October 2009, Vol. IX, Issue I
The Health Care Choice Act: Lowering Costs by
Allowing Competition in the Individual Insurance Market1
Government restrictions are artificially boosting costs and making it more difficult for families to get health insurance. More specifically, regulatory intervention by state governments is a significant problem, particularly protectionist barriers preventing consumers from buying insurance policies issued in other states. Combined with expensive mandates that states impose on health plans – for everything from chiropractors to breast reduction, the results are less competition and higher premiums. Congressman John Shadegg (R-AZ) has introduced the Health Care Choice Act (H.R. 3217) to restore unfettered interstate commerce and let consumers shop for health insurance plans in a national market. According to one estimate, freedom to purchase insurance policies issued in other states could save some families as much as 30 percent on their health policies. Unleashing the Constitution’s promise of unfettered interstate commerce is the most effective way of breaking up the inefficient oligopolies created by state politicians.
By Sven R Larson, Ph.D.
In many ways, America’s health care system is the best in the world. It has state-of-the-art technology and highly-skilled medical professionals. America is also home to most of the cutting-edge medical research in the world. However, there are also important problems, such as the “third-party payer” model where consumers rarely pay the full cost of their own health care. This creates an incentive for both excessive and expensive use of health care, a problem that would be exacerbated by current proposals for greater government control of the health care system.2
But the third-party payer problem is not the only reason that health care costs are high. State governments impose health insurance coverage mandates, often for “gold-plated” coverage, that drive up the cost of insurance. These regulations, which are unique to each state, are imposed at the behest of interest groups seeking to increase demand for their services. Combined with protectionist barriers that prevent consumers from buying policies from providers in other states, these mandates have severe unintended consequences:
- They limit competition in the health insurance market by preventing insurance buyers from shopping across state lines, creating monopolistic and oligopolistic situations in many states;
- They impose coverage mandates that force health insurance buyers to purchase coverage that they either do not want or cannot afford;
- They force insurers to use community rating instead of experience rating, which means healthy people are forced to subsidize unhealthy people – to the effect that insurance premiums rise for many buyers and healthy people are driven out of the market.
The symptoms of a dysfunctional health insurance market – foremost the significant number of uninsured, but also rising costs – are recognized by many legislators. But the problem cannot be solved, as some suggest, by means of increased government regulation.3 Indeed, government regulation is the cause of most problems in the health insurance market, not the solution.
Restoring a free market health care system would be a daunting task, one that would involve, 1) sweeping reforms to the 45 percent of health care directly financed by government programs, and 2) a complete rewrite of the tax code to remove the distortions that exist in employer-provided health insurance. This paper focuses on the so-called third leg of the stool – policies to remove government barriers and restore competition to the market for individual health insurance.
While many of the uninsured have adequate income,4 premiums are artificially expensive, particularly for those who do not obtain group coverage through their employer (federal law allows employers to buy group policies on the national market, so state mandates and protectionism are not a problem). The major stumbling block is the absence of a free market for non-employer-based health insurance – and state governments deserve the blame. First, state politicians set up cartels by requiring purchase of health insurance only from in-state insurers. Second, after setting up a cartel, the state politicians then impose a complex web of coverage mandates. These mandates drive up the cost of insurance, but since the state has imposed, for all intents and purposes, trade barriers that prohibit the purchase of insurance policies issued elsewhere, these costs get passed on to captive consumers.
The solution is to eliminate trade barriers by unleashing the Constitution’s promise of unfettered interstate commerce. This idea has thus far not been at the forefront of the reform debate. Senate Finance Committee Chairman Max Baucus (D-MT), for instance, has proposed a bill, backed by President Obama, that, according to the Wall Street Journal, would impose “vast new national insurance regulation, huge new subsidies to pay for the higher insurance costs this regulation will require and all financed by new taxes and penalties on businesses, individuals and health-care providers.”5
Governor Deval Patrick of Massachusetts, meanwhile, suggests his state’s health reform is a national model.6 However, the Massachusetts reform does not allow out-of-state purchase of insurance plans. It has also failed to achieve one of its major goals, namely universal coverage. According to the Census Bureau, in 2008 – a year into the Massachusetts reform – 352,000 residents lacked health insurance, up from 340,000 in ’07.7 And health insurance policies in Massachusetts are considerably more expensive than the national average, among the most expensive in the nation.
However, the momentum in the health care debate may be turning, at least slightly, in favor of free-market competition. Recently, Senator Feinstein (D-CA) expressed some support for reducing or eliminating restrictions on selling health insurance across state lines.8 More important, a reform to accomplish this was introduced in 2006 by Congressman John Shadegg (R-AZ). In July 2009, Congressman Shadegg and 15 co-sponsors introduced a new version, H.R. 3217, to eliminate state-based protectionism and allow a national market for non-employer-based health insurance.9
A national market would achieve two things that would help bring insurance premiums down:
- More consumer choice. Insurance buyers would be able to shop for health insurance anywhere in the country and find the plan that best meets their needs. This increases competition among sellers and improves the chances for today’s uninsured to find a plan that is both affordable and suitable to their needs and preferences. One of the leading health insurance exchanges, eHealthInsurance.com, claims to offer more than 10,000 plans from 180 carriers, though obviously only a fraction are available to individual buyers in any given state because of protectionist restrictions.10
- Lower costs. Today, each state has its own specific set of mandates. These mandates unavoidably increase the cost of coverage so long as consumers do not have the Constitutional freedom to shop across state lines. The result is a high fixed cost in creating and offering health plans. But if buyers can purchase an insurance policy from states without costly mandates, they can find health insurance that is more affordable. Moreover, state governments will be encouraged to reduce or eliminate expensive mandates once consumers start buying health insurance policies from sellers in states with lower levels of regulation.
Pseudo-Reform Will Not Work
The bill introduced by Senator Baucus in September 2009, the Framework for Comprehensive Health Reform Act11, contains a provision that would allow health insurance buyers to purchase insurance across state lines. States would be allowed to form compacts, which would be state-by-state bilateral agreements to form free-trade areas for health insurance.
But there are huge problems that make the Baucus bill a hollow gesture. First, each compact would require an approval by Congress, making it highly unlikely that a genuine national market could develop – especially if interest groups start lobbying to protect the status quo. Even more troublesome, states would have very little incentive to create compacts since that would undermine the cozy arrangements that have been created under the current system of protectionism.
The Shadegg proposal, on the other hand, does not contain any poison-pill provisions. The right to buy health insurance across state lines, which theoretically is guaranteed by the Constitution’s interstate commerce clause, would be legislatively affirmed. Congress would only have to enact it once in order to create an unrestricted, nationwide market for insurance plans.
Jurisdictional Competition is the Key to Affordable Health Insurance
Competition between governments increasingly is understood to be an important tool for good economic policy. Simply stated, politicians are less likely to over-tax, over-spend, and over-regulate when they know that individuals can work, save, shop, or invest in another jurisdiction. Borrowing from the insights of the Public Choice economists, jurisdictional competition treats governments as being competitors with each other for jobs and investment. Consider the following analogy: When there is no competition, businesses will charge high prices and offer inferior products and services. But when there is competition, businesses vie to provide better products at lower prices to attract consumers. The same principle applies to governments. When people are captive, politicians treat them shabbily. But when people can – in effect – choose their government (or at least the government where economic activity will occur), then the politicians must be less oppressive in order to keep the geese that lay the golden eggs from flying away.
Jurisdictional competition has become very controversial on the international level. Uncompetitive high-tax nations like France and Germany, for instance, are opposed to tax competition since economic activity has been migrating to lower-tax nations. Politicians from these nations want tax harmonization policies that make it difficult for people to escape oppressive policy. Not surprisingly, economists are particularly critical of these efforts. Indeed, several Nobel Prize winners have commented specifically on competition among governments. James Buchanan points out that “…the intergovernmental competition that a genuinely federal structure offers may be constitutionally ‘efficient’…” and that “…tax competition among separate units…is an objective to be sought in its own right.”12 The late Milton Friedman, meanwhile, wrote, “Competition among national governments in the public services they provide and in the taxes they impose is every bit as productive as competition among individuals or enterprises in the goods and services they offer for sale and the prices at which they offer them.”13 And Gary Becker observed that “…competition among nations tends to produce a race to the top rather than to the bottom by limiting the ability of powerful and voracious groups and politicians in each nation to impose their will at the expense of the interests of the vast majority of their populations.”14
Legal scholars also recognize the dangers of one-size-fits-all policy and government cartelization. John McGinnis of Northwestern University Law School recently wrote that, “Jurisdictional competition…is a primary mechanism for…reducing the ability of interest groups to take resources from the government. Under jurisdictional competition, sovereigns compete by providing efficient levels of public goods. Leaders are thereby restrained from rewarding themselves, their supporters, or influential special interest groups. A large, diverse democracy, where interest groups are held in check by jurisdictional competition, substantially reduces the incentives for individuals to seek rents through government action. Individuals will instead spend their time, on balance, in relatively more productive and peaceful activity.”15
These arguments all apply to the individual health insurance market in America. Under current policy, state governments do not allow consumers to shop for insurance policies issued in other states – even though the Constitution was designed in part to prevent states from imposing trade barriers. Having nonetheless imposed these trade barriers, politicians then impose mandates that force captive consumers to pay more for insurance – or go without insurance at all. But if consumers had the freedom to purchase policies from insurers in states with less onerous levels of regulation, it would be virtually impossible for states to maintain these costly mandates.
A National Insurance Market Means Big Savings for Consumers
A coverage mandate requires a health insurance provider to include coverage of a specified benefit for all policies issued in a state. The insurance buyer, of course, must then pre-pay for all of these benefits. As a consequence, the costs of insurance policies go up as more mandates are added – and rising premiums mean more families are excluded, either because the minimum cost of health insurance grows beyond their budget or because they do not think a gold-plated policy is worth the cost.
In 2006 there were a total of 1,843 coverage mandates in effect at the state level, including the District of Columbia.16 In 2008 that number had risen to 1,961. The number of mandates varies dramatically from state to state: In 2008 Idaho only has 14 mandates while Minnesota imposes 63 mandates. To further complicate the matter, no two states impose the same set of mandates.
Mandates are divided into three categories: benefits, providers and persons. Alcoholism, breast reconstruction, diabetic supplies, mammograms and maternity stays are the most common benefit mandates, each being required in at least 45 states. Two of the rarest mandates are kidney disease (only in Wisconsin) and Wilm’s tumor (New Jersey).
Provider mandates, which require insurance buyers to pre-pay for services by various medical specialists, are also commonplace. Chiropractors are most frequently mandated (46 states), followed by psychologists (44) and optometrists (43). Denturists, pain-management specialists and pastoral counselors are the rarest provider mandates, demanded by only two states in each case.
In terms of covering persons, all 50 states, plus the District of Columbia, mandate that newborns be covered. More than 40 states mandate coverage of adopted children and continuation of coverage for dependents and employees. At the other end of the scale, only 12 states mandate coverage of dependent students and two states – California and Colorado – mandate that health plans cover domestic partners.
There is a link between the states amassing coverage mandates and the rate of Americans lacking health insurance. Those who cannot pay for policies loaded with mandates are left without insurance. Merrill Matthews of the Center for Affordable Health Insurance likens the state-coverage mandates to the auto market, saying that mandatory coverage “…is like saying to someone in the market for a new car, if you can’t afford a Cadillac loaded with options, you have to walk.”17 To elaborate on the analogy, the differences between coverage mandates would be like some states requiring cars to be equipped with satellite radio, others to demand that they all have four-wheel drive, sunroof, etc. The result is undeniably higher costs. Insurance issuers must invest heavily in designing a policy that meets one state’s requirements but is not marketable in other states. That cost gets passed on to insurance buyers in the form of higher premiums.
A closer look at the load of coverage mandates in high mandate states reveals considerable differences in health insurance costs between low and high mandate states. Table 1 below shows how much the mandates in each coverage category add to the cost of a health insurance plan:18
To illustrate how mandates drive the cost of health insurance, suppose an insurance policy without any mandates costs $100. This policy would cover catastrophic health care only; presumably the insurance buyer pays cash for all non-catastrophic health care.
If the insurance buyer lives in the District of Columbia he will have to pay $17.50 extra, on top of the cost for the catastrophic-only policy. If he lived in Idaho he would pay $19.50 on top of the $100.19 By contrast, in Minnesota, with the highest number of mandates, the mandates add $66.50 to the $100 catastrophic-only policy. Hypothetically, therefore, a policy that meets the District of Columbia mandates is 29.6 percent cheaper than one that is tailored to the mandates of Minnesota.
This comparison of the costs of state mandates is, again, based exclusively on the cost mark-up from various mandates. Many other factors affect the cost of health insurance, one of which is the size of the state. However, it nevertheless demonstrates how the mandates make a real difference to the cost of health insurance premiums.
Based on this estimate alone, a family buying an insurance policy for $800 under the Minnesota mandates would cut their monthly cost by $236 per month if they could purchase a policy that met the District of Columbia criteria instead.20
Restored Competition – Good for Everyone, Including the Uninsured
Congressman Shadegg’s proposed Health Care Choice Act is an example of how free competition can be restored in the health insurance market. It allows health insurance buyers to purchase a policy out of state, thereby gutting protectionist barriers. This puts a downward cost pressure on health insurance policies, especially in states with many mandates and high rates of uninsured residents.
The link between state mandates and the uninsured rate is a compelling argument in favor of free competition on the health insurance market. As Figure 1 shows, states with many coverage mandates tend to have somewhat higher rates of uninsured than states with fewer mandates:
An analysis using the latest available data, from 2008, confirms the relationship between mandates and the uninsured rate. Unfortunately, the trend is in the wrong direction. Several states have migrated from the two lowest-mandate groups to the high-mandate group. In only two years the number of states with 40 or more mandates has increased from 16 to 23. This reflects the addition of 118 new state mandates, as identified by the Council for Affordable Health Insurance in 2008.21
The average rate of uninsured residents in those 23 states is 15 percent. This is down from 15.4 percent three years ago, but that difference is entirely attributable to Massachusetts. By forcing its residents to buy health insurance Massachusetts has cut its uninsured rate from eleven percent to 5.5 percent in two years. If we “undo” the Massachusetts reform (which has been a costly mistake22) and make the realistic assumption that the percent of uninsured would have remained at eleven percent, the average uninsured rate for the high-mandate states jumps to 15.3 percent, virtually identical to the 2006 average for the high-mandate states.
The middle group of states with 30-39 mandates has shrunk to 14 from 19 in 2006. Its average uninsured rate fell from 14.8 percent to 12.7 percent. This drop is the result of the migration of states between the three mandate groups. States with more mandates and, on average, higher uninsured rates have added more mandates and thus moved up to the higher group. A similar increase in mandates in states with fewer mandates has added states with (thus far) lower uninsured rates.
The 14 states with fewer than 30 mandates now average 13.4 percent uninsured, up from 13.1 percent. This minor change reinforces the conclusion from 2006, namely that relatively few health insurance mandates are associated with lower rates of uninsured residents. Overall, the 2008 numbers confirm that if health insurance buyers were allowed to buy insurance out of state, fewer Americans would go without any insurance.
The tendency of high-mandate states to have higher rates of uninsured also has implications for the current health reform debate in Congress. If the federal government were to introduce federal mandates, either to replace or to supplement state mandates, the outcome, all other factors held constant, will be a rise in the rate of uninsured Americans.
These differences demonstrate that if health insurance consumers were allowed to buy insurance across state lines, fewer Americans would go without any insurance. Figure 1 is also a stark warning to states considering additional coverage mandates: if imposed, they will likely throw more people into the uninsured category.
In addition to reducing the number of uninsured, free competition in the health insurance market would reflect a proper understanding of federalism. Free competition across state lines was so important to our Founding Fathers that they wrote it in to the Constitution. We know it as the Commerce Clause, or Article I, Section 8, Clause 3. Its main message is that states must not impose protectionist trade barriers. When states prevent their residents from buying insurance out of state, they do in fact impose such protectionist measures.
Congressman Shadegg’s Health Care Choice Act is one way to restore interstate commerce in the health insurance market. It is worth noting, however, that there is nothing that prevents states from beginning such a process immediately. State politicians could repeal mandates, but the challenge with this approach is that interest groups have been very effective at creating the current system, and they would fight to preserve the status quo. In any event, a state-by-state reform approach would likely take time and may only work in states that avoided going overboard with mandates. If so, little would be accomplished in restoring a free market for health insurance in high-mandate states – the places where it is needed most.
Conclusion: The Shift to Market-Based Health Care
It would be simple to achieve the free market goals for the individual health insurance market once deregulation is under way. The most critical element is to ensure consumer freedom so that people can buy an insurance policy tailored to their needs. Health Savings Accounts are important in this aspect as they allow consumers a great deal of latitude in choosing a combination of insurance for unexpected costs and out-of-pocket payments for routine expenses. Indeed, if consumers can shop around for a policy that meets their needs and preferences, they can buy catastrophic insurance with their basic premium, and finance everything else through their HSA. But they can also choose to include a large number of non-catastrophic services.
Free competition on the health insurance market is an important step toward strengthening our Constitutional right to interstate commerce. Supporters of government regulation – such as the mandates that distort the health insurance market – sometimes object that one cannot allow market forces to price people out of health insurance because health care is vital for our survival and a good life. But just because a product or a service is vital to our survival or a good life, it does not mean that the government should be the primary arbiter of how that service is designed or delivered. While we may all agree that good health is inherent to a good life, it is by no means the duty of the government to help us obtain it (or, in this case, make it harder to get). Food is even more important than health care, but we fortunately do not allow the government to step in and regulate what food we buy.
Our Constitution grants us rights, but these rights protect us from government rather than being a promise that government will take care of us by taxing other people.23 To further underscore the consequences of government intervention into the health insurance market, consider the following: A health insurance mandate forces many people to buy a service – such as coverage for a chiropractor – that they will never use. But by purchasing it, they contribute toward paying for chiropractor treatments for others who do use the service. This cross-subsidization, required by government coercion, has negative consequences.
The market for credit is a good analogy. Just like poor health, poor credit is the result of either lifestyle choices or bad luck. Some people end up with bad credit because they make foolish or risky decisions – they get more credit cards than they can handle and spend beyond their capabilities. Others have bad luck and lose their jobs or suffer other significant income losses and cannot pay their bills. In both cases the result is bad credit, with financial consequences that can be quite significant. You can lose your car or your home, be forced to rent under very poor conditions or be left out in the street.
Imagine if the government sought to cross-subsidize in the credit market? Should everyone who obtains a mortgage loan carry their share of other people’s bad credit, for example, by paying a higher rate of interest than their credit score merits? The economic consequences – and moral hazard – of this type of government intervention are unacceptable, of course, as should be intervention in the health insurance market.
The real solution to America’s health care mess is not more regulation, more mandates, more cross-subsidization, or more taxes. The problem is too much government, not too little. The Health Care Choice Act is one example of how steps can be taken to improve health care competition by reducing government intervention.
Dr Sven R Larson served as a research fellow with the Center for Freedom and Prosperity in 2006. He is currently a research fellow with the Wyoming Liberty Group. He is the author of “A Prescription for 2008: What the Next President Needs to Know about Health Reform.”
The Center for Freedom and Prosperity Foundation is a public policy, research, and educational organization operating under Section 501(C)(3). It is privately supported, and receives no funds from any government at any level, nor does it perform any government or other contract work. Nothing written here is to be construed as necessarily reflecting the views of the Center for Freedom and Prosperity Foundation or as an attempt to aid or hinder the passage of any bill before Congress.
The Center for Freedom and Prosperity Foundation, the research and educational affiliate of the Center for Freedom and Prosperity (CFP), can be reached by calling 202-285-0244 or visiting our web site at www.freedomandprosperity.org.
2 A proposed “public option” health insurance would add to the third-party payer problem by introducing a government-managed insurance plan. This would exacerbate the cost-driving problem of the third party model and bring America closer to universal, single-payer health insurance.
3 A campaign endorsed by labor unions, Americans for Health Care, http://americansforhealthcare.org/, is working across the country to convince state legislators to regulate by law how much employers spend on health insurance for their employees. This type of regulatory intervention has also been dubbed the “Wal-Mart tax” since it is typically directed toward Wal-Mart. Recently the Texas state legislature took a step in this direction, as reported by the Center for Freedom and Prosperity: http://www.freedomandprosperity.org/blog/2006-06/2006-06.shtml#091.
4 In its report Income, Poverty and Health Insurance Coverage of August 2005, the Bureau of the Census published income data of households without health insurance for 2004. It is notable that 34.6 percent of all the uninsured earned $50,000 or more, which means that more than one third of the uninsured earn more than the median household income ($44,389). This group is in fact larger than the group that earns $25,000 or less, which is exactly one third of the uninsured, or the group making $25,000-$50,000 (32.3 percent). The report is available at: http://www.census.gov/prod/2005pubs/p60-229.pdf.
5 Public Option Lite – The Baucus plan would make insurance even more expensive; Wall Street Journal Online, September 17, 2009. Available at: http://online.wsj.com/article/SB10001424052970204518504574416930475823324.html# printMode.
6 Patrick, D: Massachusetts Is a Health Reform Model; Wall Street Journal Online, September 17, 2009. Available at: http://online.wsj.com/article/SB10001424052970203440104574405252468577402.html.
7 U.S. Census Bureau: Historical Health Insurance Tables, Table HIA-4. Available at: http://www.census.gov/hhes/www/hlthins/historic/index.html.
8 Lockhead, C: Feinstein Skeptical about Health Care Costs, SFGate.com, September 12, 2009. Available at: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/09/12/MNBR19LPMV.DTL&type=p rintable.
9 The Health Care Choice Act of 2009, available at: http://thomas.loc.gov/cgi-bin/bdquery/D?d111:1:./temp/~bdHeuD:@@@L&summ2=m&|/b ss/111search.html|
10 eHealthInsurance.com, http://www.ehealthinsurance.com/ehi/DidYouKnow.ds. A search for insurance plans using this online exchange shows that an average family may have as few as two insurance plans to choose from if they live in upstate New York, or four plans if they live in Wyoming. It is rare to find more than a half dozen plans to choose from in any one state.
13 Letter to Center for Freedom and Prosperity, 2001. Available at http://www.freedomandprosperity.org/update/u05-15-01/u05-15-01.shtml#3
16 Council for Affordable Health Insurance: Health Insurance Mandates in the States 2008.
17 Matthews, Merrill: Testimony Before the Subcommittee on Workforce, Empowerment and Government Programs, Committee on Small Businesses, House of Representatives, United States Congress; Thursday April 27, 2006.
18 These are cost mark-ups from the mandates alone; in order to get a full assessment of the cost of imposing mandates, one would have to factor in the monopolization that follows when fewer insurance providers decide to offer policies in a high mandate state. In addition to that, higher premiums lead to buyer exclusion which means that insurance providers must spread the costs of offering tailored insurance policies to fewer buyers.
20 It is difficult to estimate how much they would be able to save if they could shop nationally for catastrophic-only coverage. The reason is that such policies are not allowed by the state coverage mandates. However, the laws of economics dictate that the price of catastrophic-only insurance are lower in large states and that, all thing equal, competition on a national basis would drive down the cost of such bare-bones plans further.
21 Available from CAHI at: http://www.cahi.org/cahi_contents/resources/pdf/HealthInsuranceMandates2008.pdf.
22 In addition to the aforementioned increase in the number of uninsured in Massachusetts, Massachusetts has the costliest health insurance premiums in the country. America’s Health Insurance Plans (AHIP) reports that the average annual cost is $16,897 in Massachusetts, close to three times as much as national plans. See: http://www.ahipresearch.org/pdfs/Individual_Market_Survey_December_2007.pdf.
23 Proponents of government intervention into the health market promote health care as an entitlement, but often confuse the entitlement with a right. Michael Barton of the Cascade Policy Institute explains the difference: http://www.cascadepolicy.org/pdf/health_ss/2006_06.pdf. He points out that when the government gives a person an entitlement, it promises that person a certain good or service, something that somebody else will have to provide. But there is no provision in the Constitution of the United States that grants us entitlements – what it does give us is the right to life, liberty and the pursuit of happiness. That does not mean that private solutions cannot be set up to help those in dire need. All it does is stress that such solutions are the primary responsibility of private citizens, not the government.
Americans for Health Care: http://americansforhealthcare.org/
Barton, Michael: “Right” to health care violates individual rights, Cascade Commentary, Cascade Policy Institute, May 2006, http://www.cascadepolicy.org/pdf/health_ss/2006_06.pdf.
Becker, Gary, “What’s Wrong with a Centralized Europe? Plenty,” Business Week, June 29, 1998.
Bolton, John R: “Should We Take Global Governance Seriously?” Chicago Journal of International Law, 2000.
Brennan, Geoffrey and Buchanan, James (1980), “The Power to Tax: Analytical Foundations of a Fiscal Constitution” (Cambridge University Press: Cambridge).
Bureau of the Census: Income, Poverty and Health Insurance Coverage, August 2005, http://www.census.gov/prod/2005pubs/p60-229.pdf.
Center for Freedom and Prosperity: http://www.freedomandprosperity.org/blog/2006-06/2006-06.shtml#091
Council for Affordable Health Insurance: Health Insurance Mandates in the States 2006, http://www.cahi.org/cahi_contents/resources/pdf/MandatePub2006.pdf.
Friedman, Milton: Letter to Center for Freedom and Prosperity, 2001, http://www.freedomandprosperity.org/update/u05-15-01/u05-15-01.shtml#3
Lockhead, C: Feinstein Skeptical about Health Care Costs, SFGate.com, September 12, 2009. Available at: http://www.sfgate.com/cgi-bin/article.cgi?f=/c/a/2009/09/12/MNBR19LPMV.DTL&type=printable
Matthews, Merrill: Testimony Before the Subcommittee on Workforce, Empowerment and Government Programs, Committee on Small Businesses, House of Representatives, United States Congress; Thursday April 27, 2006.
McGinnis, John O, “The Political Economy of Global Multilateralism,” Chicago Journal of International Law, 2000.
Patrick, D: Massachusetts Is a Health Reform Model; Wall Street Journal Online, September 17, 2009. Available at: http://online.wsj.com/article/SB10001424052
Review and Outlook Editorial, Public Option Lite – The Baucus plan would make insurance even more expensive; Wall Street Journal Online, September 17, 2009. Available at: http://online.wsj.com/article/SB10001424052970204518504574416930475823324.html#printMode