Should We Be Able to Buy Health Insurance Across State Lines?
I live in Texas. Right now, the only health insurance I can buy is insurance regulated under Texas law. But if bills before Congress (most notably, one sponsored by Arizona Republican Congressman John Shadegg), are enacted, I would be able to buy insurance regulated, say, by the laws of Virginia, or the laws of Delaware, or 47 other states.
Proponents claim this would greatly increase competition. Opponents claim it would undermine “consumer protections.” I think both claims are mainly wrong. I would not expect the number of insurance companies trying to sell me insurance in Dallas, Texas to change at all. And if I am worried about consumer protections, I can continue to buy Texas-regulated insurance, just as I did before.
In fact, far from losing consumer protections, I would gain access to all sorts of protections I do not now have. Specifically, I would be able to choose among 50 different regulatory regimes. And because market prices (premiums) would reflect the different regulatory costs, I could weigh cost against benefits in selecting the regulatory regime that best fits my needs. Think of it as 49 ways to leave your regulator. (Note: An earlier version of this appeared at the Health Affairs blog.)
httpv://www.youtube.com/watch?v=RTiyLuZOs1A
50 Ways to Leave Your Lover
Let’s run through a few things that a rational consumer should care about. One is guaranteed renewability and how well that is enforced. I don’t want an insurer to be able to cancel my policy or jack up my premium just because I get sick.
Dispute resolution is another issue. If I don’t agree with a coverage decision my insurer makes, what procedures are in place to make sure I get a fair hearing and an objective resolution? How difficult is this to do? How long does it take?
Every state has mandated health insurance benefits. These are laws requiring insurers to cover services ranging from acupuncture to in vitro fertilization and providers ranging from chiropractors to naturopaths — and there are considerable differences among the states. Although often described as “consumer protections” in every legislative hearing I have ever attended, it is the special interest providers (rather than patients) who are pushing for these laws.
Still, I might be concerned about a change in my plan benefits in future years. So if I want to make sure I am always covered by chiropractic services, maybe I will want a regulatory regime that requires it.
Then there are a set of technical issues that are hard for a normal consumer to understand, but that can be summarized and explained by Consumer Reports or some other independent body. If the state regulates premiums, insurance forms, or loss ratios (percent of premium spent on benefits), after-the-fact audits are better than pre-approvals — by which regulatory inertia can keep markets from quickly meeting consumer needs. Also, insurance company audits should be paid for by the regulator (not the insurer), so that regulators are not tempted to needlessly impose costs.
Competition among 50 regulatory regimes would have beneficial effects both on regulators and insurers. Regulatory regimes that impose high costs and create few benefits would soon see everyone avoiding them. In time, they would have to change or discover they have no insurance left to regulate. And once customers start focusing on the non-price aspects of insurance, insurers will have enhanced incentives to compete on those features.
Remember the phrase, “You’re in good hands with Allstate”? The advertisement asks consumers to think about how they are treated at the time claims need to be paid. I don’t recall ever seeing a health insurance company boast about its claims-paying prowess. But that would become normal if health insurance were sold in a national marketplace.
Which brings us back to the claim of the proponents. I would not expect to see more competitors. I would expect to see more competition, however, in those aspects of insurance that are today handled almost exclusively by regulators.
One thing that would not survive 50 state regulatory regime competition is guaranteed-issue and community rating in the individual market. In the six states that impose such requirements the vast majority of people who are relatively healthy are overcharged so that the small percent who are sick can be undercharged. This form of private sector socialism would quickly dissolve, as the healthy sought cheaper insurance under other regulatory regimes.
This would be a good outcome for healthy people because lower premiums would encourage the uninsured to buy insurance. But would people with pre-existing conditions (who remain in shrinking pools with rising per capita costs) be unfairly burdened? The solution that would face the least political resistance would be to exempt these six states from the proposal, unless they opt in. But a better solution would be for states to find more rational ways of subsidizing the care of high-cost patients.
Overall, University of Minnesota economists Steve Parente and Roger Feldman estimate that cross-state purchasing of health insurance would induce 12 million more people to obtain health insurance. That number would double if tax subsidies for health insurance were equalized — thus insuring 80% of the number of uninsured people the Senate (ObamaCare) health bill aims to insure — without any net cost to the federal government.
The type of competition you want to promote is among insurance commissioners, insurance regulators and state legislatures to make their states more conducive to affordable coverage. What we currently have is a 50-state patchwork where lobbyists in each state work to convince legislatures to mandate the service or disease they lobby for.
The answer to your question is: yes, of course we should.
If states that have more generous regulations are states where most people get their policies, do we still end up with the same adverse selection that occurs in situations where insurance companies advertise generous maternity benefits (or other similar diseases)?
It seems to me that a few states might be seen as “most generous,” which would drive consumers to those states, and before you know it, you’ve got most states adopting the same regulations. Would something like this happen?
Virginia,
Very unlikely, especially with your example of maternity benefits. Here’s why.
For something to be an “insurable event,” it needs two characteristics: low probability and high cost. Maternity is generally planned, not random, and so it is high probability. That’s why employers didn’t offer maternity coverage nationwide until the feds forced them into it in the mid-1970s. Health economist Jonathan Gruber wrote an excellent piece on this (an NBER report) in, I believe, the 1980s or early 1990s.
So in fact people would try to buy insurance where insurers meet the minimum mandates required by federal law but don’t go further.
Best,
David
I agree that allowing Americans to buy health insurance across state lines would allow individuals to trade off degrees of consumer protection against premiums, which would be a good thing on one condition, namely, that individuals who find themselves mauled in an only lightly regulated market refrain from running to the government for succor, as is the rugged individualist’s wont in this country.
We have seen it of recent in the mortgage business, where folks from mom and pop borrowers to bank executives ran to the government for help after they had made the wrong choices in that market.
Good points….
Here’s an aspect of the US constitution I don’t understand but that may be relevant. The constitution gives the federal government the authority to regulate interstate commerce. That always has been understood to mean that importing states cannot act to block the goods coming from outside. Does it also mean that exporting states cannot control goods made inside those states but sold only in other states, not in the state of manufacture? If so, then the federal government can impose a rule that insurance companies sold to people out of state are not subject to the regulations of either the state in which the insurance company resides or in which the purchaser resides. In other words, no state’s insurance mandates would apply to policies sold across state lines. That would put an end to all state mandates in no time at all.
Perhaps that is too little regulation. I am not an expert on insurance, so maybe there are some obvious problems that would require regulation.
Does anyone have any thoughts on any of the foregoing?
I wonder if the value of buying across state lines is not being oversold. I am in Utah. If someone in New York wants to buy in Utah, one of two things will happen. 1) Utah carriers will charge New Yorkers more premium so they can build products with competitive reimbursements in the New York market. Or, 2) the New Yorker will buy a less expensive Utah plan in which they will be subject to out-of-network coverage and balance billing, which could be enormous. Balance billing is when the patient pays the difference between the contracted rate (based on the Utah market) and the retail charge (based on the New York market). There is no real panacea from a cost perspective in buying across state lines, although I agree it may have some effect to encourage states to deregulate.
John, you continue to surprise me with your presumptions that the insurance industry is just chomping at the bit to offer their product from one state over in another. This may, or may not, be the case. Rates for health insurance vary by factors that are not at all limited to state mandated benefits. For a given set of benefits, and after age/sex, the most important actuarial factors will be some combination of geographic/area and “network” factors. Companies comfortable writing in, say, Wyoming might not be at all interested in people from California or Texas wanting to buy their policies, and those policies won’t “fit” those people because of where they live, and it will have nothing to do with state regulations. I have seen numerous blog posts and comments from people who think that they can buy that “cheap” policy they heard about from a cousin over in another state, but folks, it really doesn’t work like that. I’m not saying it won’t happen at all, just don’t expect it to be like you envision. There may be some current “national” brands who will be interested in offering a “lowest common denominator” type policy everywhere, but there won’t be many of those, certainly not at the outset. It may be a while before the “competition” really shows up. The other thing I find incredulous is that studies such as that of Parente/Feldman constantly purport to show that a little change in insurance premiums (I consider 20% a small change) will suddenly cause millions of people (and small groups) to suddenly find health insurance “affordable” and actually act on that. Most people will simply not buy health insurance unless they have to (are sick) or are forced to (mandate) or they can do so with other people’s money (employer and/or tax subsidy) or they are so rich they can self insure if they choose, but buy to protect assets. Creating a supposedly competitive market across state lines doesn’t change any of those factors. I think those kinds of projections are really out of a realistic ball park. (I believe I have seen studies that show that there is not much price elasticity of demand for health insurance, and that matches up with this actuary’s experience in the real world, not the academic one. It is what people actually do, not what they say they will do if the price changes.)
John,
Agree. That’s why we need innovetion from Docs.
Rational employees need direction from employers. That’s a start. But there are no new products.
I met with BCBS last week and will be meeting with United HC to offer a new product to employers (particularly self-funded) instead of just HMO, PPO and POS. Employers would have a totally new product to offer (and pay for) their employees when a true catastrophic insurance plan is combined with a “CONCIERGE” PHYSICIAN.
As you know, we decrease hospitalizations by 50-60%.
(MDVIP data).
If we cut the primary care piece from the insurance equation and cut the beancounters , then we decrease cost. This is a start on true, innovative change. Sorry, the government and insurers can’t solve the problems of primary care medical homes.
If only Concierge Docs in 45 states were recognized as “medical care” by Congress. BTW, I got my health insurance license last month. It’s hard to communicate if you don’t speak the same language.
BTW, solving Medicare and Medicaid “DIRECT PRACTICE,CONCIERGE,RETAINER MEDICINE) is a different discussion at adifferent time…
Your thoughts Uwe?
I agree. But doing so is a prerequisite to being able to allow cross-state purchasing, both politically and logistically.
David,
I remember reading something about how plans that advertised for specific conditions ended up with too many at-risk applicants. So, they stopped offering those coverages. I can’t remember where I read it, but it mentioned maternity care (perhaps fertility treatment, my memory fails me) and diabetes care (where an insurance company wrote letters to its customers telling them how another plan at a competing insurer was better because it could no longer afford all of the sick people).
I think you’re right about people picking states based on the minimum coverage (my policy would be cheaper if it didn’t include services which in my opinion should not be insured (fertility treatments and chiropractic work come to mind)). But, if I had a chronic disease (let’s say diabetes), I would look for a state that had some sort of regulation in place forcing insurance companies to cover diabetes. Or, I might look for a state with a community rating, guarantee issue law.
Are you saying that states will drop these regulations? Just wondering.
Crossing state borders to expand the market of underinsurance products may seem to work for the majority who are healthy and are looking only for lower insurance premiums, but that approach breaks down for those who develop significant medical problems.
We need policies that help us pay for health care, not policies that allow the healthy to escape from their social obligation to share in the financing of health care for those with needs.
I’m just an insurance guy — or a lowly one, I should say, given the vilification of industry. (Note to politicians: insurance is a cost-plus business. We are required to generate a surplus or the state regulators shut us down. Focus on costs, not premiums.)
At any rate, California is a perfect example. My young company has been asked by hospital systems and physicians to expand into California, and we have employers who want to pay us to do so. We continue to push California to the bottom of the list. Sure, it is a big market. But there are far better places to do business in the US, so we will grow other markets unless and until we feel we must go into CA. Imagine if consumers and employers in California could as easily express their interests as I can.
The issue I don’t hear spoken about often enough in the press comes down to a simple question: while we are hearing about very high premium increases – 25-35% in some markets like CA and CT – for individuals purchasing on their own, self-insured employers in those same markets are seeing their costs go up under 7%. Why?
Parts of the answer have to do with changing risk pools in a rough economy and wonderful geeky things that people like me enjoy. But a huge part of it is simply the laws passed in each state. And I’ll put my money where my mouth is — if insurance could be purchased across state lines, I would round out my network in CA and open for business there as quickly as possible. Until then, no thanks.
John Seater speaks of federal regulation through Interstate Commerce statutes. Good Point. The feds already regulate self funded employer plans (which includes a huge percentage of covered employees), and pre-empt any state regulation (and mandates). By the way, it works just fine.
HD Carroll doubts that carriers will be anxious to sell policies outside their chartered home state. I think they will indeed be anxious to widen their markets. In addition, smaller carriers who have chosen not to offer products in certain areas (due to barriers to entry in various states) will most surely re-evaluate their positions, and be inclined to offer innovative products that will bring more competition. Political graft could be greatly reduced, and cost increasing mandates will fade away. I think a 20% reduction in overall costs would be a gigantic improvement.
Mr. Reinhardt worries that we might have a “buyers remorse” backlash impacting the action at the public trough by those who have chosen lower premiums over tighter mandates. How about enforcing contracts and agreements and making entitlement disappear. We might be amazed at how diligent people would be if they had the responsibility for their decisions. Oh, and isn’t the analogy in this regard using the mortgage crisis a bit inappropriate? After all, it was the government insisting on bad loans being made that provided the impetus for that scandal. In this case the whole idea is to get the governments out of the business by reducing its power.
Ultimately, implementation of ideas like the one Shadegg is proposing will help to reduce costs.
Imagine buying car insurance where the only package available also included a year’s worth of gasoline, one oil change, and three car washes. Most economists would agree that (third degree) price discrimination is a good thing for consumers because it leads to better price discovery and more product differentation/options. For insurance purposes, Shadegg’s plan would eventually allow insurance consumers to self-select the menu from the state that provides the best value proposition for their needs–catastrophic only, catastrophic plus two physician visits, kitchen sink coverage, etc.–rather than a “one size fits all” as determined by regulators and self-interested politicians and their patron special interests who force mandates.
Insurance is, and should be, a legitimate transfer of risk rather than prepaid health care; actuaries will do a very good job of determining an “a la carte” cost benefit structure once state regulators compete with each other to have the most flexible plan options. And this will bend the cost curve down.
In all of the chatter about “cross-state” purchasing, I’ve yet to hear a rational explanation of how the resident of New York, for example, can receive services through a policy sold by an Alabama company. Does the Alabama company already have a network of hospitals, doctors and other providers in New York? If so, what is stopping that company from offering New York policies today? Don’t the national for-profit companies already offer policies in every state where it makes good business sense to do so? Help me out here.
Wes G…
Good analogies….
You almost get it right…
Mr G’s gas station presently offers gas, tune-ups, brake jobs, new tires, etc. for cash… The consumer chooses if it’s worth it and pays for car insurance
for the unfortunate car wreck.
Dr. G (like present day PCP’s, and others) offers the same service except he has to hire staff to deal
with the insurance company that the consumer has to pay for cash services.
Dr. G’s new business model is all services are included for one transparent price. The consumer will determine quality and Dr. G offers no line to get gas or fix his car.
Same with Mr. G’s house. You use insurance to pay for catastrophe, not mowing your lawn.
I know ya’ll realize how catastrophic this has become for physicians, many (but certainly not all) of whom are finding it difficult to cover their cost to keep their practice open. Hardly any med students from US Med Schools are going into primary care (Internal Medicine/Family Practice and the Perfect Storm has been here for years.
Where Mr. G gets it wrong is that consumers gladly embrace pre-paid physician fees if they so desire.
Hopefully, we will be recognized by Congress as “medical care” in the IRC of 1986 so consumers can use their HSA’s to pre-pay for primary care.
The part of physician care that can legitimately be “pre-paid” can be done so for exactly the reason that it can be considered “budget-able” – that it has a low level of variability of risk, high frequency, relatively low cost per unit. In other words, it isn’t what insurance is for. It is something else entirely, which I am sure most readers already understand and agree with. But whether we split medical care into “preventative/wellness/basic” and “true insurance” categories, we will still face two key questions for both categories: affordability and accessability. Affordability will have to do with the cost (either directly or through an intermediate contract of pre-payment or insurance) and whether it should be considered before or after taxes, and how to subsidize those who “need help.” Accessability will have to do with both resource allocation (enough primary physicians? enough specialists in the right geographic areas?) and insurability – i.e., how to deal with the “change in health status” issues such as underwriting, pre-existing limits, maximum benefits, universal coverage.
John, a few weeks ago I introduced in GA my Senate Bill 407 which is similar to Cong. Shadegg bill. In 2007 I first introduced a cross state purchasing bill in GA and ALEC picked it up as a national model bill and it has been introduced in about 20 states. I reintroduced it this year and also just worked with WY to pass it there last week.
My SB 407 is in a Senate hearing in GA tomorrow. Would love to catch up.
John, buying across state lines does not bother me. Buying insurance that is less expensive? Does that mean that doctors will accept these plans or will they only be indemity plans? Just wondering.
John,
The number one driver – even before utilization – is the actual cost of the underlying medical care. Today, you may not be able to buy healthcare “COVERAGE” across state lines, but at MediBid.com, you can buy the actual MEDICAL CARE across state lines, and that is where the savings start.
I’m not going to sit around and wait for politicians to “fix” anything, I just want them out of the way, so that American businesses like mine can create solutions. Because we don’t need change, we need solutions.
( http://www.medibid.com/ )
Jim, the answer is that companies like mine may have networks of hospitals and physicians in a state with heavy legislative/regulatory burdens but that we only sell to self-insured customers. Insured business is regulated by the states, but self-insured is (largely) not. We do this now in several states.
The problem is that companies like mine are less likely to want to go into a tough insurance market because we would have to begin by throwing away a substantial portion of the customer base there if we stick with self-insured. A classic example of this is Maine. Heavily dominated by one carrier, Anthem Blue Cross, and with a relatively small self-insured segment of the market.
The latest flavor, by the way, is ‘payment reform’. MA is struggling to find a way to pay for its new programs, and the state is investigating all sorts of capitated arrangements to limit their own costs if nothing else. Anyway, that is just too confusing and up in the air for potential new entrants (like us) to find it worthwhile to think about entering the market even though we have people who want to pay us to do so. We, like investors everywhere, simply prioritize our opportunities and act accordingly.
One of the posts above said that a change of 20 percent in a premium was a “small” change. For people buying their own policies in the markets that states need to deregulate due to (mis)regulation, family policies can run $6,000 or more for middle aged parents with a big deductible in states with more or less reasonable regulations.
A 20% change is $1,200. I’ll go out on a limb and say that a majority of Americans think that $1,200 is a “big” change. Especially lately, after having had to digest so much hope and change.
Keep in mind that if someone buys an out-of-state policy with a network limited to hospitals in another state, a few years of $1,200 savings will buy a lot of plane tickets and hotel rooms.
The stakes are even higher in states with absurd regulatory environments. In states like New Jersey, where premiums for a family plan are more than $1,000 a month thanks to regulations passed in 1992, the ability to buy insurance in Pennsylvania and save thousands would probably encourage a lot of people to hop in the car if they needed expensive medical care.
Medical tourism anyone?
In reference to Jim Morrison’s post, yes most of the largest carriers are in all or almost all states. The problem is that they all have to include each states “pet” benefit mandates in policies sold in those states. The process serves as a sort of tariff to protect the special interests in each state, and like any tariff it increases the cost for the consumer. But more importantly that process helps keep out other carriers who may be able to break the near monopolies these “large carriers” have in various areas (someone noted Maine as a good example).
HD,
good comments.
Affordability: Determined by the consumer much like you decide whether to go to McDonalds or Morton’s steak house for dinner. Most “Concierge/direct practices” charge from $100-150/month Cheaper than cigarettes/McDonald’s). It ain’t free and neither is food. I’ve seen as high as $1000/month.
Access: Our practices are small (usually ~4-600 patients). We can only see so many patients and do a good job. 24/7 access/txt/email/no waiting) eg: We discharged today an 85 yo diabetes, coronary heart disease, a pacemaker and constive heart failure that I started on an insulin drip last week. He was on a cruise ship in the middle of the Indian Ocean and I worked with the Norwegian surgeon cruise ship Doc to safely bring him back to Fort Worth. I charge him $167/month. That’s healthcare for a reasonable price.
I bet Senator Hill would love to give health stamps that the Medicaid patients can cash in at a direct practice and use Medicaid for what it’s really for..Catastrophies. Then we work for the patient, and not the government. We save Medicaid, Medicare and Don’t you think a family with an Iraq War veteran with numerous medical and surgical problems would love to pay a doctor directly to guide them through the maze of Walter Reed?
Resource Allocation: Wake up…Virtually no med students are going into primary care. My son-in-law is a 4th year med student at Southwestern in Dallas.
He thinks there are only 4 or five classmates going into primary care. Baylor in Houston just closed their family practice program.
Lastly, we take all comers regardless. Why deal with “change in health status” when what we love to do is patient care. And… many of my patients are alcoholics, drug abusers…etc and don’t have any insurance…and most take care of some patients for free but b/c we can…
Here are the stats for primary care. It should be a wake up call to all of us.
“The number of students entering family medicine residency training has fallen from a high of 3,293 in 1998 to 1,172 in 2008, according to National Residency Matching Program data. Fifty-five family medicine residency programs have closed since 2000, while only 28 programs have opened.[18]
In 2006, when the nation had 100,431 family physicians, a workforce report by the American Academy of Family Physicians indicated the United States would need 139,531 family physicians by 2020 to meet the need for primary medical care. To reach that figure 4,439 family physicians must complete their residencies each year, but currently the nation is attracting only half the number of future family physicians that we will need.[19]
The waning interest in family medicine is likely due to several factors, including the lesser prestige associated with the specialty, the lesser pay, and the increasingly frustrating practice environment in the U.S. Salaries for family physicians in the United States are respectable but lower than average for physicians, with the average being $129,295 [20] and ranging from $110,000 to $204,000[21], but when faced with debt from medical school, most medical students are opting for the higher paying specialties”.
Re: Linda Gorman post – I don’t disagree that 20% is enough to get someone who already has insurance to switch, or certainly consider switching even with a difference in coverage, and that there would likely be a robust “churn” across state lines, and competition for existing bodies/small groups. However, most of those people without insurance to start with can’t/won’t afford $4,800 a year any more than $6,000 a year. Perhaps I have become too cynical in dealing with employers and individuals who say that “Boy, if those rates were just 20% lower, I would buy insurance for my employees,” and then when you creatively come up with something that works, and is not merely mini-med, and they are faced with writing the check, they say “Well, I didn’t really mean it.” When it comes to intangibles such as insurance, most people simply don’t understand the value of “protection” as opposed to simply “using” the insurance, meaning “get money back,” and so really don’t want to pay anything for it. Besides, if they wait long enough, the government will just provide it, right?
John:
Your posting today reminded me of a question that I have wanted to ask you for some time but that I never think of when I am near a computer.
The idea of “allowing people to buy insurance across state lines” sounds reasonable on its face, of course, but doesn’t it fly in the face of the 10th Amendment to the Constitution? If one argues that it doesn’t because of the commerce clause, wouldn’t that require one to argue that existing state insurance regulations are unconstitutional?
I am against purchasing insurance across state lines. The first reason is you have just open the door for the Federal government to use “Interstate Commerce” excuse to regulate. They currently do not have jurisdiction. Second, any insurance actuary will tell you insurance rates are based on where you live and the costs in that area. You will still have rates based on where you live and what the cost of healthcare is in your area. Third, where is your local consumer protection & service? Federal bureacrat can and does not provide protection Service?
Response to David Rose and John Seater:
The federal government has authority to regulate interstate commerce. Just as it can prevent Texas from putting a tariff on Florida oranges, it can stop Texas from interfering between a Texan and a Florida insurer.
Response to HD Carroll:
I never said insurers want to do this. Certainly Blue Cross is against it. But the purpose of this blog is not to make insurers happy. I think Parente’s methodology is sound and it is consistent with other studies — including my own with Gerry Musgrave.
Response to Don McCanne:
Let’s say you have diabetes, and your insurance premiums are higher as a result. Do you want to make them higher still by tacking on mandates for in vitro, acupuncture and marriage counseling?
Response to Jim Morrison and Bobby Aga:
Yes, national insurers are in every state and have networks in every state. Under the interstate purchase, what will be different is the choice of 50 regulatory regimes.
John,
But proponents of cross-state purchasing should stop over-selling the concept. Premiums will still be based, in large part, on local factors, i.e., the prices set by hospitals, doctors, other providers, labor costs, etc. I’ve actually seen leading proponents on television suggesting that the price available in a low-cost, minimal-regulation state would be available to residents in high-cost areas.
I don’t believe I saw one post on here dealing with what really drives health care and the health insurance that pays the bills costs up, which are the externalities in the system like non-taxed employor employee health care benefits. Non-taxed employee health care benefits are artificially under priced health insurance that causes over use of health care, because those who have it don’t realize what the true cost of health care or health insurance really is. In the end the over use of health care by those that have these artificially under priced health care insurance policies all accrues to society as a whole in the form of over consumption of a finite resource (health care) driving health care costs up and the insurance that pays for it along with it. All lobbied for, and passed by Congress for the companies that sell health insurance that were started originally by doctors and hospitals for doctors and hospitals in the first place. Fix stuff like what I have mentioned above and the health care problem gets fixed, because it’s all about economics and the rules of economics doesn’t allow externalities to exist in a market place without causing a market failure like we are seeing in health care right now.
What we really need to do is to shop for medical treatment across state lines, as THAT is the basis which insurance pricing is based on.
I?ll immediately seize your rss as I can’t to find your email subscription link or newsletter service. Do you have any? Please let me recognise so that I could subscribe. Thanks.