H.R.1384, the “Medicare for All Act of 2019.”

Thank you, Mr. Chairman, members of the Committee, for this invitation to testify today on current proposals to reform the U.S. health care system. My comments will focus on the national gains in health insurance coverage since the passage of the Affordable Care Act (ACA), the problems people continue to report affording health insurance and health care, and the potential of recent Congressional health reform bills to address these problems.

The ACA brought sweeping change to the U.S. health system, expanding comprehensive and affordable health insurance to millions of lower-and middle- income Americans and making it possible for anyone with health problems to buy health insurance by banning insurers from denying people coverage or charging them more because of pre-existing conditions.

The number of uninsured people in the United States has fallen by nearly half since the ACA was signed into law, dropping from a historical peak of 48.6 million people in 2010 to 29.7 million in 2018. There was also a decline in the share of people who reported financial problems associated with medical bills or who had problems getting health care because of cost. A large body of research on the effects of the ACA shows conclusively that the overall impact of the legislation on people's ability to afford health insurance and get needed health care has been positive.

However, three distinct, yet interrelated, problems remain: millions of people remain uninsured, millions of people with insurance have plans that are leaving them underinsured, and health care costs are growing faster than median income in most states.

After dropping significantly through 2015, the national uninsured rate has held steady around 9 percent, with some ominous upticks in fourteen states in 2017. These stalled gains stem from four primary factors:

* Seventeen states have not yet expanded Medicaid, including the heavily populated states of Florida and Texas;

* People with incomes just over the marketplace subsidy threshold (about $48,560 for an individual and $100,000 for a family of four) and many in employer plans have high premium contributions relative to income;

* Congressional and executive actions regarding the individual market and Medicaid that have reduced potential enrollment in both;

* The ACA's exclusion of undocumented immigrants from eligibility for subsidies and Medicaid.

In addition to the 29.7 million people who lack insurance, an estimated 44 million working age adults with insurance are underinsured because they have high out-of-pocket costs and deductibles relative to their income. This is up from 29 million in 2010, according to Commonwealth Fund survey data. The greatest growth in the share of underinsured adults is occurring among those in employer health plans. However, people who buy plans on their own through the individual market--including the ACA marketplaces--are underinsured at the highest rates.

The growth in underinsurance is attributable to two primary factors:

* Growth in cost-sharing, particularly deductibles, in the individual market and employer plans;

* Sluggish growth in U.S. median income such that out-of-pocket health care costs and deductibles are comprising a growing share of income among low- and moderate-income families.

Leaving millions of people uninsured or underinsured has implications for families and the nation's general prosperity. Commonwealth Fund surveys have consistently found that people who lack health insurance, even for short periods of time, or who are underinsured, avoid or delay needed health care and are at risk of accumulating medical debt. Many adults with medical bill or debt problems report serious financial problems including using up all their savings to pay their bills or receiving a lower credit rating as a result of their debt. Other research has demonstrated that people who don't have adequate health insurance all their lives have fundamentally different life experiences and less economic opportunity than those who are adequately insured. This includes lower educational attainment, lifetime earnings, and life expectancy.

A major factor underlying trends in both uninsured and underinsured rates, is the overall rate of growth in U.S. health care costs. Health care costs are the primary driver of premium growth in private insurance. To temper premium growth, insurers and employers have increased deductibles, exposing enrollees to growing out-of-pocket risk. This means that health care costs ultimately drive both consumer decisions to buy insurance (via premiums) and whether to get health care (via cost-sharing). Income-based subsidies and risk reduction strategies like reinsurance can lower premiums and consumer out-of-pocket costs, but they will not address the underlying driver. Moreover, the federal and state costs of those policies will also be affected by overall cost growth. It is therefore critical that such policies be paired with strategies to lower U.S. health care costs.

There is growing evidence that prices paid to providers, especially hospitals, rather than people's use of health care services, are the primary driver of health care cost growth. There is also considerable evidence that prices explain the wide health care spending gap between the United States and other wealthy countries.

Recent research also indicates that per capita costs in U.S. private insurance are rising faster than those in public insurance programs. Since Medicare sets prices for providers while prices in commercial plans are usually the result of negotiation between providers and insurers, or employers, much of this spending differential likely stems from price differences. Gerard Anderson and colleagues note that the difference between prices paid by public and private insurers ballooned from 10 percent in 2000 to 50 percent in 2017. The authors argue that in order to lower the rate of growth in U.S. health care costs, there needs to be increased scrutiny of private insurer payments to providers.

Congressional Democrats have introduced several bills aimed at addressing these interrelated problems of uninsurance, underinsurance, and rising health care costs. These bills are similar in that they expand the public dimensions of our mixed private and public health care system. They can be characterized as falling along a continuum with single-payer or Medicare for all proposals at one end. The bills range from adding more public sector involvement into the system, to adding substantially more public sector involvement, and may be broadly grouped into three categories:

. Adding public plan features to private insurance. These bills include provisions to enhance the premium and cost-sharing subsidies for marketplace plans, fixing the so-called "family coverage glitch" in employer plans, adding reinsurance, and addressing the Medicaid coverage gap for low income people in non-expansion states.

. Giving people a choice of public plans alongside private plans. In addition to enhancing ACA subsidies and providing reinsurance, the bills in this category also give consumers a choice of a public plan, based on either Medicare or Medicaid, for people in the ACA marketplaces and employers. The bills also use the leverage of the federal government's buying power in setting premiums for the public plan, establishing provider payment rates, and negotiating prescription drug prices. Some bills also improve benefits for people currently enrolled in Medicare.

. Making public plans the primary source of coverage in the U.S. Bills in this category are single-payer or Medicare-for-all bills in which all residents are eligible for a public plan that resembles the current Medicare program, but is not the same program we have today. The bills limit or end premiums and cost-sharing and end most current forms of insurance coverage including most private coverage, with the exception of HR 7337 which retains employer coverage as an option. Benefits are comprehensive and include services not currently covered by Medicare such as dental and vision and long-term care. The approach brings substantial federal leverage to bear in setting premiums, and lowering provider and prescription drug prices.

While details will matter in terms of the degree of change, the multitude of individual provisions proposed in these bills have the potential to make the following general directional changes in the U.S health care system:

* Improve the affordability, benefit coverage, and cost protection of insurance for many to all U.S. residents;

* Lower the rate of cost growth in hospital and physician services, prescription drugs, and health plan and provider administration;

* Reduce the number of uninsured people, in some bills to near zero;

* Reduce the number of underinsured people, in some bills to near zero.

Some notable empirical estimates of the potential effects of provisions include:

* Lifting the top income eligibility threshold for marketplace premium tax credits could insure 1.7 million more people and lower silver plan premiums by 2.7 percent, at a net federal cost of $10 billion in 2020. n1

* Reinstating the ACA's reinsurance program could increase insurance coverage by up to 2 million people, lower silver plan marketplace premiums by as much as 10.7 percent and result in net deficit savings of as much $8.8 billion in 2020. n2

* Enhancing premium tax credits and lifting the income eligibility threshold could reduce annual marketplace premium contributions by enrollees from $356 to as much as $9,434. n3

* Funding and extending the cost-sharing reduction payments and pegging premium tax credits to the gold plan could decrease marketplace deductibles by $1,650 for people with incomes at 250 percent of poverty ($30, 350 for an individual) and above. n4

* Allowing HHS to negotiate prescription drug prices under a Medicare for all approach could lower drug prices from 4 percent to 40 percent. n5

* Replacing most private insurance with public insurance under a Medicare for all approach could lower insurance and provider administrative costs from a current 13.9 percent of spending in commercial plans to 6 percent to 3.5 percent of all spending. n6

* Setting provider prices at Medicare rates under a Medicare for all approach could reduce U.S. health spending in 2022 by $384 billion in 2022, or $5.3 trillion over ten years. n7

* Recent estimates of the effects of a Medicare for all proposal on overall U.S. national health care expenditures range from: declines of 9.6 percent (Pollin) and 2.1 percent (Blahous) to increases of 1.8 percent (RAND), 9.8 percent (RAND), 12.6 percent (Thorpe) and 16.9 percent (Urban Institute). n8

In the area of costs, what has captured the greatest attention in the emerging debate around Medicare for all, is the significant shift in the how national health spending would be financed. With the exception of HR 7339, which retains employer coverage as an option for employers and employees, the Medicare for all and single payer bills would shift most U.S. health care spending from households and employers and state and local governments to the federal budget. n9 This shift raises important questions about financing sources, in particular the incidence of taxation.

But in terms of policies that might lower the rate of growth in U.S. health care costs, what is notable about the range of national health spending estimates for the Medicare for all proposals is that the increase in health spending is often less than the increase in demand for health care from providing comprehensive coverage to most of the U.S. population. The range of estimates on spending is very wide. This is because the degree of potential savings and efficiencies are highly dependent on assumptions, particularly the ability of a single payer plan to lower provider payments, prescription drug costs and administrative costs. But the mechanisms for achieving slower health care cost growth in these proposals could be considered, refined and applied not only in single payer approaches but in other health reform approaches as well. For example, as part of a set of incremental ACA reforms, the Urban Institute estimated that capping provider payments at a level just above Medicare rates in the individual market could lower federal spending on the ACA's premium tax credits by $11.8 billion and household spending on premiums by $1.7 billion in 2020. n10

Conclusion

Since the ACA was passed in 2010, Congress has not passed further legislation that would insure more people or make private plans more affordable or cost-protective. Many states have stepped into the void by promulgating regulations, passing legislation, and establishing programs like reinsurance to secure insurer participation, inform consumers of their coverage options, and lower consumer costs. But people living in states that did not embrace the coverage expansions, such as Medicaid expansion or operating a state-based marketplace, are lagging further and further behind those who live in more actively engaged or resourced states. Moreover, some states that have taken actions like establishing reinsurance programs are struggling to finance them long-term.

Improving coverage for all U.S. residents will require federal legislation. These recently introduced bills are an amalgam of provisions that individually or collectively have the potential to make small to large improvements in coverage and increase the ability of people to get the health care that they need. Lowering premiums, limiting out-of-pocket cost exposure, and lowering the overall rate of health care cost growth are achievable goals and these bills provide mechanisms to move forward on each. Some ideas, like enhancing the ACA's subsidies, won't completely solve the U.S.'s significant affordability problem, but they provide a step in the right direction in providing targeted relief to several million people.

Many of these ideas can be implemented without a major reorganization of the health care system. For example, paying providers in commercial insurance plans at prices closer to those in Medicare or allowing the Secretary of Health and Human Services to negotiate prescription drug prices have potential to slow health care cost growth and would not require an immediate shift to a single payer system. The Medicare for all bills feature some of the proposed approaches in less sweeping bills as a way to transition into a single payer system. On the other hand, moving piecemeal also involves tradeoffs including the possibility, based on the experience of the ACA, that additional steps may take some time to achieve.

The committee is to be commended for taking on the issue of health reform. Hearings like these allow for fact-based consideration of policy options, their potential implications, and their trade-offs. I look forward to your questions.

Thank you.

Thank you, Mr. Chairman, members of the Committee, for this invitation to testify today on current proposals to reform the U.S. health care system. My comments will focus on the national gains in health insurance coverage since the passage of the Affordable Care Act (ACA), the problems people continue to report affording health insurance and health care, and the potential of recent Congressional health reform bills to address these problems.

The ACA Brought Sweeping Change to the U.S. Health Care System

The ACA brought sweeping change to the U.S. health system, expanding comprehensive and affordable coverage options to lower-and middle- income Americans through a newly regulated and subsidized individual market and expanded eligibility for Medicaid. The law's provisions also made it possible for people with health problems at all income levels to buy health insurance on their own by banning insurers from denying people coverage or charging them more because of pre-existing conditions.

The number of uninsured people in the United States has fallen by nearly half since the ACA was signed into law, dropping from a historical peak of 48.6 million people in 2010 to 29.7 million in 2018 (Exhibit 1). n11 Cost-related problems gaining access to health care and financial problems associated with medical bills care also declined (Exhibits 2 and 3). n12 And while people still experience coverage gaps, those gaps have shortened considerably in duration (Exhibit 4). A large body of research on the effects of the ACA show conclusively that the overall impact of the legislation on people's ability to afford health insurance and get needed health care has been positive. n13

Millions of People Remain Uninsured or are Underinsured

However, three distinct, yet interrelated, problems remain: millions of people remain uninsured, millions of people with insurance have plans that are leaving them underinsured, and growth in health care costs is outstripping that of median income in most states.

29.7 million people remain uninsured

After dropping significantly through 2015, the national uninsured rate has held steady at around 9 percent, with some ominous upticks in fourteen states in 2017 (Exhibit 5). n14 The share of working age adults who are uninsured is about 13 percent; about 5 percent of children are uninsured. (Exhibit 6). n15 These stalled gains stem from four primary factors:

* Seventeen states have not yet expanded Medicaid, including the heavily populated states of Florida and Texas (Exhibit 7);

* People with incomes just over the marketplace subsidy threshold (about $48,560 for an individual and $100,000 for a family of four) and many in employer plans have high premium contributions relative to income;

* Congressional and executive actions regarding the individual market and Medicaid that have reduced potential enrollment in both;

* The ACA's exclusion of undocumented immigrants from eligibility for subsidies and Medicaid.

Why it matters. Commonwealth Fund surveys have consistently found that people who lack health insurance, even for short periods of time, avoid or delay needed health care and are at risk of accumulating medical debt. In the 2018 Commonwealth Fund Biennial Health Insurance Survey, more than 55 percent of people who spent any time uninsured in the past year reported not getting needed health care including filling prescriptions, because of cost (Exhibit 8). n16 More than half said that they had problems paying medical bills, including paying off medical debt over time (Exhibit 9). People who are uninsured are much less likely to report getting recommended preventive care like flu shots, and cancer screens like mammograms and colon cancer screens (Exhibits 10 and 11).

In its landmark 2003 study, the Institute of Medicine (IOM) concluded that people who lack adequate health insurance all their lives have fundamentally different life experiences and less economic opportunity than those who are adequately insured, including lower educational attainment, lifetime earnings, and life expectancy. n17 At the time of the study, the IOM estimated that the aggregate, annualized cost of uninsured people's lost capital and earnings from poor health and shorter lifespans fell between $65 billion and $130 billion annually.

44 million people are underinsured

In addition to the 28 million people who lack insurance, an estimated 44 million working age adults with insurance, or 29 percent, are underinsured because they have high out-of-pocket costs and deductibles relative to their income (Exhibit 12). n18 This is up from an estimated 29 million, or 22 percent, in 2010. People who buy plans on their own through the individual market--including the ACA marketplaces--are underinsured at the highest rates. However, the greatest growth in the share of underinsured adults is occurring among those in employer health plans. The growth in underinsurance is attributable to two primary factors:

* Growth in cost-sharing, particularly deductibles, in private health plans.

* Little or no growth in U.S. median income such that out-of-pocket health care costs and deductibles are comprising a growing share of income among low- and moderate-income families.

Greater cost-sharing, especially higher deductibles, has been the predominant tool of choice by private insurers and employers in their attempts to temper premium growth over the last several years. Deductibles have grown in both proliferation and size. In 2017, 87.5 percent of single person health plans offered by employers had deductibles, compared to 70.7 percent in 2008. n19 Over that period, average deductibles more than doubled in size, from $869 to $1,808. n20

Why it matters. Commonwealth Fund surveys consistently find that underinsured adults are much more likely to skip needed health care, like filling prescriptions or going to the doctor when they are sick, than are those who are not underinsured. In 2018, 41 percent of underinsured adults reported not getting needed health care because of the cost (see Exhibit 8). n21

In addition, people who are underinsured are much more likely to report problems paying medical bills or say they are paying off medical debt over time. In 2018, 47 percent of underinsured adults reported problems paying medical bills, nearly twice the rate of adults who were insured all year but not underinsured. One-third reported that they were paying off medical debt over time, twice of the rate adults who were not underinsured (see Exhibit 9).

Many moderate- and low- income families simply do not have the assets or savings to pay for an unexpected medical bill--from an accident or acute illness and subsequent emergency room visit, for example--they may experience because of a high-deductible health plan. A recent Commonwealth Fund survey found that half of moderate- and low-income adults with employer coverage said they would not have the money to pay for an unexpected $1,000 medical bill in a month's time (Exhibit 13). n22

Paying off accumulated medical bills over time affects other aspects of people's lives. The Commonwealth Fund Biennial survey found that many adults with medical bill or debt problems reported serious financial problems: 43 percent had used up all their savings to pay their bills, 43 percent had received a lower credit rating as a result of their debt, 32 percent racked up debt on their credit cards, 18 percent said they had delayed education or career plans (Exhibit 14 ) People with lower incomes were particularly affected: 37 percent said they were unable to pay for basic necessities like food, heat or rent as a result of their bills.

Health care cost growth is outpacing growth in U.S. median income

A major factor underlying trends in both uninsured and underinsured rates, is the overall rate of growth in U.S. health care costs, particularly relative to growth in median income. Health care costs are the primary driver of premium and deductible growth in private insurance. This means that health care costs ultimately drive both consumer decisions to buy insurance and whether to get health care.

Over 2014 to 2016, U.S. health care spending rose at an annual rate of 5.3 percent and is projected to grow by 5.5 percent per year over the next decade, to nearly $6 trillion by 2027, or about 19.4 percent of GDP. n23 Median household income is growing at comparatively slower pace: 3.2 percent in 2016 and 1.8 percent in 2017. n24

Health care costs are the primary driver of premium growth in private plans comprising 80 to 85 percent of premiums. In 2017, the annual rate of growth in employer premiums ticked up by 4.4 percent for single person plans and 5.5 percent for family plans (Exhibit 15). n25

While the employee share of premium costs has stayed relatively constant over time, as employer premiums have grown, so has the dollar amount employees contribute to their premiums. Between 2016 and 2017, average annual employee premium contributions nationally rose by 6.8 percent to $1,415 for single-person plans and by 5.3 percent to $5,218 for family plans (Exhibit 16). n26 The average employee premium cost across single and family health plans amounted to nearly 7 percent of U.S. median income in 2017, up from 5.1 percent in 2008. In 11 states (Arizona, Delaware, Florida, Georgia, Louisiana, Mississippi, Nevada, New Mexico, North Carolina, Oklahoma, Texas), premium contributions were 8 percent of median income or more, with a high of 10.2 percent in Louisiana.

Because employers and insurers increase cost-sharing to temper premium growth, health care cost growth is also a key driver of the ballooning size of deductibles. In 2017, the average deductible for single-person policies rose by 6.6 percent to $1,808 (Exhibit 17). Average deductibles increased in 35 states and the District of Columbia. Deductibles ranged in size from a low of $863 in Hawaii to a high of about $2,300 in Maine and New Hampshire. Among families who spend enough on health care during the year to meet their deductibles, those at the midrange of the income distribution would spend 4.8 percent of their income on average before their coverage kicked in. n27 This is up from 2.7 percent of income in 2008.

In employer plans in 2017, total spending on premiums and potential out-of-pocket costs amounted to 11.7 percent of median income in 2017 (Exhibit 18). This is up from 7.8 percent a decade earlier. Costs were 12 percent or more of median income in 18 states. In Louisiana and Mississippi, these combined costs rose to 15 percent or more of median income.

In the individual market, premium growth stabilized in 2019 as insurers adjusted to the ACA market regulations and gained knowledge of their enrollment risk pools. While premiums will continue to be affected by external factors such as uncertainty over Congressional, executive and judicial decisions regarding the ACA's parameters, health care cost growth will be the primary source of premium growth in this market as well. In contrast to the employer market, lower and moderate-income people eligible for premium tax credits in the marketplaces are largely protected from premium increases since the ACA capped their contributions as a share of income on a sliding scale. The premium tax credits have been the central stabilizer for the marketplace enrollment. Across the states, 80 to 90 percent of marketplace coverage is subsidized.

However, people whose incomes are just over the income eligibility threshold of 400 percent of poverty ($100,400 for a family of four and $48,560 for an individual) are fully exposed to their plan premiums and year-to-year increases (Exhibit 19). For people with incomes just above that level, premiums can comprise well over 10 percent of their income, even for bronze level plans in many states. Ten percent is an important marker because that is the most people have to pay for their premiums if their income is below the subsidy eligibility threshold.

The potential of Congressional health reform bills to decrease the number of uninsured and underinsured people and lower health care cost growth

The U.S. health insurance system is comprised of both private (employer and individual market and marketplace plans) and public (Medicare and Medicaid) coverage sources, as the table below shows (Exhibit 20). In addition, both coverage sources are paid for by a mix of private and tax-payer financed public dollars.

Most Americans get their insurance through employers, who either provide coverage through private insurers or self-insure. Employers and employees share the cost through premiums and cost-sharing. But the federal government significantly subsidizes employer coverage by excluding employer premium contributions from employees' taxable income. In 2018 this subsidy amounted to $280 billion, the largest single tax expenditure. n28

About 27 million people are covered through regulated private plans sold in the individual market, including the Affordable Care Act's marketplaces. This coverage is financed by premiums and cost-sharing paid by enrollees. The federal government subsidizes these costs for individuals with incomes under $48,560.

For 44 million people, Medicaid or the Children's Health Insurance Program is their primary source of coverage. These public programs are financed by federal and state governments, and small individual premium payments and cost-sharing in some states. In most states, these benefits are provided through private insurers.

Medicare covers 62 million people over age 65 and people with disabilities. The coverage is financed by the federal government along with individual premiums and significant cost sharing. About 20 million people get their Medicare benefits through private Medicare Advantage plans and most beneficiaries either buy supplemental private insurance or qualify for additional coverage through Medicaid to help lower out-of-pocket costs and add long-term care benefits. n29

The "Medicare for All" Continuum

The recent set of proposals from House and Senate Democrats seek to address the current problems in the health care system -- millions of people uninsured or underinsured, and high health care costs -- by expanding the public dimensions of our health care system. n30 These bills can be characterized as falling along a continuum with Medicare for all proposals at one end. n31 The bills range from adding somewhat more public sector involvement into the system, to adding substantially more public sector involvement. The bills may be broadly grouped into three categories:

. Adding public plan features to private insurance

o HR 1884, Protecting Pre-Existing Conditions & Making Health Care More Affordable Act of 2019 (Rep. Pallone)

o S 2582, Consumer Health Insurance Protection Act of 2018 (Sen. Warren)

. Giving people a choice of public plans alongside private plans

o S 981, Medicare-X Choice Act of 2019 (Sens. Bennet, Kaine); HR 2000 (Rep. Delgado)

o S 2708, Choose Medicare Act (Sen. Merkley); HR 6117 (Rep. Richmond)

o HR 1346, Medicare Buy-In and Health Care Stabilization Act of 2019 (Rep. Higgins)

o S 470, Medicare at 50 Act (Sen. Stabenow)

o S 489 State Public Option Act (Sen. Schatz); HR 1277 (Rep. Lujan)

. Making public plans the primary source of coverage in the U.S.

o HR 7339, Medicare for America Act of 2018 (Rep. DeLauro)

o S 1129, Medicare for All Act of 2019 (Sen. Sanders)

o HR 1384, Medicare for All Act of 2019 (Rep. Jayapal)

o HR 676, Expanded and Improved Medicare for All Act (Rep. Ellison)

Summaries of the bills that fall within these categories are available in an interactive tool on the Commonwealth Fund website. n32 I next discuss the general provisions and implications of each category of approaches.

Adding public plan features to private insurance

The bills in this category include provisions to enhance the premium and cost-sharing subsidies for marketplace plans, fixing the so-called "family coverage glitch" in employer plans, addressing the Medicaid coverage gap for low income people in non-expansion states, and increasing the regulation of private plans such as banning non-ACA compliant plans or requiring private insurers who participate in Medicare and Medicaid to offer health plans in the ACA marketplaces.

Potential Effects: Directional

While details matter in terms of degree, the bills as a group have the potential to make the following directional changes in the health system:

o Improve the affordability and cost-protection of individual market insurance;

o Increase health plan choice in some individual markets;

o Reduce the number of uninsured people; and

o Reduce the number of underinsured people.

Potential Effects: Estimates from the Literature

Researchers have estimated the effects of several provisions in these bills. I next review some notable examples.

Enhancing premium tax credits. Lifting the income eligibility threshold for the premium tax credits (currently about $48,560 for an individual and $100,400 for family of four) would have the effect of capping the most anyone in the market would pay for premiums at 10 percent of income. This has a natural phase out -- as people's income rises, premiums take up a smaller and smaller share of their income, so fewer and fewer people are eligible for the tax credits.

Researchers Jodi Liu and Christine Eibner from the RAND Corporation estimated the coverage and federal budget effects of such a policy change. n33 They assumed current law: no individual mandate or federal reimbursement for cost-sharing reduction subsidies. They project that lifting the income threshold for the premium tax credits could insure 1.7 million more people and lower marketplace silver plan premiums by 2.7 percent at a net federal cost of $10 billion in 2020 (Exhibit 21).

Liu and Eibner also modeled the effects of lifting the threshold combined with reducing the maximum premium contribution as a share of income to a range of 1.79 percent at 100 percent of poverty to 8.5 percent of income at 300 percent of poverty and above. Under this scenario, 2.4 million more people are estimated to gain coverage and silver plan premiums would drop by 3.1 percent, at an annual net deficit impact of $18.8 billion.

In addition to increasing coverage, enhancing marketplace premium and cost-sharing subsidies would significantly increase the affordability of premiums and health care. The Urban Institute, for example, modeled the effect of lifting the premium tax credit threshold combined with reducing the maximum premium contribution as a share of income to a range of 0 percent at 100 percent of poverty to 8.5 percent of income at 400 percent of poverty and above. They pegged premium tax credits to the gold plan, rather than the silver plan. The modeling assumes the individual mandate is in place, and the cost-sharing reductions are financed. Under these policy changes, average annual premiums for single person policies are estimated to decline by $356 for adults earning 138 percent of poverty, by $721 for those earning 250 percent of poverty, $902 at 350 percent of poverty, and by $9,434 for a 64-year old at 450 percent of poverty.

The Urban Institute researchers also modeled the combined effect on cost-sharing from pegging tax credits to the gold plan and enhancing and extending the cost-reduction subsidies to people up to 300 percent of poverty. The improved cost-protection from enrolling in gold plans combined with enhanced cost sharing decreases single policy deductibles by $1,650 for adults earning 250 percent of poverty and above.

Reinsurance. Reinsurance has a proven track record in lowering marketplace premiums. The ACA's temporary reinsurance program resulted in premiums that were as much as 14 percent lower than they might otherwise have been. All seven states that have implemented reinsurance programs through the ACA's 1332 waiver program have experienced drops in premiums, some of them substantial. n34

Liu and Eibner estimated the effects of reinstating the ACA's reinsurance program which was wholly financed through insurer fees. They estimate that depending on the generosity of the program (ACA year one vs. ACA year three), reinsurance could increase insurance coverage from 300,000 to 2 million people, lower silver plan marketplace premiums by 2.4 percent to 10.7 percent and result in net deficit savings of $2.3 billion to $8.8 billion annually (see Exhibit 21).

Family coverage glitch fix. Urban Institute researchers estimated the effect of fixing the family coverage glitch by pegging unaffordable coverage in employer plans to family policies rather than single policies. n35 In 2016, the researchers estimated that more than 6 million people were affected by the glitch and were ineligible for marketplace subsidies because of it. They estimated that fixing the glitch would lower family spending on premiums from 12 percent of income on average to 6.3 percent, at a cost to the federal government of $3.7 billion to $6.5 billion in 2016. The fix was not estimated to significantly expand insurance coverage.

Comprehensive package of policy options. The Urban Institute also recently modeled a set of policy changes that build on one another, beginning with the reinstatement of the ACA's individual mandate and funding for the cost-sharing reduction subsidies. n36 The additional options include enhanced premium and cost-sharing subsidies (discussed above), expanded eligibility for Medicaid in all states, a $10 billion federal investment in a reinsurance program, and capping what providers are paid in the individual market somewhat above Medicare rates. The combined effect of these policies is a drop in the number of uninsured by 12.2 million, or 7.3 percent of the under 65 population, at a total federal cost of $119 billion in 2020.

Giving people a choice of public plans alongside private plans.

In addition to enhancing ACA subsidies and providing reinsurance, the bills in this category also give consumers a choice of a public plan, based on either Medicare or Medicaid, for people in the ACA marketplaces and employers. The bills also use the leverage of the federal government's buying power in setting premiums for the public plan, establishing provider payment rates, and negotiating prescription drug prices. Some bills also improve benefits for people currently enrolled in Medicare.

Potential Effects: Directional

Again, details matter in terms of degree, but the bills as a group have the potential to:

o Improve the affordability and cost-protection of individual market insurance and for people currently enrolled in employer plans;

o Increase health plan choice in the individual market and for people in employer plans;

o Lower rate of growth in the cost of health care and prescription drugs;

o Reduce the number of uninsured people;

o Reduce the number of underinsured people.

Potential Effects: Estimates from the Literature

Lowering health care cost growth. A major goal of introducing a public plan option to the marketplaces is to lower marketplace premiums through increased competition with a lower priced plan. The HHS secretary would set premiums. Presumably these premiums would be lower than private plans as the secretary could pay participating providers closer to Medicare reimbursement rates and would have fewer administrative costs to cover. Lower premiums in all plans would also reflect the new power accorded the secretary in negotiating prescription drug prices. The potential effects of these cost-control mechanisms are reviewed in the next section.

Making public plans the primary source of coverage in the U.S.

Bills in this category are single-payer or Medicare for all bills in which all residents are eligible for a public plan that resembles the current Medicare program, but isn't the same Medicare program we have today. The bills limit or end premiums and cost-sharing and end most current forms of insurance coverage including most private coverage, with the exception of HR 7337 which retains employer coverage as an option. Benefits are comprehensive and include services not currently covered by Medicare such as dental and vision and long-term care. The approach harnesses substantial federal leverage in setting premiums and lowering provider and prescription drug prices.

Each bill includes provisions aimed at improving coverage during the transition period, some of which appear in bills in other categories. These include providing a public plan option through the marketplaces, addressing the Medicaid coverage gap, and improving benefits for the current Medicare program.

Potential Effects: Directional

Details matter, but the bills as a group have the potential to:

o Improve the affordability, benefit coverage, and cost protection of insurance for most of the U.S. population;

o Increase health plan choice for people in employer plans, for bills that retain employer coverage;

o Lower the rate of cost growth in hospital and physician services, prescription drugs, and health plan and provider administration;

o Lower the uninsured rate close to zero;

o Lower the underinsured rate close to zero.

Potential Effects: Estimates from the Literature

The single payer bills can achieve universal coverage and eliminate underinsurance, depending on whether undocumented immigrants are included. The approach also has the potential to significantly slow the rate of growth in health care costs, including those for hospital and physician services, prescription drugs, and health plan and provider administration. But there is uncertainty about the degree of savings that might be achieved. I briefly review current estimates of the effect of a single payer approach on national health spending in five areas: provider payment, prescription drugs, administration, and overall spending. I review estimates by researchers from RAND, the Mercatus Institute, the Urban Institute, Emory University, and the University of Massachusetts Amherst.

Provider payment. There is growing evidence that prices paid to providers, especially hospitals, rather than people's use of health care services, are the primary driver of health care cost and premium growth. n37 For example, the Health Care Cost Institute (HCCI) recently found that found that between 2013 and 2017, prices of inpatient services climbed by 16 percent while utilization fell by 5 percent (Exhibit 22). n38 HCCI found similar patterns in outpatient and professional services, and prescription drugs. There is also considerable evidence that prices explain the wide health care spending gap between the United States and other wealthy countries (Exhibits 23 and 24). n39 Other research has found that this greater spending in the U.S. does not result in better health outcomes compared to other countries. n40

Recent research also indicates that per capita costs in U.S. private insurance are rising faster than those in public insurance programs and that prices are a likely culprit. Between 2007 and 2014, Cooper and colleagues found that private health spending per enrollee increased more rapidly and showed much more variability than that in Medicare. Since Medicare sets prices for providers while prices in commercial plans are usually the result of negotiation between providers and insurers, or employers, much of this spending differential likely stems from price differences. Anderson and colleagues note that the difference between prices paid by public and private insurers ballooned from 10 percent in 2000 to 50 percent in 2017. n41 The authors argue that in order to slow the rate of growth in U.S. health care costs, increased attention needs to be given to private insurer payments to providers.

The Congressional Medicare for all bills, as well as those that give consumers a choice of enrolling in a Medicare-like public plan, do exactly that: they propose setting provider prices at Medicare rates or somewhere between private and public rates. HR 1384 also proposes setting regional budgets for hospitals which has not been modeled as part of the research reviewed here. Paying providers in employer and other private insurance plans at or near Medicare rates could also be done without a public plan or single payer system. n42

Jodi Liu and Christine Eibner of RAND recently estimated the effect of a Medicare for all approach on national health spending. n43 They note that commercial insurers pay on average 167 percent of Medicare rates for hospital services and 125 percent of Medicare physician prices and that Medicaid pays about the same as Medicare for hospital prices and 72 percent of Medicare physician prices. They assume that a Medicare for all plan would pay hospitals about 124 percent of current Medicare rates and physicians 107 percent of Medicare rates, resulting in an overall blended rate of 109 percent.

The Urban Institute in their analysis assumed providers would be paid at Medicare rates, with an upward adjustment for hospitals, for an overall blended rate of 107 percent of Medicare rates. n44 Kenneth Thorpe of Emory University makes a similar assumption for an overall blended rate of 105 percent of Medicare rates. n45 In all these scenarios, payments would rise for services now covered by public plans and fall for those covered by private plans.

Charles Blahous from the Mercatus Center at George Mason University who also estimated the cost implications of a Medicare for all proposal assumed provider prices would be set at Medicare rates. n46 At those rates he estimates savings in 2022 of $384 billion, or $5.3 trillion over ten years. Robert Pollin and colleagues' analysis of a Medicare for all proposal also assumes prices would be set at Medicare rates leading to a reduction in U.S. health care expenditures of 2.8 percent. n47

None of these estimates include HR 1334's proposal to establish regional global budgets for institutional providers and separate budgets for capital projects. Such a provision could have very different implications for the cost of hospital and nursing home care than does setting payment rates at or near Medicare rates.

Prescription drugs. Most of the recent Congressional reform bills including Medicare for all and those that add a choice of public plan would allow HHS to negotiate drug prices. RAND assumes that this negotiation power would enable HHS to negotiate prices that are 10 percent lower than current levels. At that rate, RAND estimates savings of $39.2 billion in 2019. Blahous projects prices would be 12 percent lower, and estimates savings of $61 billion in 2022, or $846 billion over ten years. Thorpe estimated that negotiation could lower drug prices by 4 percent. n48 Pollin assumes a reduction of 40 percent.

The Urban Institute assumed that negotiation would leave drug prices about halfway between Medicare and Medicaid prices, after rebates. This translates into a 30 percent reduction for prices in commercial plans, an 18 percent reduction in Medicare prices, and a 29 percent increase in Medicaid prices, or about a 20 percent overall decline. n49

Administrative costs. Administrative costs for private health plans exceed those of Medicare. RAND notes that administrative costs were 6.9 percent of personal health spending on Medicare in 2017, compared to 13.9 percent in commercial plans. RAND also estimates that administrative costs such as billing comprise 13 percent of physician expenditures, 8.5 percent of hospital costs, and 10 percent of other costs. RAND assumes that Medicare for all would lower health plan administrative costs to 5.3 percent of spending and provider administrative costs to 5.6 percent, for a combined savings of $158.7 billion in 2019.

Blahous assumes health plan administrative costs would decline to 6 percent of spending for an overall savings of $83 billion in 2022, or $1.57 trillion over 10 years. The Urban Institute and Thorpe assume health plan administration of 6 percent and 4.7 percent of spending, respectively. Pollin assumes a larger decline to 3.5 percent of spending.

Demand for health care. Medicare for all would increase demand for health care because millions more people would have coverage and most people would face no cost sharing. Benefits would also include more services than many people, including those in Medicare, currently have. RAND assumes that demand for health care under Medicare for all would rise by 2.2 percent for people currently covered by Medicare, by 2.6 percent among those insured by private plans, and by 25 percent for those currently uninsured. In its estimates, RAND assumes that limits on provider capacity would leave 50 percent of the new demand either unmet, or delayed. Blahous assumes demand would increase by 11 percent for those with private coverage, 16 percent for people with Medicare who do not have supplemental coverage, and 89 percent for those currently uninsured. Thorpe assumes demand by those currently insured would climb by about 7 percent and by 60 percent for those currently uninsured, for an overall increase of about 15 percent. n50 Pollin assumes overall demand would increase by about 12 percent.

Overall spending. Based on the above assumptions, RAND estimates that national health spending under Medicare for All would increase by 1.8 percent in 2019, rising from $3.823 trillion under current law to $3.891 trillion. However, RAND estimates that if new demand for health care is fully met, overall spending would increase by 9.8 percent to $4.2 trillion. Using slightly older national expenditure data, Blahous estimates that Medicare for all would lead to a 2 percent decrease in U.S health care spending, falling from an estimated $4.562 trillion in 2022 to $4.469 trillion. Pollin estimates that health spending in 2017 would have fallen from $3.24 trillion to $2.93 trillion, or a 9.6 percent decline. Thorpe estimates an increase of about 12.6 percent in 2019. n51 The Urban Institute projects the greatest increase in national health expenditures, 16.9 percent in 2017.

In the area of costs, what has captured the greatest attention in the emerging debate about Medicare for all, is the significant shift in the how national health spending would be financed. With the exception of HR 7339, which retains employer coverage as an option for employers and employees, all the bills in this category would shift most U.S. health care spending from households and employers and state and local governments to the federal budget. This shift raises important questions about financing sources, in particular the incidence of taxation which is discussed in some of the analyses reviewed here.

But in terms of policies that might lower the rate of growth in U.S. health care costs, what is notable about the range of national health spending estimates for the Medicare for all proposals is that the increase in health spending is often less than the overall increase in demand for health care from providing comprehensive coverage to most of the U.S. population. The range of estimates on spending is very wide. This is because the degree of potential savings and efficiencies are highly dependent on assumptions, particularly the ability of a single payer plan to lower provider payments, prescription drug costs and administrative costs. But the mechanisms for achieving slower health care cost growth in these proposals could be considered, refined and applied not only in single payer approaches but in other health reform approaches as well. For example, as part of a set of incremental ACA reforms, the Urban Institute estimated that capping provider payments at a level just above Medicare rates in the individual market could lower federal spending on the ACA's premium tax credits by $11.8 billion and household spending on premiums by $1.7 billion in 2020. n52

Conclusion

Since the passage of the ACA in 2010, Congress has not passed subsequent legislation that would insure more people or improve the affordability or cost-protection of private plans. Many states have stepped into the void by promulgating regulations, passing legislation, and establishing programs like reinsurance to secure insurer participation, inform consumers of their coverage options, and lower consumer costs. But people living in states that did not embrace the coverage expansions, such as Medicaid expansion or operating a state-based marketplace, are lagging further and further behind those who live in more actively engaged or resourced states. Moreover, some states that have taken actions like establishing reinsurance programs are struggling to finance them long-term.

Improving coverage for all U.S. residents will require federal legislation. These recently introduced bills are an amalgam of provisions that, individually or collectively, have the potential to make significant improvements in coverage and increase the ability of people to get the health care that they need. Lowering premiums, limiting out-of-pocket cost exposure, and lowering the overall rate of health care cost growth are achievable goals and these bills provide mechanisms to move forward on each.

The selection of policy approach presents a host of tradeoffs and financing decisions that will require more microsimulation modeling, analysis and information gathering through hearings like these, and public vetting and discussion. But the set of policy options discussed in this testimony should be viewed as falling along a continuum. Some ideas, like enhancing the ACA's subsidies, won't completely solve the U.S.'s significant affordability problem, but they provide a step in the right direction in providing targeted relief to several million people.

Moreover, many of these ideas can be implemented without a major reorganization of the health care system. For example, paying providers in commercial insurance plans at prices closer to those in Medicare or allowing the Secretary of Health and Human Services to negotiate drug prices have the potential to slow health care cost growth and would not require an immediate shift to a single payer system. Even the Medicare for all bills feature some of the proposed approaches in less sweeping bills as a way to transition into a single payer system. On the other hand, moving piecemeal also involves tradeoffs including the possibility, based on the experience of the ACA, that additional steps may take some time to achieve. n53

The committee is to be commended for taking on the issue of health reform. Hearings like these allow for fact-based consideration of policy options and their trade-offs. I look forward to your questions.

Thank you.

n1 Jodi Liu and Christine Eibner, Expanding Enrollment Without the Individual Mandate: Options to Bring More People into the Individual Market (Commonwealth Fund, Aug. 2018.)

n2 Jodi Liu and Christine Eibner, Expanding Enrollment Without the Individual Mandate: Options to Bring More People into the Individual Market.

n3 Assumes individual mandate and funding for cost-sharing reductions are reinstated. Linda J. Blumberg, John Holahan, Matthew Buettgens, Robin Wang, A Path to Incremental Health Care Reform: Improving Affordability, Expanding Coverage, and Containing Costs, The Urban Institute, December 2018.

n4 Assumes individual mandate and funding for cost-sharing reductions are reinstated. Linda J. Blumberg, John Holahan, Matthew Buettgens, Robin Wang, A Path to Incremental Health Care Reform: Improving Affordability, Expanding Coverage, and Containing Costs.

n5 Jodi Liu and Christine Eibner, National Health Spending Estimates Under Medicare for All, The RAND Corporation, April 2019; Robert Pollin, et al., Economic Analysis of Medicare for All, Political Economy Research Institute, University of Massachusetts Amherst, November 2018; Charles Blahous, The Costs of a National Single-Payer Healthcare System, Mercatus Working Paper, Mercatus Center at George Mason University, July 2018; John Holahan, et al., The Sanders Single-Payer Health Care Plan: The Effect on National Health Expenditures and Federal and Private Spending, Urban Institute, May 2016; Kenneth E. Thorpe, An Analysis of Senator Sanders' Single Payer Plan, Unpublished paper, Emory University, January 2016.

n6 Jodi Liu and Christine Eibner, National Health Spending Estimates Under Medicare for All; Charles Blahous, The Costs of a National Single-Payer Healthcare System; John Holahan, et al., The Sanders Single-Payer Health Care Plan: The Effect on National Health Expenditures and Federal and Private Spending; Kenneth E. Thorpe, An Analysis of Senator Sanders' Single Payer Plan.

n7 Charles Blahous, The Costs of a National Single-Payer Healthcare System, Mercatus Working Paper, Mercatus Center at George Mason University, July 2018.

n8 None of these estimates include the potential effects of HR 1334's proposal to establish regional global budgets for institutional providers and separate budgets for capital projects.

n9 HR 7339 requires employers to meet the new coverage requirements of the public program and gives them and their employees the option to elect the public plan.

n10 Assumes individual mandate and funding for cost-sharing reductions are reinstated. Linda J. Blumberg, John Holahan, Matthew Buettgens, Robin Wang, A Path to Incremental Health Care Reform: Improving Affordability, Expanding Coverage, and Containing Costs, The Urban Institute, December 2018.

n11 Emily P. Terlizzi, Robin A. Cohen, and Michael E. Martinez, Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January-September 2018 (National Center for Health Statistics, February 2019).

n12 Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured (Commonwealth Fund, Feb. 2019).

n13 B. D. Sommers, B. Maylone, R. J. Blendon et al., "Three-Year Impacts of the Affordable Care Act: Improved Medical Care and Health Among Low-Income Adults," Health Affairs Web First, published online May 17, 2017; Olena Mazurenko, Casey P. Balio, Rajender Agarwal, Aaron E. Carroll, and Nir Menachami, The Effects Of Medicaid Expansion Under The ACA: A Systematic Review, Health Affairs, June 2018; M. Z. Gunja, S. R. Collins, and H. K. Bhupal, Is the Affordable Care Act Helping Consumers Get Health Care?, The Commonwealth Fund, December 2017; S.R. Collins, M.Z. Gunja, M.M. Doty, S. Beutel, Americans' Experiences with the ACA Marketplace and Medicaid Coverage: Access to Care and Satisfaction, The Commonwealth Fund, May 2016; S. R. Collins, P. W. Rasmussen, and M. M. Doty, Gaining Ground: Americans' Health Insurance Coverage and Access to Care After the Affordable Care Act's First Open Enrollment Period, The Commonwealth Fund, July 2014.

n14 Emily P. Terlizzi, Robin A. Cohen, and Michael E. Martinez, Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January-September 2018 (National Center for Health Statistics, February 2019); Edward R. Berchick, Emily Hood, and Jessica C. Barnett, Health Insurance Coverage in the United States: 2017, U.S. Census Bureau, September 2018.

n15 Emily P. Terlizzi, Robin A. Cohen, and Michael E. Martinez, Health Insurance Coverage: Early Release of Estimates From the National Health Interview Survey, January-September 2018 (National Center for Health Statistics, February 2019).

n16 Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured (Commonwealth Fund, Feb. 2019).

n17 Institute of Medicine, Committee on the Consequences of Uninsurance, Hidden Costs, Value Lost: Uninsurance in America, Washington, DC: National Academies Press, 2003.

n18 Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured (Commonwealth Fund, Feb. 2019).

n19 Commonwealth Fund analysis of the Medical Expenditure Panel Survey-Insurance Component (MEPS-IC), 2017.

n20 Sara R. Collins and David C. Radley, The Cost of Employer Insurance Is a Growing Burden for Middle-Income Families (Commonwealth Fund, Dec. 2018).

n21 Sara R. Collins, Herman K. Bhupal, and Michelle M. Doty, Health Insurance Coverage Eight Years After the ACA: Fewer Uninsured Americans and Shorter Coverage Gaps, But More Underinsured (Commonwealth Fund, Feb. 2019).

n22 Sara R. Collins, The Growing Cost Burden of Employer Health Insurance for U.S. Families and Implications for Their Health and Economic Security, Invited Testimony, U.S. House of Representatives Committee on Ways and Means, Subcommittee on Select Revenue Measures, Hearing on "How Middle-Class Families Are Faring in Today's Economy," Feb. 13, 2019.

n23 Andrea M. Sisko, et al. "National Health Expenditure Projections, 2018-27: Economic and Demographic Trends Drive Spending and Enrollment Growth," Health Affairs, March 2019.

n24 U.S. Census Bureau, Income and Poverty in the United States, 2016 and 2017.

n25 Sara R. Collins and David C. Radley, The Cost of Employer Insurance Is a Growing Burden for Middle-Income Families, Commonwealth Fund, Dec. 2018.

n26 Sara R. Collins and David C. Radley, The Cost of Employer Insurance Is a Growing Burden for Middle-Income Families.

n27 Not everyone with a deductible has enough medical expenses in a given year to meet the deductibles; some services are covered by plans before people meet deductibles. By law, preventive care services and many cancer screens must be covered pre-deductible without cost-sharing. And many plans also cover certain prescription drugs and other services before the deductible is met.

n28 Tax Policy Center, Key Elements of the U.S. Tax System, Urban Institute and Brookings Institution.

n29 Gretchen Jacobson, Anthony Damico, Tricia Neuman, A Dozen Facts about Medicare Advantage, Kaiser Family Foundation, Nov. 2018.

n30 Sherry A. Glied and Jeanne M. Lambrew, "How Democratic Candidates for the Presidency in 2020 Could Choose Among Public Plans," Health Affairs 37, no. 12 (Dec. 2018): 2084-91.

n31 Sara R. Collins and Roosa Tikkanen, The Many Varieties of Universal Coverage, The Commonwealth Fund, March 6, 2019.

n32 Sara R. Collins, Roosa Tikkanen, The Many Varieties of Universal Coverage.

n33 Jodi Liu and Christine Eibner, Expanding Enrollment Without the Individual Mandate: Options to Bring More People into the Individual Market (Commonwealth Fund, Aug. 2018).

n34 Justin Giovanelli, What Is Your State Doing to Affect Access to Adequate Health Insurance? The Commonwealth Fund, last updated April 2, 2019; Rachel Schwab, Emily Curran, Sabrina Corlette, Assessing the Effectiveness of State-Based Reinsurance: Case Studies of Three States' Efforts to Bolster Their Individual Markets, Robert Wood Johnson Foundation, November 2018.

n35 Matthew Buettgens, Lisa Dubay, and Genevieve M. Kenney, "Marketplace Subsidies: Changing The 'Family Glitch' Reduces Family Health Spending But Increases Government Costs," Health Affairs, 35, 7, July 2016: 1167-75.

n36 Linda J. Blumberg, John Holahan, Matthew Buettgens, Robin Wang, A Path to Incremental Health Care Reform: Improving Affordability, Expanding Coverage, and Containing Costs, The Urban Institute, December 2018.

n37 Z. Cooper, S. Craig, C. Gray, et al., "Variation in Health Spending Growth for the Privately Insured From 2007 to 2014," Health Affairs 38, no.2 (Feb. 2019): 230-236; Z. Cooper, S. Craig, M. Gaynor, et al., "Hospital Prices Grew Substantially Faster than Physician Prices for Hospital-Based Care in 2007-14," Health Affairs 38, no.2 (Feb. 2019): 184-189; A.M. Sisko, S.P. Keehan, J.A.Poisal, et al., "National Health Expenditure Projections, 2018-27: Economic and Demographic Trends Drive Spending and Enrollment Growth," Health Affairs, 38, no.3 (Feb. 2019):1-11.

n38 Health Care Cost Institute, 2017 Health Care Cost and Utilization Report, February 2019.

n39 G. F.Anderson, P. Hussey, and V. Petrosyan, "It's Still the Prices Stupid: Why the U.S. Spends so Much On Health Care, and A Tribute to Uwe Reinhardt," Health Affairs, 38, no.1, (Jan. 2019):87-95.

n40 E. C. Schneider, D. O. Sarnak, D. Squires, A. Shah, and M. M. Doty, Mirror, Mirror 2017: International Comparison Reflects Flaws and Opportunities for Better U.S. Health Care (The Commonwealth Fund, July 2017).

n41 G.F. Anderson, P. Hussey, and V. Petrosyan, "It's Still the Prices Stupid: Why the U.S. Spends so Much On Health Care, and A Tribute to Uwe Reinhardt," Health Affairs, 38, no.1, (Jan. 2019):87-95.

n42 Sherry A. Glied and Jeanne M. Lambrew, "How Democratic Candidates for the Presidency in 2020 Could Choose Among Public Plans," Health Affairs 37, no. 12 (Dec. 2018): 2084-91.

n43 Jodi Liu and Christine Eibner, National Health Spending Estimates Under Medicare for All, The RAND Corporation, April 2019.

n44 John Holahan, et al., The Sanders Single-Payer Health Care Plan The Effect on National Health Expenditures and Federal and Private Spending, Urban Institute, May 2016; Josh Katz, Kevin Quealy, Margot Sanger-Katz, "Would 'Medicare for All' Save Billions or Cost Billions?" The New York Times, April 10, 2019 https://www.nytimes.com/interactive/2019/04/10/upshot/medicare-for-all-bernie-sanders-cost-estimates.html

n45 Kenneth E. Thorpe, An Analysis of Senator Sanders' Single Payer Plan, Unpublished paper, Emory University, January 2016.

n46 Charles Blahous, The Costs of a National Single-Payer Healthcare System, Mercatus Working Paper, Mercatus Center at George Mason University, July 2018.

n47 Robert Pollin, et al., Economic Analysis of Medicare for All, Political Economy Research Institute, University of Massachusetts Amherst, November 2018.

n48 Josh Katz, Kevin Quealy, Margot Sanger-Katz, "Would 'Medicare for All' Save Billions or Cost Billions?" The New York Times, April 10, 2019.

n49 Author communication, April 24, 2019.

n50 Author communication, April 25, 2019.

n51 Author communication, April 25, 2019.

n52 Linda J. Blumberg, John Holahan, Matthew Buettgens, Robin Wang, A Path to Incremental Health Care Reform: Improving Affordability, Expanding Coverage, and Containing Costs, The Urban Institute, December 2018.

n53 Sherry A. Glied and Jeanne M. Lambrew, "How Democratic Candidates for the Presidency in 2020 Could Choose Among Public Plans," Health Affairs 37, no. 12 (Dec. 2018): 2084-91.

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