6. Half of Americans Live Where Population Is Too Low for Competition Source: NEJM 1993;328:148 A town’s only hospital will not compete with itself

25. “Mandate” Model for Reform Proposed by Richard Nixon in 1971 to block Edward Kennedy’s NHI proposal

26. “Mandate” Model for Reform Government uses its coercive power to make people buy private insurance.

27. “Mandate” Model for Reform 1.Expanded Medicaid-like program  Free for poor  Subsidies for low income  Buy-in without subsidy for others 2.Employer Mandate +/- Individuals 3.Managed Care / Care Management

28. What’s New Since Nixon? 1.Individual mandate 2.Promised cost savings through computerization 3.Government Brokers Private Coverage, e.g. FEHBP

29. Massachusetts 2006 “Every uninsured citizen in Massachusetts will soon have affordable health insurance and the costs of health care will be reduced. Gov. Romney.” Sources: Wall Street Journal 4/11/06 and New York Times 4/5/06. “The bill does what health experts say no other state has been able to do: provide a mechanism for all of its citizens to obtain health insurance.”

30. Massachusetts Health Reform New Coverage < Poverty - Medicaid HMO 100% - 300% poverty - Partial subsidy > 300% poverty – Buy Your Own

31. Crimes and Punishments in Massachusetts #The CrimeThe Fine 1 Violation of Child Labor Laws $50 2 Employers Failing to Partially Subsidize a Poor Health Plan for Workers $295 3 Illegal Sale of Firearms, First Offense $500 max. 4 Driving Under the Influence, First Offense $500 min. 5 Domestic Assault $1000 max. 6 Cruelty to or Malicious Killing of Animals $1000 max. 7 Communication of a Terrorist Threat $1000 min. 8 Being Uninsured In Massachusetts ~ $1000

32. Massachusetts: Required Coverage (Income > $30k) Premium: $4,080 Annually (56 year old) $2000 deductible 20% co-insurance AFTER deductible is reached

39. Massachusetts 1988 “I am very proud of the fact that Massachusetts will be the first state in the country to enact universal health insurance.” Gov. Dukakis` Sources: New York Times 4/14/88 and 4/26/88 “Massachusetts last week ventured where no state has gone before: it guaranteed health insurance for every resident.”

41. Sources:Washington Post 6/9/92 and 3/20/`93 Oregon 1992 “Today our dreams of providing effective and affordable health care to all Oregonians has come true.” Gov. Roberts “The most far-reaching health care reform in the nation.”

43. Sources: Federal & State Insurance Week 4/12/93; and NY Times 9/16/94 “The most radical health care plan in America.” “Tennessee will cover at least 95% of its citizens with health insurance by the end of 1994.” Gov. Ned McWherter Tennessee 1992

45. Vermont 1992 “This is an incredibly exciting moment that should make all Vermonters proud.” Gov. Dean Source: New York Times 4/12/92 “Governor Howard Dean, the only governor who is a doctor, signed a law here today that sets in motion a plan to give Vermont universal healthcare by 1995.”

47. Sources: New York Times 4/19/92; and Richard Reece, Medical World News 7/1/92. “Minnesota is enacting a program that will be the most sweeping effort yet to provide health insurance to people who lack it... the first complete reform proposal in the U.S.” “Minnesota is about to embark on a plan to solve the health- insurance crisis that could hold lessons for other states and the nation.” Minnesota 1992/1993

49. Washington 1993 Source: New York Times 5/2/93 Washington state “passed one of the most aggressive health care experiments in the nation, a program that would extend medical benefits to all 5.1 million residents of the state....”

51. Sources: AP Newswire 4/25/06 and Ellen Goodman, Washington Post Writers Group 7/7/03. “It’s bold and comprehensive, and it’s now the law of the state.” Gov. Baldacci Maine 2003 “Maine has just become the first state in the union to approve a plan to provide universal access to affordable health insurance.”

57. Senator Baucus’ proposal reprises the key elements of schemes that have failed again and again in states across the nation. His Mandate Model reform can only add coverage by adding costs. It expands the role of wasteful private insurers, does nothing for the tens of millions who are under-insured, and foregoes the $400 billion in annual administrative savings that could be achieved under single payer. Baucus’ approach – even if passed - would quickly founder as costs continue to rise at unsustainable rates.