who Holds It,” https://www.treasurydirect.gov/NP/debt/current.
32 Russell Heimlich, “Baby Boomers Retire,” Pew Research Center, December 29, 2010, https://www.pewresearch.org/fact-tank/2010/12/29/baby-boomers-retire/.
33 Centers for Medicare and Medicaid Services, “2019 Annual Report of the Boards of Trustees of the Federal Hospital Insurance and Federal Supplemental Medical Insurance Trust Funds,” April 22, 2019, https://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-Trends-and-Reports/ReportsTrustFunds/Downloads/TR2019.pdf?mod=article_inline, Table V.G1, Unfunded HI Obligations from Program Inception through the Infinite Horizon, p. 202, Table V.G3, Unfunded Part B Obligations from Program Inception through the Infinite Horizon, p. 204; and Table V.G5, Unfunded Part D Obligations from Program Inception through the Infinite Horizon, p. 206.
34 Chris Jacobs, “For Presidential Candidates, Some Inconvenient Truths on Entitlements,” National Review, May 12, 2016, https://www.nationalreview.com/2016/05/medicare-insolvency-entitlement-crisis-2016-hillary-clinton-donald-trump-bernie-sanders/.
35 Floor Remarks of Rep. Steny Hoyer on H.R. 3631, Medicare Premium Fairness Act of 2009, Congressional Record September 24, 2009, https://www.congress.gov/congressional-record/2009/09/24/house-section/article/H9908-1, pp. H9913-14.
36 Jonathan Ingram and Nicholas Horton, “Obamacare Expansion Enrollment Is Shattering Projections,” Foundation for Government Accountability, November 16, 2016, https://thefga.org/download/ObamaCare-Expansion-is-Shattering-Projections.PDF, p. 5.
37 Jonathan Ingram and Nicholas Horton, “A Budget Crisis in Three Parts: How Obamacare Is Bankrupting Taxpayers,” Foundation for Government Accountability, February 1, 2018, https://thefga.org/wp-content/uploads/2018/02/A-Budget-Crisis-In-Three-Parts-2-6-18.pdf.
38 Christina Cassidy, “Rising Cost of Medicaid Expansion is Unnerving Some States,” Associated Press, October 5, 2016, http://bigstory.ap.org/article/4219bc875f114b938d38766c5321331a/rising-cost-medicaid-expansion-unnerving-some-states.
39 Chris Jacobs, “How Obamacare Undermines American Values: Penalizing Work, Citizenship, Marriage, and the Disabled,” Heritage Foundation Backgrounder No. 2862, November 21, 2013, http://www.heritage.org/research/reports/2013/11/howobamacare-undermines-american-values-penalizing-work-marriage-citizenship-andthe-disabled.
40 Section 2001(a) of the Patient Protection and Affordable Care Act, P.L. 111-148, codified at 42 U.S.C. 1396d(y)(1); Department of Health and Human Services, “Federal Matching Shares for Medicaid,” Federal Register, November 21, 2017, https://www.govinfo.gov/content/pkg/FR-2017-11-21/pdf/2017-24953.pdf, Table 1, Federal Medical Assistance Percentages and Enhanced Federal Medical Assistance Percentages, Effective October 1, 2018-September 30, 2019, p. 55385.
41 Kaiser Family Foundation, “Waiting List Enrollment for Medicaid Section 1915(c) Home and Community-Based Services Waivers,” April 2019, https://www.kff.org/health-reform/state-indicator/waiting-lists-for-hcbs-waivers/?currentTimeframe=0&sortModel=%7B%22colId%22:%22Location%22,%22sort%22:%22asc%22%7D.
42 Nicholas Horton, “Waiting for Help: The Medicaid Waiting List Crisis,” Foundation for Government Accountability, March 6, 2018, https://thefga.org/wp-content/uploads/2018/03/WAITING-FOR-HELP-The-Medicaid-Waiting-List-Crisis-07302018.pdf.
43 Chris Jacobs, “Putting Obamacare in a Deep Freeze,” National Review, December 7, 2016, http://www.nationalreview.com/article/442820/obamacare-repeal-replace-enrollment-freeze-first-step.
44 Foundation for Government Accountability, “Freezing Medicaid Expansion Enrollment Will Save Taxpayers More Than Half a Trillion,” February 2017, https://thefga.org/wp-content/uploads/2017/02/MedEx-Freeze-Savings-Table.pdf.
45 Testimony of Gary Alexander, former Rhode Island secretary of Health and Human Services, on “Strengthening Medicaid Long-Term Supports and Services” before the Commission on Long Term Care, August 1, 2013, http://ltccommission.org/ltccommission/wp-content/uploads/2013/12/Garo-Alexander.pdf. The author served as a member of the Commission.
46 Lewin Group, “An Independent Evaluation of Rhode Island’s Global Waiver,” December 6, 2011, http://www.ohhs.ri.gov/documents/documents11/Lewin_report_12_6_11.pdf.
47 Jacobs, “Some Inconvenient Truths.”
48 Kaiser Family Foundation, “Medigap Reforms: Potential Effects of Benefit Restrictions on Medicare Spending and Beneficiary Costs,” July 2011, https://www.kff.org/wp-content/uploads/2013/01/8208.pdf, Exhibit 2, Changes in Medicare Spending per Beneficiary and Average Beneficiary Costs under Three Medigap Benefit Options, p. 6.
49 Congressional Budget Office, “A Premium Support System for Medicare: Updated Analysis of Alternative Options,” October 5, 2017, https://www.cbo.gov/system/files/115th-congress-2017-2018/reports/53077-premiumsupport.pdf. Estimates cited refer to CBO’s average bid option for calculating premium support payments, without grandfathering in existing beneficiaries.
50 Congressional Budget Office, “Key Issues in Analyzing Major Health Insurance Proposals,” December 18, 2008, https://www.cbo.gov/sites/default/files/110th-congress-2007-2008/reports/12-18-keyissues.pdf, pp. 85-87.
51 America’s Health Insurance Plans, “Health Savings Accounts and Consumer-Directed Health Plans Grow as Valuable Financial Planning Tools,” April 12, 2018, https://www.ahip.org/wp-content/uploads/2018/04/HSA_Report_4.12.18-1.pdf; Devenir Research, “2018 Year-End HSA Market Statistics and Trends Executive Summary,” February 27, 2019, http://www.devenir.com/wp-content/uploads/2018-Year-End-Devenir-HSA-Research-Report-Executive-Summary.pdf.
52 Institute of Medicine, “The Future of Nursing: Focus on Scope of Practice,” Report Brief, October 2010, http://www.iom.edu/~/media/Files/Report%20Files/2010/The-Future-of-Nursing/Nursing%20Scope%20of%20Practice%202010%20Brief.pdf.
53 IHS Markit, “The Complexities of Physician Supply and Demand: Projections from 2016 to 2030,” Report for the American Association of Medical Colleges, March 2018, https://aamc-black.global.ssl.fastly.net/production/media/filer_public/85/d7/85d7b689-f417-4ef0-97fb-ecc129836829/aamc_2018_workforce_projections_update_april_11_2018.pdf.
54 Matthew Mitchell, “Certificate of Need Laws: Are They Achieving Their Goals?” Mercatus Center, August 2017, https://www.mercatus.org/system/files/mitchell-conqa-mop-mercatus-v2.pdf.