personal option pennsylvania

The Personal Option for Health Care in Pennsylvania

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  • Keep and expand the health care systems that work:
    • Protect Direct Primary Care (DPC) practices.
    • Allow expanded Association Health Plans (AHPs) so small businesses can offer more affordable coverage.
  • Remove bureaucratic rules that limit access to health care providers:
    • Allow nurse practitioners (NPs) full practice authority.
    • Allow pharmacists to vaccinate children and prescribe medications for common illnesses.
    • Allow nurse anesthetists full practice authority.
  • Empower patients to shop and save by enforcing hospital price transparency rules.
  • Make health care more convenient and flexible by expanding access to telemedicine.
  • Improve and safeguard health care access in Medicaid by focusing resources on eligible patients.


Health care is confusing, expensive, and driven by ever-larger systems that make the individual feel helpless. Expanding the role of government over the past decade accelerated these trends. Overall health care costs continue to rise with a major seven percent increase in private insurance premiums reaching $24,000 for a family plan in 2024.[1]

In Pennsylvania, per capita health care spending in 2021 was $11,603, higher than the national average of $10,191. Average per capita health care spending has grown nearly 27 percent since 2014, the first year of full implementation of the Affordable Care Act (ACA), nationally.[2]

Rising health care prices are not inevitable. While medical services increased 132 percent and hospital services 228 percent since 1998, cosmetic procedures like abdominoplasty (i.e., tummy tuck) rose just 66.7 percent and Liposuction just 6.8 percent.[3] Why? Many cosmetic procedures are deemed non-essential and not covered by traditional medical insurance. This means consumers have access to real prices and more providers.

Instead of a public option or Medicare for all, we need a personal option or individualized care for all. If we give Pennsylvanians more control over their health care, they will get the affordability they need, the quality services they deserve, and the doctors they trust. Everyone, regardless of income, deserves the ability to personalize their health care. This report summarizes five state-level reforms that would begin to personalize Pennsylvanian’s health care.

1. Keep and Expand the Health Care Delivery and Insurance Options That Work

Allowing the marketplace to develop more service models or insurance options can lower costs. Specifically, Pennsylvania should protect the alternative DPC primary health care model and allow for broader AHPs.

The DPC model allows patients to pay a primary health care provider a yearly fee for their routine primary and preventative care. DPC is personalized health care because there is no insurance company involved. Moreover, the goal of both physician and patient is the patient’s health.

  • According to the DPC Frontier open forum, Pennsylvania is home to more than 40 direct care practices with monthly memberships at around $60 per person.[4]
  • House Bill 886, introduced by Rep. Seth Grove, would protect these practices from being regulated as insurance. Affordable rates are only possible because these physicians do not have to pay multiple staff to handle insurance paperwork and overhead.[5]
  • Further federal reforms are needed to allow more Americans to join a DPC. Currently, DPC memberships are not categorized as a tax-deductible medical expense. Patients cannot use a Health Savings Account (HSA) to pay for a membership.

AHPs allow small businesses to pool their employees to provide affordable medical insurance. Spreading costs over a larger group of employees allows small businesses to gain the same economies of scale as large corporations. The ACA limited the kinds of businesses that could form an AHP.

  • Unsurprisingly, fewer small businesses offered health insurance. The Commonwealth Fund found enrollment for small groups declined by more than 27 percent, from 18.1 million enrollees in 2012 to 13.1 million by 2018.[6]
  • In 2018, the Trump administration implemented a new rule expanding access to AHPs.[7] Specifically, the rule allows businesses in different industries and independent contractors or self-employed individuals to form associations that provide group health insurance.
    • A Congressional Budget Office (CBO) analysis of the new rule estimated premium reductions of 30 percent compared to coverage in the regular small group market.[8]
    • The newly created AHPs have provided affordable and high-quality coverage to millions of Americans, with savings of up to 29 percent on average, according to research by the Foundation for Government Accountability (FGA).[9]
    • For example, the Vermont Association of Chamber of Commerce Executives (VACE) created an AHP resulting in tens of thousands of savings. A solar panel installation company in Randolph, Vermont achieved $14,500 in savings in one year.
  • Unfortunately, the rule faced immediate litigation in federal court from 11 states (including Pennsylvania) and the District of Columbia. Gov. Josh Shapiro, then-state attorney general, said, “We took action against association health plans to enforce that law and protect Pennsylvanians’ care.”[10] After a federal judge struck down the rule in March of 2019, the U.S. Department of Labor appealed the decision, where it remains unresolved.[11]

Critics of AHPs say they allow businesses to skirt mandates like pre-existing conditions or essential health benefit plans. Yet the new AHPs set up in 2018 provided all these benefits voluntarily. In fact, AHP legislation in the Pennsylvania House (HB 555) requires protections for essential benefits and makes coverage guaranteed renewable.

  • HB 555, introduced by Rep. Valerie Gaydos, would codify into state law the existence of broader AHPs, compelling the state insurance department to work with small businesses to expand their risk pools and reduce costs to employees.[12]
  • Currently, about 30 states allow expanded AHPs by law or under regulatory guidance. The 11 states, alongside the District of Columbia, which filed the original lawsuit already prohibit expanded AHPs.[13] In Pennsylvania’s case, there is no law against expanded AHPs, but guidance from the Insurance Department does not allow expanded AHPs. Changing that guidance would require a new law, like HB 555.[14]

In the meantime, the federal CHOICE Arrangement Act (H.R. 3799) includes provisions that would expand access to AHPs,[15] and the CBO estimates the policy would increase the number of people with health insurance purchased through AHPs by about 200,000 per year.[16]

2. Remove Bureaucratic Rules That Limit Access to Primary Care and Advanced Providers

Today, 621,346 Pennsylvanians live in a Human Resources and Services Administration (HRSA) designated primary care Health Professional Shortage Areas (HPSAs).[17] A shortage of primary care providers disproportionately affects those residing in rural areas and persons of color in low-income areas.[18] Currently, many advanced health care providers cannot work to the full extent of their training. The commonwealth maintains some of the strictest regulations on scope of practice, or limits on how and where NPs, pharmacists, and nurse anesthetists can practice. Removing the red tape can increase access to health care.

  • Twenty-six states allow NPs to serve patients without a physician collaborative agreement. Pennsylvania’s scope of practice regulations forbid NPs from practicing without two expensive collaborative agreements with physicians. These agreements can cost a thousand dollars each month and do not impact quality.
    • Comparing Maryland’s experience, a Commonwealth Foundation study calculates full practice authority in Pennsylvania would increase the number of Certified Nurse Midwives (CNMs) in Pennsylvania by an estimated 26.7 percent, and the number of NPs by 29.5 percent.[19] Further research estimates full practice authority would allow each NP to see an additional 109 patients each year.[20]
    • Senate Bill 25, introduced by Sen. Camera Bartolotta, would give NPs with three years and 3,600 hours of experience full practice authority.[21]
    • Allowing pharmacists to administer vaccines to children and prescribe medications for common illnesses is another way to expand access to care. Making common yet critical vaccinations available at the local grocery store can prevent sickness and resulting complications. Legislation like 2021’s SB 511 would make COVID waivers allowing pharmacists to provide vaccinations to children as young as three permanent.[22] All states allow pharmacists to prescribe Naloxone and Paxlovid, while a growing number are allowing pharmacists to prescribe medications for common illnesses.[23]
    • Finally, giving certified registered nurse anesthetists the ability to care for patients during surgery without a supervising anesthesiologist in the same room could increase the number of surgeries hospitals can perform. This reform, included in SB 899, introduced by Sen. Judy Ward, reinstates the freedom given to these advanced providers through COVID waivers.[24]

In 2021, physician assistant (PA) reforms increased the supervising physician ratio from 4:1 to 6:1, removed requirements that a physician be on-site, and other red tape allowing PAs to treat more patients.[25] In addition to the policy reforms mentioned above, Pennsylvania can go further to enact a universal reciprocity policy and automatically recognize all out-of-state health professional licenses in good standing.

3. Empower Patients to Shop and Save by Enforcing Hospital Price Transparency Rules

Patients are disconnected from the price of care because the patient is not the customer. The employer, or in the case of Medicare and Medicaid, the government, is the customer. Hospitals and insurance companies often negotiate secret deals that set the price of services, which make prices hard for patients to determine. Moreover, prices at one hospital can be vastly different at another hospital for the exact same procedure. An analysis of hospital billing by Johns Hopkins University found UPMC Presbyterian in Pittsburgh has a markup of 11.9 times the cost of care, in contrast, the markup at Lehigh Valley Hospital is 7.6 times.[26]

The lack of pricing transparency prevents shopping or comparison, leading to higher costs. According to the Pennsylvania Health Access Network, half of Pennsylvanians struggle to afford health care, and around one-quarter of them delay or avoid needed treatments for financial reasons.[27]

In a free market, companies post their prices voluntarily; health care is not a free market. Executive Order 13877, “Improving Price and Quality Transparency in American Healthcare to Put Patients First,” signed by President Trump in 2019, is an effort to increase access to meaningful price information with a hospital pricing mandate.[28]

The order requires each hospital operating in the United States to publish standard charges for services with established rates, including bundled services. Those rates should include discounted cash prices, negotiated prices with third-party providers, and the lowest payer prices. The information needs to be available in two ways. Hospitals need to share the information in a consumer-friendly way on their website including at least 300 shoppable services, and in a machine-readable data file.

  • In the first two years, compliance was lacking with enforcement almost nonexistent. In 2021, about 14 percent of hospitals complied with the rule in some way.[29] Some hospitals disclosed average, median, or estimated rates rather than the required standard charge for each item and service.
  • In 2022, compliance improved. The Centers for Medicare and Medicaid Services (CMS) and the American Hospital Association claimed 70 percent of hospitals were compliant. However, the Foundation for Government Accountability analyzed CMS records and found just 40 percent of Pennsylvania hospitals were compliant.[30]
  • By July of 2023, a report from Patient Rights Advocate found just 36 percent of hospitals fully compliant. In Pennsylvania, just 16 percent were compliant.[31]
  • As of April 2023, CMS reports issuing more than 730 warning notices and 269 requests for corrective action plans.[32] Just twelve hospitals were fined for noncompliance this year and only two hospitals were fined in 2022.[33] Penalties for noncompliance are on a per-bed, per-day basis, with a daily maximum of $5,500 and an annual maximum of about $2 million.[34]

Mandates of any kind tend to lead to additional mandates. States should be cautious about adding transparency mandates that could make it more difficult for hospitals to be flexible with treatment plans. Both the intended and unintended consequences require careful study ahead of adjusting regulations. States are experimenting with different ways to promote price information.

  • Colorado enacted a bill to protect patients from collection for bills incurred at hospitals that are not compliant with the federal transparency rules, and it gives them the right to sue hospitals to compel compliance.[35]
  • In 2023, the Arkansas State Legislature passed legislation to require the Department of Health to fine hospitals found in violation of federal requirements.[36]
  • Pennsylvania lawmakers held a hearing exploring ways to codify hospital pricing mandates into state law and add additional enforcement mechanisms. No legislation currently exists.[37]

Since most health care providers schedule procedures in advance, hospitals should be competing on price. Lawmakers must continue to explore ways to allow patients to compare prices, without creating added administrative costs.

4. Make Health Care More Convenient and Flexible by Expanding Telemedicine

Telemedicine allows patients to visit a doctor virtually via a computer or smartphone. Studies show that the use of telemedicine can reduce appointment no-shows, reduce hospitalization rates, and save employers and employees money.[38] The Pennsylvania Insurance Department encouraged the expansion of telemedicine during the pandemic, while the federal government issued guidance to reimburse telemedicine services for Medicare and Medicaid patients.[39]

However, Pennsylvania’s leap forward was short-lived. In 2020, former Gov. Tom Wolf vetoed SB 857, an initiative requiring insurers to cover telemedicine services.[40] Then, in October of 2022, waivers that allowed doctors out of state to care for Pennsylvania patients via telemedicine expired.[41]

  • Today, Pennsylvania is just one of seven states that do not require insurance reimbursement. There is no current statute either authorizing or prohibiting the use of telemedicine.[42] Telemedicine provider reimbursements are at the discretion of each insurance company. This means providers are not guaranteed reimbursement for a telemedicine appointment.[43]
  • Despite the lack of clarity in state laws, telemedicine use remains elevated above pre-pandemic levels. Utilization differs by specialty with mental health, especially benefiting from virtual options. A McKinsey analysis found that 50 percent of psychiatry appointments were virtual by February 2021.[44] In response to this trend, Pennsylvania gave behavioral health providers the flexibility to meet supervision regulations related to advanced practitioners, but policymakers also need to provide more certainty.[45]
  • Legislation like SB 739 introduced by Sen. Vogel, which explicitly provides for telemedicine insurance coverage and a framework for its operation would help to facilitate the growth of telemedicine and improve the continuity of care.[46]
  • In addition, Pennsylvania should reestablish telemedicine reciprocity, allowing a patient in Pennsylvania virtual access to a doctor in another state without requiring the doctor to obtain a Pennsylvania license.[47]

5. Improve Health Care Access in Medicaid by Focusing on Eligible Patients

Medicaid, or Medical Assistance, serves Pennsylvanians with incomes below 138 percent of the Federal Poverty Level, low-income children, and those with intellectual disabilities and physical disabilities. It is common for individuals to increase their income and move between Medicaid, private insurance, and Pennie, the commonwealth’s health coverage marketplace. But during the COVID-19 Public Health Emergency, the federal government prohibited states from removing anyone from the Medicaid program, even if they became ineligible. The Families First Coronavirus Response Act’s (FFCRA) “continuous enrollment condition” ended on March 31, 2023, with an estimated 600,000 ineligible Pennsylvanians receiving government-funded health care benefits.[48]

By March, the state cost of the ineligible population in Pennsylvania was an estimated $78 million a month.[49] In April, Pennsylvania resumed regular eligibility reviews. Yet, the pace of eligibility reviews is concerning. At the current pace, it will take 18 months to complete eligibility reviews.

  • The current system incentivizes Managed Care Organizations to keep ineligible individuals enrolled since they receive a monthly, per-member fee. In fact, eligibility errors are the most common type of Medicaid fraud. In 2020, Shapiro, as attorney general, indicated Medicaid fraud likely tops $3 billion per year.[50]
  • In addition, there is evidence many ineligible individuals have access to employer-sponsored health insurance. The Urban Institute estimated that 18 million will become ineligible for Medicaid and more than half of those individuals are likely eligible for employer or subsidized coverage.[51]
  • The state should stop wasting resources on Pennsylvanians who have access to other forms of health insurance by prioritizing eligibility reviews for those most likely to be ineligible.

It is also important to note the safeguards against inappropriate disenrollments. Specifically, Pennsylvanians incorrectly removed from Medicaid become eligible for three months of retroactive coverage, can secure presumptive eligibility at a hospital if they need emergency services, or maintain their coverage during an appeal.[52] In short, no one eligible for assistance will lose their ability to secure health care.

Empowering patients through a credit to purchase their own health care services or creating incentives to start a portable HSA could better align the goals of Medicaid providers and patients. For example, H.R. 5608, or the ACCESS Act, would let low-income Americans redirect insurance premium subsidies to a tax-free HSA.[53] But first, the state must get serious about protecting resources for the eligible.


Pennsylvania is on a path toward Medicare for all and a public option. These policies to increase government control of our health care decisions will increase the cost of health care without improving the quality of care.

Pennsylvanians need a personal option, individualized health care for all, and policies that empower the patient over the middleman. Allowing more kinds of health care delivery, tearing down barriers to doctors and advanced providers, creating the conditions for real prices, and protecting Medicaid patients will make health care more accessible and, in return, more affordable. An insurance card is not the same as convenient access to health care. Pennsylvania lawmakers need to pursue reforms to increase access, drive down prices, and ultimately put the patient first.

[1]Kaiser Family Foundation (KFF), “Benchmark Survey: Annual Family Premiums for Employer Coverage Rise 7 Percent to Nearly $24,000 in 2023; Workers Contribute $6,575 on Average Now, But Potentially More Soon,” news release, October 18, 2023,

[2]Centers for Medicare and Medicaid Services, “NHE [National Health Expenditure] Fact Sheet,” September 6, 2023 [update],

[3]Aesthetic Society, “Aesthetic Plastic Surgery National Databank Statistics for 2022,” August 2023,; Federal Reserve Bank of St. Louis, “FRED Economic Data: Consumer Price Indexes (CPI and PCE), accessed October 18, 2023,

[4]DPC Frontier, “DPC Frontier Mapper,” accessed October 20, 2023,

[5]Rep. Seth Grove, House Bill 886, Pennsylvania General Assembly, Regular Session 2023–24,

[6]Michael J. McCue and Mark Hall, “How the Small-Business Health Insurance Market Is Faring,” Commonwealth Fund [blog], April 22, 2020,; Kev Coleman, “Small Business Health Insurance Equity through Association Health Plans,” Paragon Health Institute, April 26, 2023,

[7]Employee Benefits Security Administration, U.S. Department of Labor, “Definition of ‘Employer’ Under Section 3(5) of ERISA-Association Health Plans,” Federal Register (83 FR 28912), June 6, 2018,

[8]Congressional Budget Office, “How CBO and JCT Analyzed Coverage Effects of New Rules for Association Health Plans and Short-Term Plans,” January 2019,

[9]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,

[10]Pennsylvania Office of the Attorney General, “Statement by Attorney General Josh Shapiro on Court’s Rejection of Trump Administration’s Attempt to Undermine Affordable Care Act,” March 29, 2019,

[11]Timothy S. Jost, “The Past and Future of Association Health Plans,” Commonwealth Fund [blog], May 14, 2019,

[12]Rep. Valerie S. Gaydos, House Bill 555, Pennsylvania General Assembly, Regular Session 2023–24,

[13]Christopher E. Condeluci, “Association Health Plans (AHPs) and States’ Rights: An Accounting of How States Want to Regulate AHPs,” Bloomberg Tax [Reproduced with permission from the Tax Management Compensation Planning Journal 47, No. 11 (October 28, 2029)],

[14]Pennsylvania Insurance Department, “Association Health Plans in Pennsylvania – Frequently Asked Questions,” December 4, 2018,

[15]Rep. Kevin Hern (R-OK), H.R. 3799 [Custom Health Option and Individual Care Expense (CHOICE) Arrangement Act], 118th Congress (2023–24),

[16]Congressional Budget Office, “Estimated Direct Spending and Revenue Effects of Rules Committee Print 118-9 (H.R. 3799, CHOICE Arrangement Act), as amended by Amendment 8 (Smith),” June 20, 2023,

[17]Bureau of Health Workforce, Health Resources and Services Administration, “Fourth Quarter of Fiscal Year 2023: Designated HPSA Quarterly Summary,” U.S. Department of Health and Human Services, September 30, 2023,

[18]Amelia Goodfellow et al., “Predictors of Primary Care Physician Practice Location in Underserved Urban or Rural Areas in the United States: A Systematic Literature Review,” Academic Medicine 91, No. 9 (September 2016), 1313–21,,

[19]Kihwan Bae et al., “Maryland’s Health Care Lesson for Pennsylvania: How Full Practice Authority Can Increase Access and Improve Outcomes,” Commonwealth Foundation, November 15, 2022,

[20]Moiz Bhai and David T. Mitchell, “Health Care Access: The Easy Way,” Commonwealth Foundation, May 9, 2023,

[21]Sen. Camera Bartolotta, Senate Bill 25, Pennsylvania General Assembly, Regular Session 2023–24,

[22]Sen Judy Ward, Senate Bill 511, Pennsylvania General Assembly, Regular Session 2021–22,

[23]Alex Evans, “Prescribing Authority for Pharmacists: Rules and Regulations by State,” GoodRX Health, July 22, 2022,

[24]Sen Judy Ward, Senate Bill 899, Pennsylvania General Assembly, Regular Session 2023–24,

[25]Pennsylvania Office of Rural Health, “Physician Assistant Modernization Bills Passed in Pennsylvania,” news release, September 2021,; Pennsylvania Society of Physicians Assistants, “Legislative Update October 2021,” October 3, 2021,

[26]Michelle McGhee and Will Chase, “How America’s Top Hospitals Hound Patients with Predatory Billing,” Axios, June 2021,

[27]Pennsylvania Health Access Network, “Survey Shows Pennsylvanians Struggling with High Healthcare Costs,” February 25, 2021,

[28]President Donald Trump, Executive Order 13877 of June 24, 2019: “Improving Price and Quality Transparency in American Healthcare To Put Patients First,” Federal Register (84 FR 30849), June 27, 2019,

[29]Americans for Prosperity, “Background on Hospital Price Transparency (Prepared Remarks of Dean Clancy, Senior Health Policy Fellow, Americans for Prosperity at a meeting of the Pennsylvania Republican Policy Committee, Lewisburg, PA),” May 4, 2023,

[30]Hayden Dublois, “How the Biden Administration Is Enabling Hospitals to Violate Price Transparency Requirements,” Foundation for Government Accountability, June 28, 2023,

[31]Patient Rights Advocate, “Fifth Semi-Annual Hospital Price Transparency Compliance Report [Appendix D],” July 2023,

[32]Centers for Medicare and Medicaid Services, “Hospital Price Transparency Enforcement Updates,” April 26, 2023,

[33]Centers for Medicare and Medicaid Services, “Enforcement Actions,” October 18, 2023 [update],

[34]Centers for Medicare and Medicaid Services, “CMS OPPS/ASC Final Rule Increases Price Transparency, Patient Safety and Access to Quality Care,” news release, November 2, 2021,

[35]American Legislative Exchange Council, “Hospital Price Transparency Act,” July 28, 2022 [introduced],; Rep. Patrick Neville et al., House Bill 22-1285 (enacted June 8, 2022), Colorado General Assembly, 2022 Regular Session,

[36]Dublois, “How the Biden Administration Is Enabling Hospitals.”

[37]David Rowe, “You Deserve to Know What You Pay for Hospital Care,” op-ed, Philadelphia Inquirer, June 7, 2023,; Pennsylvania House Republican Policy Committee, “[Rep.] Rowe Hosts Policy Committee Hearing on Hospital Pricing Transparency,” news release, May 4, 2023,

[38]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,; Madison Geib and Jo Loomis, “Utilizing Telehealth to Decrease Hospital Readmissions for Heart Failure Patients,” University of San Francisco, School of Nursing and Health Professions, March 23, 2023,; Krisda H. Chaiyachati and Christopher K. Snider, “Economics of a Health System’s Direct-to-Consumer Telemedicine for Its Employees,” American Journal of Managed Care 29, No. 6 (June 2023),

[39]51 Pa.B. 1292, “Notice Regarding Coronavirus (COVID-19) Insurance Coverage (Notice 2021-03),”; Kaiser Family Foundation (KFF), “Medicaid Emergency Authority Tracker: Approved State Actions to Address COVID-19,” July 1, 2021,

[40]Sen. Elder A. Vogel Jr., Senate Bill 857, Pennsylvania General Assembly, Regular Session 2019–20,

[41]Pennsylvania General Assembly, 2022 Act 30 (P.L. 392, No. 30), “Health Care Facilities Act – Licensure, COVID-19 Regulatory Flexibility Authority and Repeal,”

[42]National Policy Center – Center for Connected Health Policy, “State Telehealth Laws and Reimbursement Policies – State Summary Chart,” Telehealth Resource Centers, May 15, 2023,,

[43]Pennsylvania Department of State, “Frequently Asked Questions About Telemedicine in Pennsylvania,” accessed October 25, 2023,

[44]Oleg Bestsennyy et al., “Telehealth: A Quarter-Trillion-Dollar Post-COVID-19 Reality?” McKinsey & Company, July 9, 2021,

[45]Pennsylvania General Assembly, 2022 Act 76 (P.L. 773, No. 76), “Outpatient Psychiatric Oversight Act – Requirements,”

[46]Sen. Elder A. Vogel Jr. et al., Senate Bill 739, Pennsylvania General Assembly, Regular Session 2023–24,

[47]Pennsylvania Department of State, “Pennsylvania Authorizes Licensed Health Care Professionals to Provide Services via Telemedicine During Coronavirus Emergency,” news release, March 18, 2020,

[48]Elizabeth Stelle, “Unwinding Medicaid Continuous Enrollment,” Commonwealth Foundation, April 10, 2023,;; Pennsylvania House Republican Caucus, “Pennsylvania Department of Human Services Budget Hearing Wrap,” April 11, 2023,

[49]Paragon Health Institute, “Setting the Record Straight on Medicaid Redeterminations (Pennsylvania),” August 2023,

[50]John L. Micek, “Pa. Lawmakers Roll out Bipartisan Proposal Aimed at Curbing Medicaid Fraud,” Pennsylvania  Capital-Star, January 13, 2020,

[51]Matthew Buettgens and Andrew Green, “The Impact of the COVID-19 Public Health Emergency Expiration on All Types of Health Coverage,” (Washington, D.C.: Urban Institute, December 5, 2022),

[52]Gary D. Alexander, Brian Blasé, and Nic Horton, “Pandemic Unwinding: How States Should Clean up Their Medicaid Rolls,” (Arlington, VA: Paragon Health Institute, May 2023), 6,

[53]Rep. Gregory Steube (R-FL), H.R. 5608 [Affordable Care and Comprehensive Economic Support through Savings (ACCESS) Act], 118th Congress (2023–24), and; Americans for Prosperity, “ACCESS Act Gives More Americans a Personal Option in Health Care,” news release, September 2023,