| 摘要 | At least three broad problems characterize U.S. health care and insurance: (1) high and rapidly growing costs, (2) large numbers of nonelderly people without insurance, and (3) enormous projected Medicare deficits and continued Medicaid cost growth. The health care reform debate and reform proposals have focused largely on expanding the number of people with health insurance. On November 7, 2009, the U.S. House of Representatives narrowly approved legislation to mandate that all individuals be covered by health insurance coupled with Medicaid expansion, premium subsidies for low-income persons, creation of a health insurance exchange (or exchanges) with strong restrictions on health insurance underwriting and pricing, and creation of a government-run health insurer to compete with private health plans. While the details differ, on November 21 the U.S. Senate voted 60-39 along straight party lines to approve for floor debate a bill with the same broad outlines.
Passage of health care legislation with these features would transform U.S. health insurance. Massachusetts is the only state with an individual health insurance mandate, enacted in 2006. The California Legislature rejected an individual mandate in 2008. Maine and Vermont programs offering subsidized health insurance without a mandate have attracted relatively few applicants. The Connecticut General Assembly overrode a veto by the state’s governor to enact legislation in 2009 appointing a board to develop a public health insurance option to promote universal coverage, including low-income subsidies, to take effect by July 2012. The board is authorized “to evaluate implementation of an individual mandate.” As part of its reforms, Massachusetts fines employers who fail to make reasonable contributions to employee health coverage. Hawaii has required employers to offer coverage to employees working at least 20 hours weekly since 1974. Subsequent employer mandates in Massachusetts, Oregon, Washington, and California were either repealed or never took effect.
Relatively few states have strict restrictions on health insurance underwriting and pricing of the type proposed in the Congress. Six states require guaranteed issue in the individual market (Kaiser Family Foundation, 2009). Ten states have a rate band system limiting permissible variation of rates based on health status. Five states have adjusted (modified) community rating laws that permit rates to vary in relation to factors such as age, location, and coverage, but not health status. New Jersey and New York have pure community rating, which requires an insurer to accept all applicants for a given type of coverage and location at the same rate. The small group health insurance market has more restrictions. In conjunction with federal law, all states require guaranteed issue. Thirty-five states have rating bands, 11 states have adjusted community rating, and New York has pure community rating. Three states and the District of Columbia have no rating restrictions. As an alternative to strict underwriting and rating restrictions, 34 states have a high-risk pool with guaranteed issue of basic coverage at subsidized (but still relatively high) rates, regardless of preexisting conditions.
Debate over the majority Democrats’ proposals for expanding health insurance has been highly partisan. Democrats stress the importance of expanding coverage. Liberal and progressive members strongly favor a public insurer to compete with private insurers. Some favor a public plan as a significant step toward the ultimate goal of universal coverage under a single payer system. Congressional Republicans are nearly unanimous in their opposition to the Democrats’ reform agenda, especially the creation of a public plan. They propose narrowly target reforms and market-oriented changes in health insurance markets and taxation to expand coverage while helping to control costs.[1]
This article provides an overview of the U.S. health care debate and reform bills under consideration by the U.S. House and Senate, with a focus on proposals that deal directly with health insurance.[2] It begins by briefly elaborating the main problems that confront U.S. health care and insurance: high and rising costs, a large uninsured population, and large projected deficits for Medicare. It then turns to the House and Senate bills, outlining the key provisions for expanding and regulating health insurance and CBO projections of the proposals’ costs, funding, and impact on the number of people with health insurance. The next section considers the potential effects of the mandate that individuals have health insurance, premium subsidies, and proposed insurance market reforms. The proposed creation of a public health insurance plan and/or nonprofit cooperatives and provisions that would modify permissible grounds for health insurers to rescind coverage and repeal the limited antitrust exemption for health and medical liability insurance are then considered. The article concludes by contrasting the reform bills with market-oriented reforms and with brief perspective on future developments.
MOTIVATION FOR REFORM
Costs and Cost Growth
Figure 1 shows U.S. health expenditures as a percentage of gross domestic product (GDP) and annual growth rates in per capita health spending during 1962-2007. The percentage of GDP devoted to health care grew from under 6 percent to over 16 percent during that time. Real annual growth in per capita expenditures averaged 4.3 percent. Real per capita spending grew 6.2 percent annually during the 1960s, which included the creation of Medicare and Medicaid in 1965, and then 3.6 percent and 3.9 percent annually during the 1970s and 1980s, respectively. Real per capita spending growth slowed to 2.6 percent in the 1990s and has increased at 3.3 percent annually this decade.
Figure 2 shows per capita health expenditures in 2007 for OECD countries with available data, adjusted for U.S. purchasing power parity. The U.S. expenditure of $7,290 was 53 percent larger than that of the second highest country. Figure 3 plots compound annual growth rates in per capita health expenditures for Organisation for Economic Co-operation and Development (OECD) countries during 1997-2006 versus the countries’ per capita expenditure in 1997.[3] While the 6 percent (nominal) U.S. compound growth rate in per capita expenditures ranked 15th out of 25 countries, the U.S. growth rate is a clear outlier compared with trend.
Explanations of why the United States spends much more than other countries generally point to greater rates of technology adoption and diffusion and higher compensation for health care providers, along with the lesser role played by government in financing medical care.[4] The consensus is that the U.S. system of government and private insurance has significantly increased expenditures and expenditure growth.[5] Despite the large numbers of uninsured, the United States ranks well above average among OECD countries in the proportion of national health expenditures reimbursed by insurance (see Figure 4). It ranks first by a large margin in the proportion of spending reimbursed by private insurance.
The high average health expenditure in the United States is associated with high average health insurance premiums. The Kaiser/HRET survey of employer-sponsored health benefits reports an average premium (employer and employee combined) for family coverage in 2009 of $13,375, 131 percent greater than for 1999, with an average worker contribution of $3,515 (Kaiser/HRET, 2009). The average premium for single coverage in 2009 was $4,824, with the worker contributing an average of $779. Given greater average cost sharing and less generous benefits chosen, average individual health insurance market premiums in 2009 were much lower, despite higher expense loadings. According to an AHIP survey of 2.5 million policies, the average premium for single coverage in the individual market was $2,985, and the average premium for family coverage was $6,328 (AHTP, 2009). The average annual premium for individual (family) coverage ranged from $1,429 ($2,967) for 18- to 24-year-olds to $5,715 ($9,952) for 60- to 64-year-olds (see Figure 5).
The question of whether the higher cost of U.S. medical care produces significantly higher quality is much debated. U.S. infant mortality rates are high among developed countries. Americans do not have higher average life expectancies. The U.S. ranks highly on survival rates for certain cancers (Preston and Ho, 2009). It generally is characterized by greater innovation and more rapid diffusion of medical technology, new drugs, and biologies. Waiting times for noncritical surgeries are significantly lower in the United States than in many other countries. Health care expenditures and quality of care vary widely within the United States. A sizable literature, for example, documents large regional variations in Medicare spending and considers whether that variation is related to quality, as well as whether Medicare expenditures could be cut in high-cost regions without significantly reducing quality (see, e.g., Skinner et al., 2009; Cooper, 2009).
The Uninsured
The high costs of health care and insurance influence many people to forego coverage.[6] High premiums and the large number of uninsured have contributed to allegations that private insurance markets are substantially dysfunctional (see below). The most widely cited estimates of the uninsured population are based on the Current Population Survey (CPS). It is estimated from that source that approximately 46 million U.S. residents did not have health insurance in 2008, representing 17.4 percent of the nonelderly population.[7] Compared with the insured nonelderly, the uninsured on average have significantly lower income and educational attainment, are less likely to be employed full-time, are more likely to be black and /or of Hispanic origin, are more likely to be young adults than middle aged, and are less likely to report being in excellent or very good health.[8] Roughly a quarter of the uninsured were eligible for Medicaid but had not enrolled (Kaiser Family Foundation, 2009; see also NIHCM, 2008). Roughly 10 million lived in households where a member declined employer-sponsored coverage.
An estimated 38 million (20.4 percent) of the adult nonelderly population were uninsured. About 8 million were non-U.S. citizens. Estimates suggest that at least half of those persons are unauthorized immigrants (see NIHCM, 2008). Approximately 4 million had income above 400 percent of the federal poverty level9 in 2008 (Kaiser Family Foundation, 2009, Supplementary Data Tables, p. 3). The duration of time spent without insurance varies widely. The proportion of nonelderly uninsured has remained relatively steady since 1990, with a decrease in private insurance offset by an increase in public coverage (Cohen et al., 2009).
Uninsured rates vary widely across U.S. states in relation to income, age, race, ethnicity, and other socioeconomic and demographic factors. Figure 6 illustrates crossstate variation in uninsured rates during 2007-2008 (obtained from Kaiser Family Foundation, 2009) for the continental United States. It shows the average percentage of the adult nonelderly population without health insurance for quartiles of states ranked by the percentage uninsured, along with the within quartile averages of the percentage of the population with income below federal poverty level (FPL), the percentage of the state’s population that was African-American (black), and the percentage of the population of Hispanic origin (Hispanic). States with the highest uninsured rates had considerably greater poverty and proportions of black and Hispanic residents than states with the lowest uninsured rates. Median household income is considerably lower in the states with high uninsured rates (not shown).
Again using data for the lower 48 states, Table 1 shows descriptive linear regressions (with no pretense of causal inference) of the percentages of the adult nonelderly population in 2007-2008 with employer-sponsored health insurance and no insurance as functions of state median household income, the proportion of the adult nonelderly population with public coverage (Medicaid and Medicare or military), and the proportion of the total population that is black or Hispanic.[10] The employer coverage rate is strongly and positively related to median household income, and it is strongly and negatively related to the proportion of nonelderly adults with public coverage, and, especially, the proportion of the state’s total population that is Hispanic. The uninsured rate is strongly and negatively related to median household income and public coverage, and it is positively related to the proportion black and the proportion Hispanic.
Estimates suggest that the uninsured pay about a third of the cost of their medical care and produced an estimated $56 billion in uncompensated care for providers in 2008, with government funding covering about 75 percent of the cost of uncompensated care and approximately $14 billion potentially being shifted to private health insurance (Hadley et al., 2008). n While causal inference is challenging given unobserved heterogeneity and related issues, the consensus is that lack of insurance negatively affects access to health care and health.[12] The uninsured are entitled to hospital emergency/acute care to stabilize their conditions without regard to ability to pay, and many uninsured with low incomes obtain care from community health centers. But being uninsured on average is associated with a lower likelihood of having a usual source of medical care, less use of preventive medical care, greater likelihood of foregoing medical care due to cost, and, while the magnitude of the increase is debated, a greater likelihood of bankruptcy due to unpaid medical bills.
While the number of people that are uninsured in relation to preexisting conditions and loss of insurance after job loss and exhaustion of continuation of coverage benefits is not known, these sources of uninsurance and difficulty in affording health insurance are widely regarded as problematic. Figure 5 also shows individual health insurance denial rates by age group from AHIP (2009) survey data. The overall denial rate was 12.7 percent. The extent to which applicants denied coverage were able to obtain coverage from another insurer or source is not known. The AHIP survey also reports that 34 percent of offers were at higher than standard premium rates (36 percent of offers were below standard rates) and that 6 percent of offers included a waiver of coverage for one or more health conditions. While health insurance policy rescissions are unlikely to represent a significant source of uninsurance, health insurers’ rescission practices have received scrutiny (see below). The possibility of being denied coverage, or having to pay a higher premium if disclosure is truthful, likely leads to more applications with misrepresentations or concealments and to higher rescission frequencies.
The Medicare/HealthCare Spending Deficit
Large projected Medicare deficits and continued Medicaid cost growth represent a third major problem confronting U.S. health care.[13] The funding of Medicare in particular poses major challenges from real cost increases per enrollee and aging of the population. The Medicare Trustees (2009) estimated the present value of the projected Medicare deficit over the next 75 years at $38 trillion as of year-end 2008 (using their intermediate economic assumptions about real interest rates, general inflation, Medicare spending growth, GDP growth, and population growth). That figure is equivalent to about 2.6 times 2008 U.S. GDP, or about $250,000 per adult aged 16-64.[14] While much of projected deficit reflects forecasts beyond 2020, the hospital insurance trust fund is projected to exhaust in 2017 under the status quo.
Of the $38 trillion projected present-value deficit, $13.4 trillion is for projected shortfalls in payroll taxes versus expenditures for the Medicare hospital insurance program (Part A). The remaining $24.4 trillion is for projected future general revenue transfers to pay the federal government’s share (about 75%) of projected Medicare spending for outpatient services and prescription drugs (Parts B and D). The federal government transferred $184 billion of general revenues to pay its share of Medicare spending for outpatient services ($147 billion) and prescription drugs ($37 billion) in 2008. That $184 billion and future increases commensurate with GDP growth might be viewed as already built into the federal budget, so that the $37.8 trillion figure overstates the effective deficit. If the $184 billion were to grow at the Trustees’ projected growth rates for GDP, the present value of the required general revenue transfers for outpatient services and prescription drugs would be $13.5 trillion less than the $24.4 trillion included in the $37.8 trillion figure. The combined deficit for excess of GDP outpatient service and prescription drug spending growth and the hospital insurance program is $27 trillion, about 1.9 times 2008 GDP, or roughly $175,000 per adult aged 16-64.[15] The unsustainability of Medicare spending has significantly influenced the debate over how to finance expanded health insurance for the nonelderly.
HOUSE AND SENATE REFORM PROPOSALS
The U.S. House of Representatives approved the Affordable Health Care for America Act on November 7, 2009 by a vote of 220-215 with one Republican voting in favor. On November 21, the Senate voted 60-39 with no Republican support to approve the Patient Protection and Affordable Care Act for floor debate. The bill reflects a number of changes to the one approved by the Senate Finance Committee in October, including a proposed public option. If the full Senate approves the bill, with or without amendments, the House and Senate conferees will negotiate final terms for a vote by both chambers.
Table 2 summarizes the major features of both bills, which are similar in many key respects. A number of the bill’s main features are consistent with President Obama’s campaign platform for health care reform. Notable differences include the proposed mandate for adults to be insured and the proposed public insurance plan. Both bills would establish a pool for offering coverage to buyers with preexisting conditions at subsidized premium rates as a transition mechanism until creation of the health insurance exchange (or exchanges) with premium subsidies and implementation of marketwide underwriting and rating restrictions.
Coverage Expansion
Both bills would require most legal residents to have health insurance that meets minimum requirements specified by the government, beginning in 2013 in the House bill and 2014 in the Senate bill. Eligibility for the taxpayer-funded Medicaid program would be expanded to all persons with income below 150 percent of FPL in the House bill and 133 percent of FPL in the Senate bill. Substantial premium subsidies would be provided to non-Medicaid-eligible buyers with incomes up to 400 percent of FPL through a sliding threshold of premium caps as a percentage of income, and lower-income households would be able to purchase coverage with a higher estimated actuarial value and thus lower cost-sharing at the subsidized rates. Figure 7 illustrates the maximum premiums that a family of four would have to pay and the associated actuarial values of coverage. Apart from very small establishments, the House bill would require employers to offer health coverage and contribute much of the cost or pay a tax up to 8 percent of payroll. The Senate bill would require employers with 50 or more workers who fail to offer coverage to pay $750 per worker. Both bills would provide modest tax credits for very small businesses that provide coverage. The CBO projects that the House (Senate) bill would result by 2019 in coverage of 96 percent (94 percent) of nonelderly legal residents, compared with approximately 83 percent today.[16]
Insurance Market Reforms
Both bills would dramatically alter insurance markets and regulation. The House bill would establish a new federal regulatory and oversight agency. The Senate bill would utilize the Department of Health and Human Services and leave most enforcement to the states. Subsidy-eligible and other persons not covered through employmentbased coverage, Medicare, or Medicaid would be able to buy coverage through a new health insurance exchange (or, in the Senate bill, state-level exchanges) patterned after reforms enacted in Massachusetts in 2006 (discussed further below).[17] The government would mandate broad coverage of services and levels of cost sharing from which consumers could choose (with additional limits on cost sharing for lowincome buyers as noted above). Health insurers would have to accept all applicants regardless of health status, without excluding coverage for preexisting conditions. Premium rates would be allowed to vary by coverage, geographic region, and, within a restricted range, a person’s age. The House bill would permit a 2-1 age range; the Senate bill would permit a 3-1 range. The Senate bill also would allow variation up to 1.5-1 for tobacco use. Both bills propose ex post risk adjustment among insurers to help equalize underwriting experience across insurers.[18]
The House bill would repeal the antitrust exemption for the “business of insurance” for health insurance and for medical liability insurance, subject to a safe harbor clause governing projected loss development and certain other activities. The House bill would require all health insurers to achieve a irtinimum loss ratio of 85 percent and to refund premiums, if necessary, to achieve that minimum, subject to regulatory discretion to relax the criterion to avoid undue market disruption. Both bills would prohibit insurers from rescinding policies for material misrepresentations or concealment unless the insurer could prove fraud or intentional by the applicant.
Both bills would create a government-run health insurer–a public plan–to offer insurance through the exchange in competition with private insurers. The bills stipulate that the public plan would be self-sustaining and would negotiate rates with providers. The Senate bill would allow states to opt out of the public plan provisions. Both bills also would provide grants and loans for the creation of nonprofit health insurance cooperatives on a state or regional basis. The public plan and cooperative proposals are discussed further below.
Funding Coverage Expansion
According to CBO 10-year projections, the expansion of coverage is projected to cost $1,052 billion under the House bill and $848 billion under the Senate bill (Table 2). The CBO projects $781 billion in taxes and fees under the House bill, including $460 billion in tax surcharges on high-income taxpayers and $168 billion in individual and employer penalties for noncompliance. Projected Medicare spending would decline by close to $400 billion under the House bill, including $170 billion in reduced reimbursement to Medicare Advantage. The CBO projects that the Senate bill would generate $486 billion in revenues, including $54 billion in new taxes on high-income earners for Medicare Part A, $149 billion in excise taxes on high-cost health plans, $60 billion in taxes on health insurers, and $41 billion in taxes on brand name drug and medical device manufacturers. Projected Medicare spending would fall by $436 billion under the Senate bill, including $118 billion in cuts in Medicare Advantage. Overall, the CBO projects that the House and Senate bills would reduce the 10-year federal deficit by $138 billion and $130 billion, respectively.
The CBO’s cost, revenue, and deficit projections depend on numerous assumptions and are subject to considerable uncertainty, as well as to pay-as-you-go accounting. The cost projections would be significantly higher if not for the delayed implementation of Medicaid expansion and premium subsidies. The House and Senate bills project $102 billion and $72 billion in deficit reduction, respectively, from net receipts from creation of a federal long-term care insurance program, without reflecting the new program’s projected accrual of liabilities (Harrington 2009). The projections of Medicare savings assume that payment rates for many providers would be held below the rate of inflation and that a proposed independent advisory board for Medicare would be “fairly effective in reducing costs” (see Elmendorf, 2009, regarding the Senate bill). In his November 19 commentary on the Senate bill projections, CBO Director Douglas Elmendorf stated that extrapolations beyond 10 years indicate that Medicare spending growth will average 6 percent over the next two decades (2 percent real growth per beneficiary), compared with annual growth of 8 percent in the past two decades (4 percent real growth per beneficiary). He concluded (Elmendorf, 2009): “Whether such a reduction in the growth rate could be achieved through greater efficiencies in the delivery of health care or would reduce access to care or diminish the quality of care is uncertain.”
THE INDIVIDUAL MANDATE, SUBSIDIES, AND RATING RESTRICTIONS
A centerpiece of the House and Senate bills is the mandate for individuals to have health insurance, along with expanded Medicaid eUgibiUty, premium subsidies, creation of an exchange (or exchanges), and restrictions on health insurance underwriting and rating. The basic structure of the proposals largely mimics the 2006 Massachusetts reforms, which included an individual mandate, Medicaid expansion, premium subsidies for people with incomes up to 300 percent of the FPL, merger of the small group and individual markets, and an annual fine of $295 per worker on employers who fail to make a “fair and reasonable” contribution toward workers’ health coverage. The Massachusetts’ reforms were followed by an estimated increase in the insured population from 90 percent to 97 percent. Surveys indicate that a significant majority of people are satisfied with the reforms, although half of those surveyed who were forced to buy insurance disapproved (Blendon et al., 2008). The costs of Medicaid expansions and premium subsidies have exceeded projections, in part because take up has exceeded expectations. A state-appointed commission has recommended that the state move toward universal managed care with capitation as a means to control costs (Steinbrook, 2009).
The welfare effects of an individual mandate with Medicaid expansion, premium subsidies, and health insurance underwriting and rating restrictions are extremely complex (CBO, 2008). [19] An individual mandate might have informational and behavioral effects on purchase decisions of the uninsured apart from financial incentives provided by subsidies and penalties. Expanding health insurance coverage with a mandate, Medicaid expansion, premium subsidies, and underwriting and rating restrictions involves explicit Medicaid costs and premium subsidies and implicit (off budget) premium subsidies to buyers who are able to obtain insurance at belowmarket rates due to underwriting and rating restrictions. The approach also involves implicit (off budget) taxes in the form of above-market premium rates for some buyers.[20] The net benefits of the proposals would depend among other factors on the magnitude of consumption externalities (the value placed by people on knowing that others have coverage); on the amounts, types, and costs of increased utilization of medical care; and on labor market effects. Reductions in uncompensated care would reduce the net cost of subsidies.
Explicit premium subsidies and a mandate with sanctions for noncompliance will increase demand for coverage. Underwriting and rating restrictions will lower the supply price for older and/or less healthy buyers, while increasing the price for younger and/or healthier buyers. By increasing demand, a mandate reduces the total cost of explicit subsidies needed to achieve any given increase in the percentage of people with insurance, including the costs that arise from crowding out unsubsidized coverage due to imperfect targeting of subsidies. A mandate also increases the size of the implicit tax base to fund below-cost premiums for older and/or less healthy buyers. The greater the penalties for noncompliance, the lower will be the explicit cost of required subsidies. A “weak mandate” will require larger subsidies and/or result in fewer people being insured than a “strong mandate.”
The effects of health insurance underwriting and rating restrictions on decisions to insure and average premium rates also will depend on the strength of the individual mandate and the magnitude of explicit premium subsidies. Guaranteed issue of coverage without preexisting condition exclusions, prohibition of premiums based on health status, and limits on age-related premium variation will generate some degree of adverse selection as some younger and healthier people face higher premiums and delay buying coverage until they need expensive care, increasing the average cost of coverage that is purchased. The effects could be large without either generous subsidies or a strong coverage mandate with sizable penalties for failure to comply.
The Senate bill includes relatively weak penalties for an adult’s failure to buy coverage compared to the House proposal (and Massachusetts law). The fine would start at $95 in 2014, increase to $350 in 2015, $750 in 2016, and be indexed to the Consumer Price Index thereafter. People who faced premiums for rrdnimunri coverage that exceeded 8 percent of their income would be exempt. The approval of similar low penalties by the Senate Finance Committee in early October generated substantial pushback by private health insurers, who had previously agreed to support proposed insurance underwriting and rating restrictions provided they were coupled with a strong mandate. PricewaterhouseCoopers (PWC, 2009) released a report, sponsored by AHIP, estimating that the Senate Finance Committee bill’s weak mandate, in conjunction with its underwriting and rating restrictions, could increase average premiums for individual coverage by 47 percent by 2016 compared with current law, including the effects of proposed new taxes on several health care sectors and possible increased cost shifting from Medicare to private plans. Gruber (2009) responded that the PWC study did not consider proposed premium subsidies and ignored CBO projections that the Senate Finance Committee bill would result in lower premiums for comparable coverage than under current law. In a subsequent study sponsored by the Blue Cross Blue Shield Association, Oliver Wyman (2009) projected that proposed insurance reforms coupled with a weak mandate would produce a 50 percent increase in average medical costs per insured 5 years after reforms took effect compared with current law. While the assumptions underlying the PWC and Oliver Wyman projections are not transparent and debatable, the CBO’s cost projections, also based on opaque assumptions, do not consider the potential for adverse selection.[21]
Apart from the possible adverse selection issue, and without regard to policies that could reduce health care cost growth, an individual mandate with premium subsidies would be expected to put upward pressure on total health care expenditures. Utilization of health care, on average, will increase for people who obtain coverage in response to the reforms. In addition, a mandate necessarily requires government prescription of the types and amounts of medical services that must be insured.[22] The proposed minimuin permissible coverage packages include broader benefits and less cost sharing than some people currently obtain voluntarily. Various provider groups will press for inclusion of their services. In principle, significant rninimum benefits are needed to achieve the basic goal of expanding coverage. They also may be needed to reduce the ability of lower risk people who face higher than market rates from underwriting and rating restrictions from sorting into low-coverage groups to mitigate implicit taxes. Increased coverage will lead to some increase in moral hazard and “excessive” utilization, a widely acknowledged contributor to high health care costs. Costs also could increase due to higher prices for medical services until the supply of health care providers e |
