Fact Sheet

health care myths and facts conservative reform

Health Care Myths and Facts

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Summary

  • Pennsylvanians want personalized, flexible, accessible, and cost-effective health care.
  • Market-based reforms to make price information available, expand telemedicine, and modernize Pennsylvania’s Nursing Law can reduce health care costs and expand access to quality care.
  • In contrast, recent policy changes to increase government spending and restrict patient options did not reduce health care costs. Medicaid, taxpayer-funded health insurance, is now the largest line item in Pennsylvania’s state budget and the largest cost driver of the commonwealth’s structural deficit.
MYTH: Markets do not work in health care. Everyone needs health care regardless of their means, and you can’t pick your hospital or doctor when your life is in danger.
FACT: Outside emergencies, most trips to the doctor and the hospital require scheduling ahead of time. Market-based reforms to make price information available can reduce health care costs without reducing quality.
  • Reference pricing creates a standard price for a drug, procedure, or service. Under this system, the health plan pays up to the standard price, and members pay any allowed costs above the standard price. The national nonprofit Catalyst for Payment Reform (CPR) notes that reference pricing has proved to lower costs in drug plans, and in its application to procedures, CPR cites the California Public Employees’ Retirement System (CalPERS) findings that reference pricing reduced joint replacement costs by 26 percent in two years.[1]
  • A Cicero Institute study of health care pricing in Nashville, Tennessee, found that cash prices for health care services are often lower than insurance rates.[2] In some cases, paying out of pocket for health care services can lead to significant savings.
  • The Direct Primary Care (DPC) model changes the traditional fee-for-service model by allowing patients to pay a primary health care provider a yearly fee for their routine primary and preventative care. DigitalGlobe employees using DPC saw a 25.4 percent drop in per-member per-month costs.[3]
MYTH: Washington, D.C. controls health care. States cannot lower costs or improve the quality of care.
FACT: States can lower prices and improve quality by giving patients access to more pre-paid, insurance, or other service arrangements.
  • The DPC model avoids insurance overhead and allows doctors to spend twice as much time with patients.[4] House Bill (HB) 886, introduced by Rep. Seth Grove, would clarify DPC is not insurance and not subject to insurance regulations, giving much-needed certainty to the industry.[5]
  • State lawmakers can allow expanded Associated Health Plans (AHPs). AHPs allow small businesses to pool their employees to provide more affordable medical insurance. According to the Foundation for Government Accountability, newly created AHPs provided savings of up to 29 percent.[6] HB 555, introduced by Rep. Valerie Gaydos, codifies a mechanism for small businesses to establish AHPs into state law.[7]
  • States can expand telemedicine to drive down costs and expand access to care.[8] Temporary waivers from the pandemic required insurance reimbursement for telemedicine services and allowed out-of-state practitioners to care for Pennsylvania patients via telemedicine.[9], [10]
  • Today Pennsylvania is one of seven states that does not require insurance reimbursement for telemedicine services.[11] Senate Bill (SB) 739, introduced by Sen. Elder Vogel, would require insurance coverage for telemedicine services.[12] In addition, in most cases only doctors licensed in the commonwealth can treat Pennsylvanians. Reestablishing telemedicine reciprocity with out-of-state providers would give Pennsylvanians convenient access to specialists across the country.
MYTH: The Affordable Care Act (ACA) lowered the uninsured rate by making health care affordable.
FACT: The ACA lowered the uninsured rate by creating new subsidies that hide rising costs of health care.
  • Per capita health care spending in Pennsylvania has grown by 27 percent since the Obama administration fully implemented the ACA in 2014.[13]
  • Premium data from Pennie, Pennsylvania’s ACA-mandated health care market, shows premiums rose by 3.9 percent on average for 2024.[14]
  • The cost of employer-provided insurance is increasing too. A recent study from the Kaiser Family Foundation showed that family premiums rose by 7 percent in 2023, with employee costs for those plans expected to grow in the coming years.[15]
  • The Medicaid expansion under the ACA accounted for more than half of the decline in the uninsured rate, according to the Commonwealth Fund.[16] In other words, the law reduced uninsured rates by enrolling more individuals in taxpayer-funded health insurance.
  • The rest of the reduction in the uninsured rate came from an avalanche of subsidies in the individual insurance market. The Paragon Health Institute found that the cost for each additional insurance exchange enrollee was $36,798, more than three times the original cost estimate. In fact, 2024’s record enrollment is largely due to the availability of insurance plans with a $0 premium.[17]
MYTH: Nurse Practitioners (NPs) provide a lower quality of care compared to physicians. People want health care from a doctor.
FACT: People want choices, including the ability to see the providers they want, and where they want. Current state regulations limit the number of patients advanced providers, like NPs, can see.
  • Research shows no statistically significant difference between the quality of care provided by advanced practitioners, like NPs, compared to a primary care physician.[18]
  • Polling shows that most voters want personalized, flexible, accessible, and cost-effective health care.[19]
  • Currently, state law requires NPs to practice with two collaboration agreements with physicians. SB 25, sponsored by Sen. Camera Bartolotta, would modernize the Professional Nursing Law by eliminating this paperwork requirement,[20] and thereby, increase the number of NPs by 29.5 percent.[21] Full practice authority would also increase the number of patients seen by NPs by 1,792 per week.[22]
MYTH: Medicaid is a benefit to the state, with the federal government paying most of the cost. We should expand the program to help more Pennsylvanians access health care.
FACT: Medicaid consumes one-third of Pennsylvania’s state spending and is a major cause of our structural deficit. There is no evidence Medicaid is better than private insurance.
  • Medicaid is the largest line item in the budget and the largest cost driver of the structural deficit. Medicaid accounted for one-third of state expenditures in Fiscal Year (FY) 2023–24.[23] According to a recent report from the Independent Fiscal Office (IFO), certain Medicaid costs are growing at over three times the rate of revenue.[24]
  • Pennsylvania is one of 40 states that decided to extend Medicaid coverage to healthy, low-income adults.[25] In 2023, expenditures for this population reached $7 billion with the federal government covering about 90 percent.[26] In contrast, the federal government covers about 53 percent of expenditures for seniors, kids, and those with disabilities.[27]
  • Empowering patients to make their own choices with a voucher for purchasing insurance or a portable Health Savings Account (HSA) better aligns with the goals of Medicaid providers and patients. Along this line, H.R. 5608, or the ACCESS Act, would let low-income Americans who receive coverage from the ACA marketplace redirect insurance premium subsidies to an HSA account.[28]

[1]Catalyst, “Action Brief: Reference Pricing,” August 13, 2018, https://employerptp.org/files/resources/Reference-Pricing-Action-Brief.pdf.

[2]Cicero Institute, “Can Cash Prices for Healthcare Be More Affordable Than Insurance Rates?,” September 25, 2023, https://ciceroinstitute.org/research/can-cash-prices-for-healthcare-be-more-affordable-than-insurance-rates/.

[3]Darcy Bryan, “Benefits of Direct Primary Care in Improving Quality and Reducing Costs of Healthcare,” Testimony before the Montana Senate Committee on Business, Labor, and Economic Affairs, January 19, 2021, (representing the Mercatus Center at George Mason University), https://www.mercatus.org/research/state-testimonies/benefits-direct-primary-care-improving-quality-and-reducing-costs.

[4]Darcy N. Bryan, “Benefits of Direct Primary Care.” See also Amy R. Melchey, “Direct Primary Care: A Successful Financial Model for the Clinical Practice of Lifestyle Medicine,” American Journal of Lifestyle Medicine 15, No. 5 (2021), 557–562, https://doi.org/10.1177%2F15598276211006624.

[5]Rep. Seth Grove, House Bill 886,  Pennsylvania General Assembly, Regular Session 2023–24, https://www.legis.state.pa.us/cfdocs/billinfo/billinfo.cfm?syear=2023&sind=0&body=H&type=B&bn=886..

[6]Hayden Dublois, “Association Health Plans Work: How the Trump Administration Expanded Access to Affordable and Quality Health Care,” Foundation for Government Accountability, October 27, 2020, https://thefga.org/research/association-health-plans-trump-administration/.

[7]Rep. Valerie S. Gaydos, House Bill 555, Pennsylvania General Assembly, Regular Session 2023–24, https://www.legis.state.pa.us/cfdocs/billInfo/billInfo.cfm?sYear=2023&sInd=0&body=H&type=B&bn=0555.

[8]Kaylan Muppavarapu et al., “Study of Impact of Telehealth Use on Clinic ‘No Show’ Rates at an Academic Practice,” Psychiatric Quarterly 93 (2022), 689–99, https://link.springer.com/article/10.1007/s11126-022-09983-6.

[9]51 Pa.B. 1292, “Notice Regarding Coronavirus (COVID-19) Insurance Coverage (Notice 2021-03),” https://www.pacodeandbulletin.gov/Display/pabull?file=/secure/pabulletin/data/vol51/51-10/349.html.

[10]Pennsylvania General Assembly, 2022 Act 30 (P.L. 392, No. 30), “Health Care Facilities Act – Licensure, COVID-19 Regulatory Flexibility Authority and Repeal,” https://www.legis.state.pa.us/cfdocs/legis/li/uconsCheck.cfm?yr=2022&sessInd=0&act=30.

[11]National Policy Center – Center for Connected Health Policy, “State Telehealth Laws and Reimbursement Policies – State Summary Chart,” Telehealth Resource Centers, October 24, 2023, https://telehealthresourcecenter.org/resources/fact-sheets/state-telehealth-laws-reimbursement-policies-state-summary-chart/.

[12]Sen. Elder A. Vogel Jr. et al., Senate Bill 739, Pennsylvania General Assembly, Regular Session 2023–24, https://www.legis.state.pa.us/cfdocs/billinfo/bill_history.cfm?syear=2023&sind=0&body=S&type=B&bn=739.

[13] Centers for Medicare and Medicaid Services, “NHE [National Health Expenditure] Fact Sheet,” September 6, 2023 [update], https://www.cms.gov/data-research/statistics-trends-and-reports/national-health-expenditure-data/nhe-fact-sheet.

[14] Kris B. Mamula, “Pennsylvania Obamacare Rates Rise to an Average 3.9% in 2024,” Pittsburgh Post-Gazette, September 28, 2023,  https://www.post-gazette.com/business/healthcare-business/2023/09/28/obamacare-pennie-affordable-care-act-pennsylvania-insurance-department/stories/202309280101.

[15]Kaiser Family Foundation, “Benchmark Survey: Annual Family Premiums for Employer Coverage Rise 7% to Nearly $24,000 in 2023; Workers Contribute $6,575 on Average Now, But Potentially More Soon,” news release, October 18, 2023, https://www.kff.org/health-costs/press-release/benchmark-survey-annual-family-premiums-for-employer-coverage-rise-7-to-nearly-24000-in-2023/.

[16]David Blumenthal, Sara R. Collins, and Elizabeth Fowler, “The ACA at 10 Years: What’s the Effect on Health Care Coverage and Access?,” the Commonwealth Fund, February 26, 2020, https://www.commonwealthfund.org/publications/journal-article/2020/feb/aca-at-10-years-effect-health-care-coverage-access.

[17]Daniel Cruz and Greg Fann, “The Shortcomings of the ACA Exchanges,” Paragon Health Institute, September 2023, https://paragoninstitute.org/wp-content/uploads/2023/09/Shortcomings_of_the_ACA-Cruz_Fann-FOR-RELEASE_V1.pdf; Drew Gonshorowski and Theo Merkel, “Nearly Half of Exchange Enrollees Now Have Income Below 150% of the Federal Poverty Level,” Paragon Health Institute, January 2024, https://paragoninstitute.org/figure-medicare-merkel-gonshorowski-poverty-exchange-enrollees-20240117/

[18]Danny R. Hughes, et al., “A Comparison of Diagnostic Imaging Ordering Patterns between Advanced Practice Clinicians and Primary Care Physicians Following Office-Based Evaluation and Management Visits,” JAMA Internal Medicine 175, No.1 (2015) 101–7, https://doi.org/10.1001/jamainternmed.2014.6349.

[19]Commonwealth Foundation, “Personal Option for Healthcare,” accessed January 17, 2024, https://www.commonwealthfoundation.org/personal-option/.

[20]Sen. Camera Bartolotta, Senate Bill 25, Pennsylvania General Assembly, Regular Session 2023–24, https://www.legis.state.pa.us/cfdocs/billInfo/billInfo.cfm?sYear=2023&sInd=0&body=S&type=B&bn=0025.

[21]Commonwealth Foundation, “How Full Practice Authority Can Increase Access and Improve Outcomes,” November 15, 2022,  https://www.commonwealthfoundation.org/research/full-practice-authority-pennsylvania/.

[22]Commonwealth Foundation, “Expanding Health Care Access: The Easy Way”, Commonwealth Foundation, May 9, 2023, https://www.commonwealthfoundation.org/research/expanding-health-care-nurse-practitioners/.

[23]Gov. Josh Shapiro, “Executive Budget, 2023–2024,” March 7, 2023, https://www.budget.pa.gov/Publications%20and%20Reports/CommonwealthBudget/Documents/2023-24%20Budget%20Documents/Budget%20Book%202023-24%20WEB%20V.5.04182023.pdf.

[24]Pennsylvania Independent Fiscal Office, “Pennsylvania Economic and Budget Outlook, Fiscal Years 2023–24 to 2028–29,” November 15, 2023, http://www.ifo.state.pa.us/download.cfm?file=Resources/Documents/Five_Year_Outlook_2023.pdf.

[25]Kaiser Family Foundation, “Status of State Medicaid Expansion Decisions: Interactive Map,” December 1. 2023, https://www.kff.org/medicaid/issue-brief/status-of-state-medicaid-expansion-decisions-interactive-map/.

[26]Governor Josh Shapiro, “Executive Budget 2023–2024.”

[27]Elizabeth Williams, Robin Rudowitz, and Alice Burns, “Medicaid Financing: The Basics,” Kaiser Family Foundation, April 13, 2023, https://www.kff.org/medicaid/issue-brief/medicaid-financing-the-basics/.

[28]Rep. Gregory Steube (R-FL), H.R. 5608 [Affordable Care and Comprehensive Economic Support through Savings (ACCESS) Act], 118th Congress (2023–24), https://www.congress.gov/118/bills/hr5608/BILLS-118hr5608ih.pdf.