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Health Reform and Theories of Cost Control

Published online by Cambridge University Press:  01 January 2021

Erin C. Fuse Brown
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Abstract

Health care costs and affordability are critical issues to consumers. Just as we assess the coverage impacts of a health reform proposal, we should be able to evaluate how the plan will constrain health care costs: its theory of cost control. This essay provides a framework to assess health reform plans on their theories of cost control, identifying the key policy tools to constrain health care costs organized in a two-by-two matrix across the following dimensions: price vs. utilization and public vs. private payers. It then applies the framework to the Affordable Care Act (ACA) and the Republican's 2017 legislative efforts to repeal and replace the ACA to identify their general theories of cost control, revealing on the plans' strengths, blind spots, and incoherence.

Type
Symposium Articles
Information
Journal of Law, Medicine & Ethics , Volume 46 , Issue 4: Next Steps in Health Reform , Winter 2018 , pp. 846 - 856
Copyright
Copyright © American Society of Law, Medicine and Ethics 2018

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References

Emanuel, E. et al., “Measuring the Burden of Health Care Costs on U.S. Families: The Affordability Index,” JAMA 318, no. 19 (2017): 1863–1864, at 1863.CrossRefGoogle Scholar
Jost, T.S., “Affordability: The Most Urgent Health Reform Issue for Ordinary Americans,” Health Affairs Blog, February 29, 2016, available at <https://www.healthaffairs.org/do/10.1377/hblog20160229.053330/full/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Hartman, M. et al., “National Health Care Spending in 2016: Spending and Enrollment Growth Slow After Initial Coverage Expansions,” Health Affairs 37, no. 1 (2018): 150–160, at 150.Google Scholar
Gaynor, M., “Examining the Impact of Health Care Consolidation,“ Statement before the Committee on Energy and Commerce Oversight and Investigation Subcommittee, U.S. House of Representatives 5, February 14, 2018.CrossRefGoogle Scholar
Id.Google Scholar
Claxton, G. et al., “Payments for Cost Sharing Increased Rapidly Over Time,” Peterson-Kaiser Health System Tracker, April 12, 2016, available at <https://www.healthsystemtracker.org/brief/payments-for-cost-sharing-increasing-rapidly-overtime/#item-start> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Sage, W., “Fracking Health Care: The Need to Safely De-Medicalize Health Care and Recover Trapped Value for its People,” New York University Journal of Law and Liberty 11 (2017): 635–671, at 661-664.Google Scholar
Gostin, L.O., “Five Ethical Values to Guide Health System Reform,” JAMA 318, no. 22 (2017): 2171–2172, at 2171.CrossRefGoogle Scholar
Emanuel, E.J., “The Real Cost of the US Health Care System,” JAMA 319, no. 10 (2018): 983–985, at 983.CrossRefGoogle Scholar
Johnson, E.M., “Physician Induced Demand,” in Culyer, A.J., ed., Encyclopedia of Health Economics 3, no. 77 (Oxford: Elsevier, 2014): 77–83.CrossRefGoogle Scholar
See Pauly, M., “The Economics of Moral Hazard,” The American Economic Review 58, no. 3 (1968): 531–537, at 533-534.Google Scholar
See Pauly, M., “Taxation, Health Insurance, and Market Failure,” Journal of Economic Literature 24, no. 2. (1986): 629–675, at 641.Google Scholar
See for example, Rosenthal, M., “Beyond Pay-for-Performance — Emerging Models of Provider-Payment Reform,” NEJM 359, no. 12 (2008): 1197–1200, at 1199.Google Scholar
The False Claims Act, 31 U.S.C. §§3729 to 3733; Anti-Kick-back Statute, 42 U.S.C. §1320a-7b; and the Ethics in Patient Referrals Act (the Stark Law), 42 U.S.C. §1395nn.Google Scholar
Newhouse, J.P. and the Insurance Experiment Group, Free for All? Lessons from the Rand Health Insurance Experiment (Cambridge: Harvard University Press, 1986): at 40–42.Google Scholar
White, C. et al., “Understanding Differences Between High-and Low-Price Hospitals: Implications for Efforts to Rein In Costs,” Health Affairs 33, no. 2 (2014): 324–331, at 330.Google Scholar
“Health Care Industry Consolidation: What is Happening, Why it Matters, and What Public Agencies Might Want to Do About It,” Hearing Before the House Comm. on Energy, 115th Cong. 3, February 14, 2018, (statement of Leemore Dafny, Professor of Business Administration, Harvard Business School).Google Scholar
White, C. et al., “High and Varying Prices for Privately Insured Patients Underscore Hospital Market Power,” Center for Studying Health System Change, Research Brief No. 27, 2013, available at <http://www.hschange.org/CONTENT/1375/?words=High%20and%20Varying%20Prices%20for%20Privately%20Insured%20Patients%20Underscore%20Hospital%20Market%20Power> (last visited October 18, 2018).+(last+visited+October+18,+2018).>Google Scholar
Havighurst, C. and Richman, B., “The Provider Monopoly Problem in Health Care,” Oregon Law Review 89, no. 3 (2011), 847–883, at 871; T.L. Greaney, “Coping With Concentration,” Health Affairs 36, no. 9 (2017): 1564-1571, at 1565-1566.Google Scholar
Berenson, R.A. et al., “The Growing Power of Some Providers to Win Steep Payment Increases from Insurers Suggests Policy Remedies May Be Needed,” Health Affairs 31, no. 5 (2012): 973–981, at 973; B.C. Vladeck, “Paradigm Lost: Provider Concentration and the Failure of Market Theory,” Health Affairs 33, no. 6 (2014): 1083-1087, at 1086.Google Scholar
Frankford, D. and Rosenbaum, S., “Taming Health Care Spending: Could State Rate Setting Work?” Health Affairs Blog, March, 20, 2017, available at <https://www.healthaf-fairs.org/do/10.1377/hblog20170320.059262/full/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Murray, R., “Setting Hospital Rates to Control Costs and Boost Quality: The Maryland Experience,” Health Affairs 28, no.5 (2009): 1395–1405.Google Scholar
Brown, E.C. Fuse, “State Strategies to Address Rising Prices Caused by Health Care Consolidations,” National Academy for State Health Policy, September 2017, available at <https://nashp.org/wp-content/uploads/2017/09/Consolidation-Report.pdf> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Brown, E.C. Fuse, “The Blind Spot in the Patient Protection and Affordable Care Act's Cost Control Policies,” Annals of Internal Medicine 163, no. 11 (2015): 871–872, at 871.CrossRefGoogle Scholar
Gawande, A., “The Cost Conundrum,” New Yorker, June 1, 2009, available at <https://www.newyorker.com/magazine/2009/06/01/the-cost-conundrum> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Medicare Shared Savings Program, 42 U.S.C. § 1395jjj (2012); Hospital Value-Based Purchasing Program, 42 U.S.C.A. § 1395ww(o) (West 2015); National Pilot Program on Payment Bundling, 42 U.S.C. § 1395cc-4 (2012); Cutler, D., “How Health Care Reform Must Bend the Cost Curve,” Health Affairs 29, no. 6 (2010): 1131–1135.Google Scholar
Muelstein, D. et al., “Growth of ACOs and Other Alternative Payment Models in 2017,” Health Affairs Blog, June 28, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20170628.060719/full/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Id.Google Scholar
Greaney, T.L., “Regulators as Market-Makers: Accountable Care Organizations and Competition Policy,” Arizona State Law Review 46, no. 1 (2014): 1–40.Google Scholar
42 U.S.C. §18071.Google Scholar
Excise tax on high cost employer-sponsored health coverage, 26 U.S.C. §4980I.Google Scholar
Furman, J. and Fiedler, M., “The Cadillac Tax — A Crucial Tool for Delivery System Reform,” NEJM 374, no. 11 (2016): 1008–1009; Mankiw, N.G. and Summers, L., “Uniting Behind the Divisive ‘Cadillac’ Tax on Health Plans,” New York Times, October 24, 2015, available at <https://www.nytimes.com/2015/10/25/upshot/uniting-behind-the-divisive-cadillac-tax-on-health-plans.html> (last visited October 19, 2018).CrossRefGoogle Scholar
Lemieux, J. and Moutray, C., “About That Cadillac Tax,” Health Affairs Blog, April 25, 2016, available at <https://www.healthaffairs.org/do/10.1377/hblog20160425.054627/full/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Consolidated Appropriations Act, 2016, Pub. L. No. 114-113, Div. P §101 (2015).Google Scholar
Extension of Continuing Appropriations Act, 2018, H.R.J. Res. 125, 115th Cong. § 4002 (2018). This continuing resolution was passed on January 22, 2018 to end a partial government shutdown. It also delayed the ACA's medical device excise tax until 2020. Id. 4001.Google Scholar
Letter from Douglas Elmendorf, Director, Cong. Budget Off., to John Boener, Speaker of the House, July 24, 2012, at 13; Kliff, S., “Romney's Right: Obamacare Cuts Medicare by $716 Billion. Here's How,” Washington Post, August 14, 2012, available at <https://www.washingtonpost.com/news/wonk/wp/2012/08/14/romneys-right-obamacare-cuts-medicare-by-716-billion-heres-how/?utm_term=.bfd8adaf9aa1> (last visited October 19, 2018). (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=Letter+from+Douglas+Elmendorf,+Director,+Cong.+Budget+Off.,+to+John+Boener,+Speaker+of+the+House,+July+24,+2012,+at+13;+Kliff,+S.,+“Romney's+Right:+Obamacare+Cuts+Medicare+by+$716+Billion.+Here's+How,”+Washington+Post,+August+14,+2012,+available+at++(last+visited+October+19,+2018).>Google Scholar
Patient Protection and Affordable Care Act, Pub. L. No. 111-148, §3403, 124 Stat. 119, 489-506, modified by §10320 (2010) (codified at 42 U.S.C. §1395kkk).Google Scholar
Marciarille, A.M. and DeLong, J.B., “Bending the Health Cost Curve: The Promise and Peril of the Independent Payment Advisory Board,” Health Matrix: The Journal of Law-Medicine 22, no.1 (2012): 75–121, at 105.Google Scholar
See Cunningham, P.W., “The Health 202: Republicans Kill Obamacare's Controversial ‘Death Panel,’” Washington Post, February 9, 2018, available at <https://www.washingtonpost.com/news/powerpost/paloma/the-health-202/2018/02/09/the-health-202-republicans-kill-obamacare-s-controversial-death-panel/5a7c601d30fb041c3c7d76c7/> (last visited October 19, 2018). (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=See+Cunningham,+P.W.,+“The+Health+202:+Republicans+Kill+Obamacare's+Controversial+‘Death+Panel,’”+Washington+Post,+February+9,+2018,+available+at++(last+visited+October+19,+2018).>Google Scholar
Ho, C.S., “Budgeting on Autopilot: Do Sequestration and the Independent Payment Advisory Board Lock-In Status Quo Majority Advantage?” Tulsa Law Review 50, no. 3 (2015): 695–758.Google Scholar
See Fuse Brown, supra note 24.Google Scholar
Ginsburg, P.B. and Pawlson, L.G., “Seeking Lower Prices Where Providers are Consolidated: An Examination of Market and Policy Strategies,” Health Affairs 33, no. 6 (2014): 1067–1075.Google Scholar
Dafny, L. et al., “Narrow Networks on the Health Insurance Marketplaces: Prevalence, Pricing, and the Cost of Network Breadth,” Health Affairs 36, no. 9 (2017): 1606–1614.Google Scholar
Greaney, supra note 29.Google Scholar
Berenson, R. et al., “Getting to a Public Option that Contains Costs: Negotiations, Opt-Outs, and Triggers,” Health Policy Center, Urban Institute, November 2009.Google Scholar
Hervey, D. et al., “State Single-Payer and Medicaid Buy-In: A Look at California, New York, and Nevada,” Health Affairs Blog, June 30, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20170630.060852/full/> (last visited October 19, 2018); S. Kliff, “Nevada's Legislature Just Passed a Radical Plan to Let Anybody Sign Up for Medicaid,” Vox, June 6, 2017, available at <https://www.vox.com/policy-and-politics/2017/6/6/15731622/nevada-medicaid-for-all> (last visited October 19, 2018). (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=Hervey,+D.+et+al.,+“State+Single-Payer+and+Medicaid+Buy-In:+A+Look+at+California,+New+York,+and+Nevada,”+Health+Affairs+Blog,+June+30,+2017,+available+at++(last+visited+October+19,+2018);+S.+Kliff,+“Nevada's+Legislature+Just+Passed+a+Radical+Plan+to+Let+Anybody+Sign+Up+for+Medicaid,”+Vox,+June+6,+2017,+available+at++(last+visited+October+19,+2018).>Google Scholar
Holahan, J. et al., “The Evidence on Recent Spending Growth and The Impact of the Affordable Care Act,” Health Policy Center, Urban Institute, May 2017, at 2–4.Google Scholar
Cubanski, J. and Neuman, T., “The Facts on Medicare Spending & Financing,” Kaiser Family Foundation, July 18, 2017, available at <https://www.kff.org/medicare/issue-brief/the-facts-on-medicare-spending-and-financing/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Lewis, V.E. et al., “Explaining Sluggish Savings Under Accountable Care,” NEJM 377, no. 19 (2017): 1809–1811.Google Scholar
Papanicolas, I. et al., “Health Care Spending in the United States and Other High-Income Countries,” JAMA 319, no. 10 (2018): 1024–1039.Google Scholar
Hancock, J. and Luthra, S., “Studies: Employer Costs Slow As Consumers Use Less Care, Deductibles Soar,” Kaiser Health News, September 14, 2016, available at <https://khn.org/news/studies-employer-costs-slow-as-consumers-use-less-care-deductibles-soar/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
PwC, “Medical Cost Trend: Behind the Numbers 2018,” June 2017, at 7–8.Google Scholar
Tseng, P. et al., “Administrative Costs Associated with Physician Billing and Insurance-Related Activities at an Academic Health Care System,” JAMA 319, no. 7 (2018): 691–697.CrossRefGoogle Scholar
The American Health Care Act, H.R. 1628, 115th Cong. (as passed by House, May 4, 2017).Google Scholar
The Better Care Reconciliation Act, H.R. 1628, 115th Cong. (2017).Google Scholar
Senate Amendment 1030 to H.R. 1628, 115th Cong. (2017).Google Scholar
Tax Cuts and Jobs Act of 2017, Pub. L. No. 115-97 §11081 (2017); See Jost, T.S., “The Tax Bill and the Individual Mandate: What Happened and What Does It Mean?” Health Affairs Blog, December 20, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20171220.323429/full/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Pear, R., “Trump Officials, After Rejecting Obama Medicare Model, Adopt One Like It,” New York Times, January 10, 2018, available at <https://www.nytimes.com/2018/01/10/us/politics/medicare-trump-administration-obamacare.html> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Sweeney, E., “Amid Deep Cuts Across HHS, Trump's Budget Maintains Focus on Healthcare Fraud Enforcement,” Fierce Healthcare, March 21, 2017, available at <https://www.fiercehealthcare.com/antifraud/amid-deep-cuts-across-hhs-trumps-budget-maintains-focus-healthcare-fraud> (last visited October 19, 2018). (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=Sweeney,+E.,+“Amid+Deep+Cuts+Across+HHS,+Trump's+Budget+Maintains+Focus+on+Healthcare+Fraud+Enforcement,”+Fierce+Healthcare,+March+21,+2017,+available+at++(last+visited+October+19,+2018).>Google Scholar
Office of Public Affairs, Department of Justice, “Justice Department Recovers Over $3.7 Billion From False Claims Act Cases in Fiscal Year 2017,” December 21, 2017, available at <https://www.justice.gov/opa/pr/justice-department-recovers-over-37-billion-false-claims-act-cases-fiscal-year-2017> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Kaiser Family Foundation, “Compare Proposals to Replace the Affordable Care Act,” updated September 25, 2017, available at <https://www.kff.org/interactive/proposals-to-replace-theaffordable-care-act/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Medicare Modernization Act of 2003, Pub. L. 108-173 §1201 (2003).Google Scholar
See Levey, N. and Kim, K., “A Side-By-Side Comparison of Obamacare and GOP Replacement Plans,” L.A. Times, March 8, 2017, updated July 13, 2017, available at <http://www.latimes.com/projects/la-na-pol-obamacare-repeal/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
See Altman, D., “Why Deductibles Would Rise Under the GOP Health Care Plan,” Kaiser Family Foundation, March 22, 2017, available at <https://www.kff.org/health-reform/perspective/why-deductibles-would-rise-under-the-gop-health-care-plan/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
See Kaiser Family Foundation, supra note 61.Google Scholar
Id.Google Scholar
Id.; See Fiedler, M., “Like the AHCA, The Senate's Health Care Bill Would Weaken ACA Protections Against Catastrophic Costs,” USC Brookings-Schaeffer on Health Policy, June 23, 2017, available at <https://www.brookings.edu/blog/usc-brookings-schaeffer-on-health-policy/2017/06/23/like-the-ahca-the-senates-health-care-bill-could-weaken-aca-protections-against-catastrophic-costs/> (last visited October 19, 2018). (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=Id.;+See+Fiedler,+M.,+“Like+the+AHCA,+The+Senate's+Health+Care+Bill+Would+Weaken+ACA+Protections+Against+Catastrophic+Costs,”+USC+Brookings-Schaeffer+on+Health+Policy,+June+23,+2017,+available+at++(last+visited+October+19,+2018).>Google Scholar
See Kaiser Family Foundation, supra note 61.Google Scholar
Nyman, J.A., “Is Moral Hazard Inefficient? The Policy Implications of a New Theory,” Health Affairs 23, no. 5 (2004): 194–199.Google Scholar
See Newhouse, supra note 15, at 162.Google Scholar
Fung, V. et al., “Financial Barriers to Care Among Low-Income Children With Asthma: Health Care Reform Implications,” JAMA Pediatrics 168, no. 7 (2014): 649–656; A. Trivedi et al., “Increased Ambulatory Care Copayments and Hospitalizations among the Elderly,” NEJM 362, no. 4 (2010): 320-328; M. Rosenthal and N. Daniels, “Beyond Competition: The Normative Implications of Consumer-Driven Health Plans,” Journal of Health Politics, Policy, and Law 31, no. 3 (2006): 671-85, at 675.CrossRefGoogle Scholar
See Kaiser Family Foundation, supra note 61.Google Scholar
Bipartisan Budget Act of 2018, Pub. L. No. 115-123 (2018).Google Scholar
Cong. Budget Off., “H.R. 849, Protecting Seniors’ Access to Medicare Act,” Cost Estimate, Oct. 27, 2017.Google Scholar
See Rosenbaum, S., “Medicaid: What Happens Now?” Health Affairs Blog, May 17, 2017, available at <https://www.healthaf-fairs.org/do/10.1377/hblog20170517.060134/full/> (last visited October 19, 2018); S. Rosenbaum, “Medicaid Round Two: The Senate's Draft ‘Better Care Reconciliation Act of 2017,’” Health Affairs Blog, June 24, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20170624.060800/full/> (last visited October 19, 2018); S. Rosenbaum, “Medicaid Redux: Graham Cassidy Again,” Health Affairs Blog, September 25, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20170925.062166/full/> (last visited October 19, 2018). (last visited October 19, 2018); S. Rosenbaum, “Medicaid Redux: Graham Cassidy Again,” Health Affairs Blog, September 25, 2017, available at (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=See+Rosenbaum,+S.,+“Medicaid:+What+Happens+Now?”+Health+Affairs+Blog,+May+17,+2017,+available+at++(last+visited+October+19,+2018);+S.+Rosenbaum,+“Medicaid+Round+Two:+The+Senate's+Draft+‘Better+Care+Reconciliation+Act+of+2017,’”+Health+Affairs+Blog,+June+24,+2017,+available+at++(last+visited+October+19,+2018);+S.+Rosenbaum,+“Medicaid+Redux:+Graham+Cassidy+Again,”+Health+Affairs+Blog,+September+25,+2017,+available+at++(last+visited+October+19,+2018).>Google Scholar
Cong. Budget Off., “H.R. 1628, American Health Care Act of 2017,” Cost Estimate, May 24, 2017, [hereinafter CBO Score for AHCA].Google Scholar
Cong. Budget Off., “H.R. 1628, Better Care Reconciliation Act of 2017,” Cost Estimate, June 26, 2017, [hereinafter CBO Score for BCRA]; Cong. Budget Off., “Preliminary Analysis of Legislation That Would Replace Subsidies for Health Care with Block Grants,” Cost Estimate, September 2017, [hereinafter CBO Estimate for Graham-Cassidy].Google Scholar
See Kaiser Family Foundation, supra note 61.Google Scholar
Kaiser Family Foundation, “Medicaid Waiver Tracker: Which States Have Approved and Pending Section 115 Medicaid Waivers?” March 5, 2018, available at <https://www.kff.org/medicaid/issue-brief/which-states-have-approved-and-pending-section-1115-medicaid-waivers/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Prokop, A., “At Its Core, the Senate Health Bill Slashes Medicaid to Finance a Tax Cut for the Rich,” Vox, June 22, 2017, available at <https://www.vox.com/policy-and-politics/2017/6/22/15854762/senate-health-bill-medicaid-cuts> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
CBO Score for AHCA, supra note 76 at 17; CBO Score for BCRA, supra note 77, at 16.Google Scholar
CBO Estimate for Graham-Cassidy, supra note 77, at 7.Google Scholar
Ippolito, B., “Resolving the AHCA's Incoherence on Cost Discipline,” American Enterprise Institute, June 15, 2017, available at <http://www.aei.org/publication/how-congress-can-fix-the-gop-healthcare-bill-to-lower-costs/> (last visited October 19, 2018). (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=Ippolito,+B.,+“Resolving+the+AHCA's+Incoherence+on+Cost+Discipline,”+American+Enterprise+Institute,+June+15,+2017,+available+at++(last+visited+October+19,+2018).>Google Scholar
Stein, J., “GOP Senators are Rushing to Pass Graham-Cassidy. We Asked 9 to Explain What It Does,” Vox, September 20, 2017, available at <https://www.vox.com/policy-and-politics/2017/9/20/16333876/republican-senators-graham-cassidy> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Sperling, G. and Shapiro, M., “How the Senate's Health Care Bill Would Cause Financial Ruin for People With Preexisting Conditions,” The Atlantic, June 23, 2017, available at <https://www.theatlantic.com/business/archive/2017/06/ahca-senate-bill-preexisting-conditions/531375/> (last visited October 19, 2018). (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=Sperling,+G.+and+Shapiro,+M.,+“How+the+Senate's+Health+Care+Bill+Would+Cause+Financial+Ruin+for+People+With+Preexisting+Conditions,”+The+Atlantic,+June+23,+2017,+available+at++(last+visited+October+19,+2018).>Google Scholar
CBO Estimate for AHCA, supra note 76; Sanger-Katz, M., “Who Wins and Who Loses in the Latest GOP Health Bill,” New York Times, May 4, 2017, available at <https://www.nytimes.com/2017/05/04/upshot/who-wins-and-who-loses-in-the-latest-gop-health-care-bill.html> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Jost, T.S., “House GOP Moves to Add ‘Invisible Risk Sharing Program’ to AHCA; Other ACA Developments,” Health Affairs Blog, April 6, 2017, available at <https://www.healthaffairs.org/do/10.1377/hblog20170406.059530/full/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Congressional Budget Office, “Repealing the Individual Health Insurance Mandate: An Updated Estimate,” Nov. 2017, available at <https://www.cbo.gov/publication/53300> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
Trump, D.J. (@realDonaldTrump), Twitter, May 4, 2017, 1:56 PM, available at <https://twitter.com/realDonaldTrump/status/860191508619722752/> (last visited October 19, 2018).+(last+visited+October+19,+2018).>Google Scholar
See Ippolito, supra note 83.Google Scholar
Capretta, J., “The GOP's Ongoing Health Care Confusion,” American Enterprise Institute, July 7, 2017, available at <http://www.aei.org/publication/the-gops-ongoing-health-care-confusion/> (last visited October 19, 2018); R. Moffit, “Assessing the American Health Care Act: Moving Toward a Fair Federal Tax Treatment for Health Insurance,” The Heritage Foundation, April 18, 2017, available at <https://www.heritage.org/health-care-reform/report/assessing-the-american-health-care-act-moving-toward-fair-federal-tax> (last visited October 19, 2018). (last visited October 19, 2018); R. Moffit, “Assessing the American Health Care Act: Moving Toward a Fair Federal Tax Treatment for Health Insurance,” The Heritage Foundation, April 18, 2017, available at (last visited October 19, 2018).' href=https://scholar.google.com/scholar?q=Capretta,+J.,+“The+GOP's+Ongoing+Health+Care+Confusion,”+American+Enterprise+Institute,+July+7,+2017,+available+at++(last+visited+October+19,+2018);+R.+Moffit,+“Assessing+the+American+Health+Care+Act:+Moving+Toward+a+Fair+Federal+Tax+Treatment+for+Health+Insurance,”+The+Heritage+Foundation,+April+18,+2017,+available+at++(last+visited+October+19,+2018).>Google Scholar
Extension of Continuing Appropriations Act, 2018, H.R.J. Res. 125, 115th Cong. §4002 (2018).Google Scholar
See Stein, supra note 84.Google Scholar
Emanuel, E. et al., “Measuring the Burden of Health Care Costs on U.S. Families: The Affordability Index,” JAMA 318, no. 19 (2017): 1863–1864.Google Scholar
See Cox, C. and Sawyer, B., “How Does Cost Affect Access to Care?” Peterson-Kaiser Health System Tracker, November 29, 2016, available at <https://www.healthsystemtracker.org/chart-collection/cost-affect-access-care-2-3/#item-adults-worse-health-difficulty-accessing-care-due-cost> (last visited March 28, 2018).+(last+visited+March+28,+2018).>Google Scholar