Code Red: Two Economists Examine the U.S. Healthcare System

December 14, 2010

The Grinch that Stole Obamacare

Filed under: Health insurance,Health Reform,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 3:38 pm

Article 1, Section 8, Clause 3 of the Constitution, better known as the Commerce Clause, states that Congress has the power to “regulate Commerce…among the several States.” To supporters of health reform, the Commerce Clause is the Grinch that stole Obamacare. To opponents, the Commerce Clause might seem like a Sanity Clause (apologies to the Marx Brothers.) One thing now seems certain. Obamacare is on the fast track to the Supreme Court, where a ruling on the Commerce Clause could have far reaching implications for health reform and, frankly, for many other federal interventions into economic activity.

Virginia officials cited the Commerce Clause in arguing that the individual mandate was beyond the power of Congress. U.S. District Judge Henry Hudson agreed with the centrality of the Commerce Clause:

While this case raises a host of complex constitutional issues, all seem to distill to the single question of whether or not Congress has the power to regulate and tax a citizen’s decision to participate in interstate commerce.

Judge Hudson sided with Virginia, stating that “no specifically articulated constitutional authority exists to mandate the purchase of health insurance.”

Judge Hudson does not reject health reform in its entirety. Although he speculates as to whether the bill would have been enacted without the exchange, he notes that the record in the case is insufficient for a final determination and thus he “severs (the individual mandate) with circumspection,” leaving the rest of the bill intact. In doing so he provides a road map to others attempting to strike down the entire legislation, provided they can find some evidence that votes hinged on the inclusion of the exchange.

Suppose that the Supreme Court ultimately agrees with Judge Hudson’s ruling. Is there anything of substance left in Obamacare? Consider the following:

– The law puts barely a dent in the $300 billion tax subsidy for health insurance, thereby losing the single best opportunity for containing costs and funding increased enrollments. Even the economists on Obama’s health reform team regret this failure. Instead, cost containment relies on cutting payments to providers, cuts that may never materialize.

– The law makes strides towards creating electronic health records, but this effort is physician-centric when it should be equally management-centric. This will limit our ability to transform how health care is delivered. Besides, there is not enough money in the bill to promote nationwide adoption of EHR.

– The law encourages the creation of Accountable Care Organizations, the “lite” version of Health Maintenance Organizations. ACOs have far less potential for cost containment and may even exacerbate costs if providers use ACOs as cover for mergers that enhance market power.

For all of the changes to healthcare that are buried in the 2000+ pages of legislation, the centerpiece of Obamacare has always been the expansion of health insurance coverage through the creation of health insurance exchanges. The individual mandate is an essential element of exchanges, intended to assure a broad risk pool so as to encourage insurers to reduce premiums. Take away the mandate and the exchange becomes an overly regulated version of the private insurance market, with little to attract private insurers.

Without the mandate, the exchanges are likely to be no more successful than state regulated insurance pools. Nearly every state has created an insurance pool for individuals and small business that were shut out of the individual market. Many of these pools welcomed low risk enrollees but few applied. The resulting adverse selection caused costs per enrollee to skyrocket, stretching state budgets to the breaking point and limiting combined enrollments across all the states to about 200,000 individuals. This works out to less than 0.5% of the uninsured! California did see some success with its Health Insurance Purchasing Cooperative, a government sponsored private exchange administered by the Pacific Business Group on Health. In the early 2000s, HIPC had nearly 150,000 enrollees, but by mid-decade the program had fallen prey to adverse selection and HIPC folded in 2006.

Two states have full-fledged exchanges. Maine’s Dirigo Health, has been an unmitigated disaster. Prior to Dirigo, Maine had about 135,000 uninsured. The state imposed a 2.14 percent tax on all private health insurance claims to help subsidize enrollments in Dirigo. Enrollment is voluntary and thus far about 15,000 people have signed up, but the majority was previously insured. It is rare to find such a large, broad-based tax that benefits so few individuals.

The Massachusetts Connector is more successful, with about half of the uninsured now covered through the state exchange. But Massachusetts receives substantial subsidies from the federal government (who can Obama turn to, China?). Of greater note, Massachusetts has an employer pay-or-play mandate that is analogous to the purchase mandate that Judge Hudson struck down.

And therein lies the Constitutional rub. States have powers to regulate commerce within their borders that are not available to Congress, which is restricted by the Commerce Clause to regulating industries with nontrivial interstate commerce. Judge Hudson apparently did not believe that health insurance involved substantial interstate commerce and ruled accordingly. Thanks to Obamacare, the Supreme Court is going to have a chance to revisit the Commerce Clause and perhaps provide guidelines for defining “substantial,” guidelines that may apply well beyond the realm of health insurance.

Ironically, Republicans had been calling for new rules allowing the interstate sale of health insurance. Had they succeeded, Judge Hudson might well have found that health insurance was covered by the Commerce Clause and that Congress did have the power to create exchanges.

September 22, 2010

Profit-seeking Health Insurers Seek Profits

Filed under: Health insurance,Health Reform,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 1:02 pm

No one who sees this headline should read any further. There is no news here. So why is everyone getting lathered up about it? Let me explain.

Healthcare reform becomes official this week, as many of the provisions of the legislation kick in. One provision requires insurers to accept children with preexisting conditions while capping what they can charge, undoing a standard industry practice. Several insurers have indicated that they will stop selling child-only policies. Industry officials are having a field day criticizing insurance industry greed.

Maybe these officials haven’t noticed, but insurers are greedy and there is nothing anyone in the Obama administration can do about it. Maybe it needs repeating. Insurers are greedy, have always been greedy, and always will be greedy. So are all investor-owned companies. People don’t invest in health insurance companies (or any other investor-owned companies) for charity. They invest in them to make money. (Investors tend to be greedy too, and that includes the pension funds that most working Americans rely upon for their comfortable retirements.)

Greed lends a certain degree of predictability to policy making. If the government requires a company to alter a product in such a way that it cannot make money selling it, then the company will refuse to sell that product. Usually our legislators have enough wisdom to understand that they cannot banish greed, but not this time. Didn’t anyone tell President Obama that insurers have relied on preexisting condition exclusions to make child-only policies profitable? (A disproportionate percentage of individuals who seek child-only policies do so because of preexisting conditions and this appears to be a far worse problem in the child-only insurance market than in the adult market.) If the government bans these exclusions, insurers will naturally stop selling the policies. Why is anyone shocked when managers do the bidding of their owners?

By choosing to heavily regulate the insurance market, President Obama has shown the same policy ambivalence that seems to mark his entire administration. Here he wants to sustain privately financed healthcare and simultaneously achieve the end results of government financed healthcare. He can’t have it both ways. If he really wanted a privately financed system, he should have done so with the least amount of intervention and let the profit motive work for the greater good, as it does in most markets. Economists have shown how to do this: End the tax subsidy, provide financial incentives for insurers to cover the very ill (risk adjustments? separate high risk pools?) and accept that some individuals will still fall through the cracks and have to rely on safety net providers. If he really wanted the end results of government financed healthcare, then he should have jettisoned the market-based insurance system altogether. We know how to do this to, by following Canada’s lead. Socialized medicine is not without its benefits, and perhaps markets don’t have all that much to offer in healthcare anyway. (That is a debate for another blog, or one hundred blogs.) Pick a side! Healthcare reform is devilish, but the devil you know is better than the one you don’t.

There is, of course, a far more cynical explanation for what is going on. Perhaps President Obama really does prefer socialized medicine, but realizes that he has neither legislative support nor the support of voters. (I doubt I am the first to offer this conjecture.) So he gives us a plan that is sure to fail and lays the blame at the feet of private insurers. Heck, most Americans rank private insurers right down there with tobacco executives, so this populist approach could have traction. After Obama gets done thrashing insurers over these child-only policies, Americans might further lower their opinion of insurers, ranking them right alongside Congress.

September 14, 2010

The Health Insurance Purchase Mandate: Peeking Into Pandora’s Box?

Filed under: Health insurance,Health Reform,Tax deduction,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 8:58 am

Governors from most twenty mostly red states are suing to block the implementation of health reform. I have no idea whether they will win on the legal merits. But when it comes to the economics of the issue, they are on the wrong side. But even as my head says that the mandate is a good thing, my heart tells me otherwise.

Mandating the purchase of a good or service should be anathema to any card-carrying economist. But healthcare is unlike other goods and services in one critical way. No one will sell you food or clothing or anything else that you cannot pay for. But if you need surgery to save your life, someone will operate on you. Healthcare providers are trained to “treat now, bill later.” And while providers pursue (and sometimes harass) the uninsured for payment, the lion’s share of their costs end up as bad debt or charity write-offs. So the uninsured get their care while the rest of us pay for it. An insurance mandate is supposed to prevent such free riding. It is as if we are saying, “We can’t stop ourselves from taking care of everyone who needs medical care, so we will force everyone to pay their fair share.”

This concern about free riding is how we got health insurance in the first place. During the Great Depression, many patients couldn’t pay their bills. So hospitals and doctors encouraged individuals to prepay for their share of the community’s medical costs in exchange for guaranteed access. Even then, many remained uninsured and some had trouble getting medical care. By the 1950s, the new Hill-Burton program subsidized nonprofit hospitals in exchange for guarantees that they would take in the uninsured. A building spree of taxpayer funded county hospitals and community health centers further bolstered the safety net.

This safety net worked quite well for a long time. Thanks in part to tax subsidies, most Americans purchased insurance. Health insurers generously reimbursed private providers and the government had little trouble raising the money to subsidize county hospitals and community care centers, so there was enough money to care for the uninsured. The uninsured might not have had immediate access or seen the best providers, but few died on the streets. But this safety net has grown torn and tattered amidst a perfect storm of economic forces. Providers are either competing away their profits or using market power to build up empires to deter future competition. Either way, they have lost their appetite for serving the uninsured. Counties are cash poor due to the skyrocketing costs of running their hospitals and clinics. And all of this is occurring even as the percentage of uninsured is reaching new highs.

For the better part of the past half century the U.S. healthcare system could accommodate the free riders, but not anymore. So what are we to do? Let the uninsured die on the streets? (I call this the “Dickensian” proposal.) Eliminate market competition so that providers can make enough money to restore the safety net? (If we do this, we might as well embrace the “Canadian” proposal.) Force providers to increase their charity care and bad debt burden? (Although many nonprofit hospitals do not do enough to justify their tax exemptions, this won’t go very far.) Seen in this light, the insurance mandate makes a lot of sense to a lot of people. The uninsured impose a wealth externality on everyone else. Why not use the classic economic solution to externalities and “tax” the unwanted behavior?

But take off the economist’s glasses and the slippery slope comes into view. I am not concerned about mandates, per se. Purchase mandates are hardly exceptional. Children must get vaccinations. Car buyers must pay for airbags. Homeowners must have smoke detectors. Heretofore, most of these mandates have something to do with health and public safety and in many cases, there are genuine health externalities to justify the mandates. But in the last few years, policy makers are increasingly justifying mandates with wealth externalities. Force motorcycle riders to wear helmets because the cost of their head injuries drives up insurance premiums for everyone. By similar logic, tax cigarettes and banish sugary soft drinks from our schools. Why stop there? We can mandate (and monitor?) twice-weekly turns on the treadmill and, God forbid, ban deep dish pizza, char-dogs, and all the other delicacies that make life in Chicago worth living. Health insurance creates a Pandora’s Box of wealth externalities. Perhaps it is best to keep the lid on tightly.

August 4, 2010

The Insurance Mandate Revolt

Filed under: Health insurance,Health Reform,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 8:56 am

Missouri voters have passed a symbolic referendum renouncing the Obama insurance purchase mandate. This follows on the heels of a Virginia federal district court judge agreeing to hear arguments on the constitutionality of the requirement. I can’t comment on the latter but I can’t keep quiet about the former.

I wonder how Missourians would have voted on the following proposition: No one shall receive medical care that they cannot pay for. We don’t have laws like that in other markets for the simple reason that sellers won’t normally sell you something unless you can pay. Maybe our doctors are lousy business people (or maybe they are good humanitarians), but if you need medical care in the U.S. you will receive it, whether you can pay or not. Surgeons don’t ask for your bank statement before they sew you up! But if you don’t pay for your surgery, rest assured someone else will.

We require, through the tax system, that everyone contribute towards the cost of government sponsored education. If we had a nationalized health system, we would do the same — raise taxes and give everyone government sponsored health care. Is that what Missourians want? It seems a worthy goal to avoid socialized medicine and yet make everyone pay their fair share of medical costs. The current system has too many free riders. Say what you want about Obamacare, but if you believe in individual responsibility, you should support the purchase mandate. Unless you are willing to die on the operating table if you can’t afford the sutures.

July 29, 2010

My Blago Blog

Filed under: Health insurance,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 12:21 pm

Yesterday, attorney Sam Adam Jr. said this about his client Rod Blagojevich:

“I love Rod Blagojevich…I love that man,” Adam said outside the courtroom.” My daughter was born 1 pound six ounces and All Kids was the reason she was allowed to live…my wife and I now have a beautiful 35 pound baby.”

The All Kids program is supposed to be for low income individuals who can’t afford health insurance. Sam Adam is, by all accounts, one of the most successful trial attorneys in the country. Given his proven abilities, I will be careful about what I say next. Either there is more to the story of his daughter’s eligibility for All Kids than meets the eye, or he has been feeding at the public trough. If the latter, this has to be the worst example I have ever seen of “crowd out”, where someone who can afford their own insurance lets taxpayers buy it for them.

And Adam says it all with a straight face. What a system.

June 14, 2010

In the News

Filed under: Health services research,Health spending,Research methods,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 8:31 am

I have been away from my blog for a couple of weeks but I have been busy. More on that in a moment.

There are several health related news stories this morning. Price Waterhouse Coopers released a study forecasting a 9 percent increase in health insurance premiums, with deductibles exceeding $400 in the median plan. The nation’s news media took the premium increase in stride but was apoplectic about the size of the deductible. I guess it okay if “employers pay” $15,000 per employee for medical care but it is big news if workers have to pay a few hundred dollars annually. (I scoff because we all know that higher premiums mean lower wages.) I think the bigger news is that despite these big deductibles, health spending keeps going up. I think consumer directed health plans have their place, but they are clearly no panacea.

The other big health stories pertain to the uninsured. A new survey finds that uninsured cancer patients forego some medical care because of the cost. I am guessing that if uninsured cancer patients purchased all the medical care their doctors recommended, they might have to forego housing expenses, food, and other necessities of life because of the cost. The circumstances facing uninsured cancer patients are dire. But is the best solution to provide more medical care? The surveyors are silent on this seemingly essential point. Another study reminds us that the uninsured die sooner. Like similar studies before it, this one fails to determine whether the problem is a lack of insurance, or other individual characteristics unobserved by the researchers.

Let’s stipulate that it stinks to be uninsured and that like it or not, Obamacare might do something about this. With this stipulation, can we stop funding poorly designed studies that attempt to show what we already know?

I confess to being missing in the blogosphere. In the past few weeks, my friend and co-conspirator Will White and I have written a proposal for a new book. Northwestern University Press seems willing to publish it and so we have embarked on this new adventure. The tentative title is “The 17 Percent Solution” which refers to the percent of GDP spent on healthcare and indirectly to an old Sherlock Holmes film. The book will explain why we remain unbridled optimists about the future of private sector healthcare delivery. We will explore past and ongoing attempts to radically restructure the delivery of care and explain why this time may really be different. “Efficient healthcare delivery” may not be an oxymoron much longer.

The important point is we will be blogging excerpts from draft chapters. We want you to understand the ongoing sea change in healthcare delivery and describe what we believe to be best practices worthy of imitation. And we look forward to your feedback. Let us know if we are on target, or half crazy. Give us your examples of best practices. We look forward to sharing our adventure with you.

April 11, 2010

The Camel, the Needle, and the Massachusetts Connector

Filed under: Competition,Health Reform,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 8:07 am

Last week’s events in Massachusetts should serve as a disturbing warning to those folks (myself included) who are crossing their fingers and hoping that exchanges will provide a long term fix to the inequities of free market health insurance. The Massachusetts Connector is the prototype for national health insurance exchanges. Last week, Massachusetts Governor Patrick announced that he would reject 90 percent of the requested premium increases for policies offered through the exchange. Insurers countered that they were losing money in the exchange and would withdraw their policies if premiums did not increase. Patrick fired back that insurers would not be permitted to do business in the state if they stopped participating in the exchange. No one knows how this will ultimately end.

This battle over premiums has exposed a critical weakness in the Connector. Although individuals face penalties if they remain uninsured, the fines are modest and many choose not to buy coverage. Not surprisingly, the uninsured are healthier than average. To make matters worse, individuals can move in and out of coverage at any time; the result is that shrewder individuals wait until they need costly medical care before joining the exchange. This drives up costs and has led to the premium spikes. This in turn pushes out relatively healthy individuals and leads to the death spiral that I blogged about last month.

It is a delicate matter to make an exchange work. Whoever is setting the rules for the Pelosicare exchanges will have to balance several objectives:

1) Encourage everyone to participate – offer high subsidies.
2) Avoid being punitive – keep the penalties for not buying coverage low. (Barack Obama derided Hillary Clinton’s proposal to mandate purchases but this was a sensible idea. Even so, mandates do not by themselves mean anything. Punishments must be meted out to those who fail to comply.)
3) Keep popular support for the exchange – ask all individuals to contribute towards their insurance so as to establish individual accountability and avoid further tax increases

It may be easier for a camel to pass through the eye of a needle than to meet all three objectives.

March 4, 2010

The Yeti

Filed under: Health insurance,Health spending,Uncategorized,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 11:05 pm

Like the fabled Yeti, the adverse selection death spiral is the stuff of legend, intimidating, capable of untold devastation, yet seldom seen. Even today, as it leaves a path of destruction, bystanders point their fingers elsewhere, finding scapegoats among mere mortals. But I believe that I have seen the death spiral. And it is truly abominable.
How else to explain the shocking increases in some health insurance premiums — 20 percent, 30 percent, even 40 percent! If this is the exercise of market power by evil insurers, they must also be stupid insurers. Why wait until now to extort their customers when they have presumably possessed this evil power all along? And why fan the flames of populist hatred when the political winds are already blowing so hot and hard? Besides, the bottom line profits do not square up with the premium increases. Even with these premium increases, insurers will still use the vast majority of their revenues to cover provider costs. It has always been this way before; there is no reason to believe it will change now.

No, I swear it is the death spiral at work. I’ve seen its footprints. During this latest downturn, many individuals have dropped their insurance. It stands to reason that those who need insurance the most, those with chronic healthcare needs, are disproportionately clinging to their coverage. As the risk pool loses its healthiest members, premiums must climb. There is no other logical explanation for what is going on. And, unfortunately, it won’t stop here. Facing steep increases in premiums, more healthy Americans will drop coverage, and premiums for those who still demand coverage will soar yet again, making a mockery of the whole concept of insurance. Thus the death spiral leaves its trail of destruction.

This is how it must be in a competitive health insurance market when employers no longer feel obligated to offer insurance and legislators lack the wisdom to mandate coverage. I fear that before too long, private health insurance will be the exclusive province of those fortunate enough to work for large employers who have natural risk pools. Congress tried to destroy private health insurance by giving us the government option. But Congress is no match for the supernatural forces of the market. The death spiral may yet accomplish what Nancy Pelosi has long dreamed.

Note:  This is the original Code Red blog — Independent, willing to take on all self-serving political rhetoric, and based on economic research.  Do not accept substitutes!

January 17, 2010

Jon Gruber and the Massachusetts Referendum

Filed under: Health Reform,Health services research,Health spending,Research methods,Tax deduction,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 9:00 am

I don’t know if my friend and colleague, MIT economist Jon Gruber, enjoys being in the frying pan, but that is right where he has landed. What started several years ago as a good faith effort to expand health insurance coverage in his home state of Massachusetts has combined with Tuesday’s special election to replace Senator Edward Kennedy to become the single most important political event in the history of health reform. While no election is ever about a single issue, Tuesday’s vote is, more than anything else, a referendum on Gruber’s brainchild, the Massachusetts Health Plan. Gruber now hopes to take his ideas nationwide, with the President’s blessing. But if residents of Massachusetts decide that the experiment has failed, or if they think that Congress’ perverse rewrite of the plan will only make things worse, Republican Scott Brown will upset Democrat Martha Coakley and national health reform will be dead once again.
I suspect that most of you know Jon Gruber. He is a brilliant public finance economist — maybe the best of his generation. (He is also a really nice guy.)  His work on the impact of health insurance costs on labor markets is seminal. Massachusetts could not have chosen more wisely when it asked Gruber to play a lead role in designing a reform plan. It has been a noble experiment. But Gruber has come under attack from some circles for failing to “properly” disclose a $300,000 contract with Health and Human Services to evaluate the impact of national health reform. Yes, there is the potential for conflict of interest, inasmuch as Gruber is more or less evaluating his own proposal. But no one has accused Gruber of fabricating numbers and they shouldn’t – I have never known a more careful researcher. The fact is that Gruber is the most qualified person out there to conduct this research. Yet given the circumstances, perhaps HHS should have asked someone else to conduct the study (or at least ponied up a little bit more money to have some independent validation.)

(Memo to the Wellpoint, whose study showing that health reform could raise premiums by as much as 100% and is praised by the Wall Street Journal: Perhaps you could submit your study to an academic journal and get some serious feedback that would help sharpen your analyses and generate more accurate predictions. The peer review process is a wonderful thing.)

While I think the world of Gruber, I am not sold on his reform proposal and it seems that many in Massachusetts share my skepticism. The state appears evenly split between supporters, those opposed, and the undecided. The plan has sharply reduced the number of uninsured, but taxes have soared and so have premiums. The plan has no serious cost controls and taxpayers appear fed up with having to pay more for their own healthcare while subsidizing health care for others. The national plan is no better, now that the Democrats in Congress have eviscerated the one semi-serious cost containment mechanism by granting favorable tax status to unions and government workers. Add to that the perverse bribes offered to Nebraska’s Ben Nelson and others and the Massachusetts plan looks far more attractive than what Congress will give us.

Economists rarely have the national spotlight shined on them. It is Gruber’s time. The vote on Tuesday is a referendum on his ideas. But if the Republican wins, it may also have been a referendum on the corruption that now pervades Congress. The Democrats are subverting Gruber’s good faith efforts. Maybe it is time for him to respond. Either fish or cut bait.

January 4, 2010

The Health Insurance Mandate

Filed under: Health insurance,Health Reform,Uncategorized,Uninsured — David Dranove and Craig Garthwaite (from Oct 11, 2013) @ 1:56 pm

Two news stories about the proposed health insurance mandate caught my attention this weekend. The Wall Street Journal ran an opinion piece questioning the constitutionality of the mandate. The author argued that Congress cannot mandate that Americans purchase anything. I will leave that one to the lawyers. The Chicago Tribune ran a front page article stating that neither liberals nor conservatives like the mandate. Liberals think it is too expensive for low income folks and conservatives think it violates free market principles. This is ideologically-driven nonsense. Of all the aspects of health reform that are worth debating, this is not one of them.

To understand why the mandate makes sense, bear in mind that sick people in America do receive health care regardless of ability to pay. Doctors and hospitals usually treat first and ask questions (about insurance) later. Okay, sometimes providers ask questions first but enough of them treat patients that no one (well, almost no one) who is uninsured is left on the street to die.
There just isn’t enough charity out there to cover all the costs of the uninsured, so the rest of us feel the pinch.

Conservatives who oppose insurance mandates need to answer the following questions: Are you going to mandate that providers stop treating the uninsured? Or are you going to mandate charity? If neither, then the uninsured are going to receive care and free ride on the rest of us. Government has every right to act on the behalf of the majority and limit the free riding. Look at it this way. Conservatives endorse the right of the government to raise taxes to pay for the national defense, lest those who do not want to pay their share free ride on the rest of us. Just as the national defense protects all of us, so do our medical providers. The parallel to health care is close to exact.

What about the liberals who think that the mandate is too costly? Providing health insurance without some means-tested contribution is just another form of wealth redistribution, and this at a time when all levels of government are looking to raise marginal tax rates on the wealthy just to balance budgets. Why don’t the liberals just tell us how much redistribution they want?

A means-tested insurance mandate will limit free riding and permit a politically negotiated level of wealth redistribution. It ought to be a central component of any market-based health reform.

Next Page »

Blog at

%d bloggers like this: