funding hr 676 friedman

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Funding HR 676: Te Expanded and Improved Medicare for All Act

How we can afford a national single-payer health plan

Gerald Friedman, Ph.D.ProessorDepartment o EconomicsUniversity o Massachusetts at Amherst

[email protected]

July 31, 2013

I am grateul to Michael Ash, Benjamin Day, Ida Hellander, David Himmelstein, Debra Jacobson, and SteffieWoolhandler or comments. I remain solely responsible or any errors.


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Executive Summary

Te Expanded and Improved Medicare or All Act, HR 676,introduced into the 113th Congress by Rep. John Conyers Jr.and 37 initial co-sponsors, would establish a single authorityresponsible or paying or medically necessary health care orall residents o the United States.

Under the single-payer system created by HR 676, the U.S.could save an estimated $592 billion annually by slashing theadministrative waste associated with the private insuranceindustry ($476 billion) and reducing pharmaceutical prices toEuropean levels ($116 billion). In 2014, the savings would beenough to cover all 44 million uninsured and upgrade benefitsor everyone else. No other plan can achieve this magnitude osavings on health care.

Specifically, the savings rom a single-payer plan would bemore than enough to und $343 billion in improvements to thehealth system such as expanded coverage, improved benefits,enhanced reimbursement o providers serving indigentpatients, and the elimination o co-payments and deductibles in2014. Te savings would also und $51 billion in transition costssuch as retraining displaced workers and phasing out investor-owned, or-profit delivery systems.

Health care financing in the U.S. is regressive, weighingheaviest on the poor, the working class, and the sick. With theprogressive financing plan outlined or HR 676 (below), 95% oall U.S. households would save money.

HR 676 (Section 211, Appendix 2) specifies a financing planor single-payer that includes Maintaining current ederal financing or health care Increasing personal income taxes on the top 5% o income

earners Instituting a modest tax on unearned income Instituting a modest and progressive tax on payroll, sel-

employment Instituting a small tax on stock and bond transactionsTe ollowing progressive financing plan would meet thespecifications o HR 676: Existing sources o ederal revenues or health care ax o 0.5% on stock trades and 0.01% tax per year to

maturity on transactions in bonds, swaps, and trades 6% high-income surtax (applies to households with

incomes > $225,000) 6% tax on unearned income rom capital gains, dividends,

interest, profits, and rents 6% payroll tax on top 60% o income earners (applies to

incomes over $53,000, tax paid by employers) 3% payroll tax on the bottom 40% o income earners

(applies to incomes under $53,000, tax paid by employers)

HR 676 would also establish a system or uture cost controusing proven-effective methods such as negotiated ees, globabudgets, and capital planning. Over time, reduced healthcost inflation over the next decade (bending the cost curve)would save $1.8 trillion, making comprehensive health benefitssustainable or uture generations.

Section I: Financing needs or single payer

Regressive and obsolete unding sources to be replaced by

progressive taxation

Health expenditures under the existing health care systemare projected to total $3.13 trillion in 2014, plus $32 billion inspending by employers or administering employer-based healthinsurance plans.1 Health care financing in the U.S. is highlyregressive, with low-income households and those dealing withserious illness or injury paying larger shares o their incomestowards health care than high-income and healthy households.

Under HR 676, progressive ederal taxes (i.e. taxes that reducethe proportion o income paid by low-income householdsand those aced with a serious illness or medical care) would

replace current regressive, income-invariant sources o healthcare financing such as spending by businesses and 80% o out-o-pocket spending by individuals.2

Progressive ederal taxes would also replace regressiveand obsolete unding sources including ederal, state, andlocal government spending on private health insurance orgovernment employees, and state and local governmentspending on Medicaid and other health programs. Accordingto data rom the Centers or Medicare and Medicare Services(CMS), these expenditures will total $1,723 billion in 2014. Seeable 1.

Current spending on ederal government programs to beapplied to unding HR 676 amounts to $1,344 billion.3

Tisincludes ederal spending or the Medicare program, theMedicaid program, and the Childrens Health InsuranceProgram. Other unding sources include $47 billion in revenuerom new Medicare taxes included in the Affordable Care Acto 2010, and the remaining 20% o out-o-pocket spending byindividuals. ogether, these unding sources amount to $1,454billion o spending retained or unding HR 676 in 2014.

Funding HR 676: Te Expanded and Improved Medicare or All ActHow we can afford a national single-payer health plan

By Gerald Friedman, Ph.D. J ,


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Estimated cost o system improvements and transition costs

A single-payer program would improve the health systemin many ways. It would extend coverage to all uninsuredAmericans.4It would reduce barriers to access or the currentlyinsured by eliminating burdensome co-payments, deductiblesand other out-o-pocket spending or medical care. It wouldoffer improved benefits by covering services like dental andlong-term care. It would eliminate inequity in the treatment

o less-affluent patients by paying providers the same ee oreach patient regardless o income or employment.5 Teseimprovements would cost an estimated $343 billion annually.

ransition costs o implementing HR 676 would include thecost o unemployment insurance and retraining o displacedinsurance and provider administrative personnel.6In addition,the cost o converting investor-owned health care acilities tonon-profit status would be incurred and is spread out over 15years.7Including transition costs o $51 billion in the first year,the estimated cost o expanding and improving Medicare is$394 billion. See able 2.

Section II: Single-payer systemsavings as a source o financing

Savings on provider administrative overhead and drug price

For decades, health care costs have risen much aster thanincome in the United States. As a result, total health carespending has risen rom 5% o Gross Domestic Product in 1960to nearly 18% today. While some o the increase in costs in the

United States is due, as in other countries, to improvements incare, innovative technologies and greater longevity, costs haverisen much aster in the United States than elsewhere becauseo the growing administrative burden o our private healthinsurance system.

Because o the large number o separate insurance programsand the ragmented billing system, American physicians andhospitals incur much greater costs or billing and insurance-related activities than do their oreign counterparts. Comparedwith doctors in Ontario, Canada, or example, Americans spendnearly our times as much on billing and insurance related

Source: http://www.cms.gov/NationalHealthExpendData/downloads/tables.pd; and http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-rends-and-Reports/NationalHealthExpendData/downloads/sponsors.pd.

able 1. Regressive and obsolete unding sources to bereplaced by progressive taxation (in billions o dollars)

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Note: Te cost o coverage expansion includes overhead on all new coverage under the single payer ($25 billion) as well as $85 billion tocover the estimated 44 million who will be uninsured in 2014. It assumes the uninsured spend 55% as much on health care as the insured andwould spend 80% with insurance; the lower spending is based on the age distribution o the uninsured. It is assumed that the ACA would havelowered the share without insurance by 11 million rom 2013 to 2014, to 16% o the nonelderly population in 2014.[8] Utilization expansionassumes a 3% increase or most activities with a 20% increase or dental care (currently not provided or many insurance plans), a 20% increasein nursing home care, and a 40% increase in home health care. Current Medicaid physician rates are 34% below those paid under Medicare,and the ACA provides or an increase in rates or primary care to Medicare levels; this adjustment assumes that they will be equalized or allphysician services.9

able 2. Estimated cost o health system improvementsand transition costs under HR 676 (in billions o dollars)

Sources: Administrative savings are the difference between overhead costs in the United States and Canada in 1999 rom Steffie Woolhandler,erry Campbell, and David Himmelstein, Cost o Health Care Administration in the United States and Canada, New England Journal oMedicine no. 349 (2003); relative drug prices are rom McKinsey Global Institute, Accounting or the Cost o Health Care in the United States,January 2007; projected spending under the ACA in 2014 is rom Centers or Medicare and Medicaid Services.

able 3. Savings on provider administrative overhead and

pharmaceutical costs (in billions o dollars)

able 4. Savings on administrative costs o insurers,Medicaid, and employers (in billions o dollars)

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activities ($83,000 per physician versus $22,000 in Ontario),and nursing staff, including medical assistants, spent 20.6 hoursper physician per week interacting with health plans nearlyten times that o their Ontario counterparts.9

In addition to the administrative savings within provideroffices, a single payer system could lead to dramatic savingsby negotiating reduced prices or pharmaceuticals which costapproximately 60% more in the U.S. than in Europe.10See able3. oday, Medicare is the only entity in the world excluded rom

negotiating lower prices on medications or its beneficiaries.

Savings on the administrative costs o private insurers,Medicaid, and employers

In addition to reducing the overhead o providers like doctors

and hospitals, eliminating private insurance plans wouldalso generate administrative savings on insurance overheadCurrently, private insurers have a medical loss ratio (the shareo health care spending going or medical services) o barely88%. Te 12% administrative cost average includes the cost oadvertising, enrollment, collecting premiums, paying claimsbureaucratic red-tape designed to discourage the submissiono claims, inflated executive compensation, and profit, as wellas relatively high administrative cost due to the small scale o

many companies. A single-payer system would eliminate mosto these costs, raising the share o spending going to providersup to the 98% rate or Medicare. With almost a trillion dollarsin premiums paid into private health insurance, lowering theadministrative ratio to the Medicare rate would save over $197billion.11

Figure 1. Single-payer system savings rom reducedadministrative costs and drug prices (in billions o dollars)

Sources: Government Printing Office, Analytical Perspectives, Budget o the United States, 2012, 243. Estimates or 2010 have been adjustedor 2014 at the rate o increase in general health care expenditures 1991-2009 rom http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-rends-and-Reports/NationalHealthExpendData/downloads/sponsors.pd.

able 5. Savings on ederal tax expendituresor health care (in billions o dollars)



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Further savings o $26 billion would come rom the reductionin the administrative expenses o running Medicaid as a

joint ederal-state means-tested program. Currently, 5.7% oMedicaid expenses go or administration, including the cost ochecking eligibility and operating a payment system separaterom Medicare and other insurance systems.12

In addition, employers will save $32 billion on the direct costso managing their employer-provided health insurance systems,including the costs o collecting and processing payments as

well as consultant charges or choosing an insurance carrier. Seeable 4.

Altogether, administrative savings rom the single-payersystem, on providers overhead costs, and on administrativeexpense among insurers, Medicaid, and employers, come to$476 billion in 2014. Adding in the savings on prescriptiondrugs o $116 billion brings the total savings to $592 billion.See Figure 1. Moreover, a single-payer system would slowthe growth in health care spending rom year to year, greatly

reducing the burden o health care costs over the long term.13

HR 676 would eliminate the need or ederal subsidies or thepurchase o private health insurance by business and individualsAlong with deductions or medical savings accounts, medicaexpenses and some smaller tax breaks associated with theprivate insurance system, eliminating tax subsidies would save$260 billion (able 5).

Section III: A progressive unding plan or HR 676

Te health care improvements and transition costs o a single-payer system ($394 billion, able 2), including expandingcoverage to 44 million uninsured Americans and upgradingcoverage or everyone else, would be unded under HR 676by $592 billion in savings on administrative costs and reducedpharmaceutical prices. As a result o implementation o HR676, health spending in the first year would all by $198 billionto $2,964 billion (able 6).

able 6. National Health Expenditures with and

without Implementation o HR 676 (in billions o dollars)

able 7. A progressive financing plan or HR 676 that replaces regressive undingsources and improves and expands comprehensive benefits to all (in billions o dollars)

Sources: Revenue rom the obin ax rom Dean Baker, et al., Te Potential Revenue rom Financial ransactions axes. Te Baker et al.estimates are or 2011 and I have extrapolated assuming revenue will grow at the same pace as the GDP; this conservative assumption leads toan understatement o revenue. Income distribution is rom the updated background tables or Tomas Piketty and Emmanuel Saez, IncomeInequality in the United States.[16] Revenue is calculated by applying the tax rates to the reported income; since Piketty and Saez use IRSincome data, I am assuming the same rate o noncompliance as under the current tax law. I have extrapolated rom 2006 assuming that allincome groups and all income types grew equally with the GDP; this conservative assumption leads to an understatement o revenue.



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With the progressive unding plan outlined in able 7, regressiveand obsolete unding sources would be replaced by progressive

taxes, including a new tax on financial transactions (a so-calledobin ax14), a progressive payroll tax and tax on unearnedincome, and surtax on high income individuals. Under the plandeveloped here, revenues would exceed expenditures by $154billion in the first year, generating unds that could be investedin health proessional education or used or deficit reduction.15

Te proposed taxes would be highly progressive, especiallycompared with current health care spending which alls mostheavily on lower-income households. On average, only 5% oAmericans would pay more under this proposal, which wouldmean savings or Americans with household incomes up to wellabove $200,000. See Figure 2.

Conclusion: Single payer covers more, costsless than current system or 95% o Americans

Tis analysis shows that it is possible to reorm the U.S. healthfinancing system to make it more efficient and equitable.Universal health care with comprehensive benefits could beachieved under a single-payer system as embodied in HR 676.Improved Medicare or All would cost less or 95% o householdsand reduce the deficit by $154 billion in the first year.

Figure 2. Change in afer-tax household income due to adoption o progressivefinancing or HR 676: 95% o Americans are better off under a single-payer system

Note: Te percentages shown here are the difference between the share o income spent on health care now and the amount that would be spent under theproposed single-payer plan including the taxes proposed to replace the current regressive unding system. Te taxes included here are a obin tax (describedin the text), a 6% surtax on the richest 5% o households, a 6% tax on unearned income (including capital gains, dividends, interest, profits, and rents), a 6%tax on the top 60% o wages and salaries, and a 3% tax on the bottom 40%. Te first our bars rom the lef represent the income o the bottom our quintileso the population; the next bar (or an average income o $216,922) represents the next 15% (rom the 80th to the 95th percentile); the next bar representsthe next 4%; the next bar (or an average income o $2,994,817) represents the mean income o the richest 1% o the population; and the final bar (with anaverage income o $166,592,800) represents the wealthiest 400 American households based on their tax returns.17Note that the only groups in the populationwho would pay more or care are the richest 5%.

Progressive financing o HR 676 is possible using a obin orRobin Hood tax as one o the unding sources. Although the

obin tax is desirable or a number o reasons, HR 676 singlepayer may be financed without the obin tax i necessary. SeeAppendix 1.

Tis analysis is done or one point in time, 2014. Over timethe health care system in the United States has become moreexpensive both relative to the cost o providing equivalenservices in the past and relative to other countries.18Under theederal reorm law o 2010, it is projected that health care costwill continue to grow, creating growing pressure to cut costs byreducing access and quality o care.

In contrast, HR 676 would establish a system or uture coscontrol using proven-effective methods such as negotiated

ees, global budgets, and capital planning. Over the nextdecade, savings rom reduced health inflation (bending thecost curve) would equal $1.8 trillion. On top o the enormouadministrative savings o single payer, the savings rom effectivecost-control would make it possible to provide universacoverage and comprehensive benefits to uture generations19ata sustainable cost.

Gerald Friedman is professor, Department of EconomicsUniversity of Massachusetts at Amherst. He can be reached a

[email protected].



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Appendix 1- Summary ables o Alternatives Financing Plans or HR 676

With obin ax (transactions or Robin Hood tax)In billions o dollars



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Appendix 1- Summary ables o Alternatives Financing Plans or HR 676

Without obin ax (transactions or Robin Hood tax)In billions o dollars

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Notes

1. Centers or Medicare and Medicaid Services, National Health ExpenditureProjections, 2011-2021 (Washington, D.C.: Department o Health and HumanServices, Center or Medicare and Medicaid Statistics, n.d.) able 2; employerexpenditures administering health insurance plans came to 4.2% o healthinsurance spending in Steffie Woolhandler, erry Campbell, and DavidHimmelstein, Cost o Health Care Administration in the United States andCanada, New England Journal o Medicine no. 349 (2003): 76875. Tis ratio hasbeen applied to employer-based health insurance in 2014.

2. While the largest components o out-o-pocket expenditures, prescription drugsand co-payments and deductibles, will be covered under HR 676, other medically-optional expenditures, such as some dental procedures or luxury eyeglasses, wouldnot be covered, nor would most vitamins and some alternative medical practices.For the breakdown o out-o-pocket spending, see Ann Foster, Out-o-pocketHealth Care Expenditures: a Comparison, Monthly Labor Review (February2010): 320.3. HR 676 does not incorporate the Indian Health Service or the first five years,or the Veterans Administration or the first ten years (Sec 401). For this study,however, these have been included both on the revenue and the expenditure side.4. Te Congressional Budget Office estimates that there will be 44 millionuninsured in 2014 afer the Affordable Care Act goes into effect; CongressionalBudget Office, February 2013 Estimate o the Effects o the Affordable Care Acton Health Insurance Coverage, February 2013, http://www.cbo.gov/sites/deault/files/cbofiles/attachments/43900_ACAInsuranceCoverageEffects.pd.5. Physicians who accept Medicaid patients are paid ar less than those who serve

other patients. Raising rates would be a transer to providers who would be paidmore or services they are currently perorming. It would also improve access byallowing providers to perorm services better, by spending more time with eachpatient; and it would encourage more providers to provide services or less-affluenpatients.6. In Section 303, HR 676 provides or up to two years o unemployment insurancand priority in retraining or clerical, administrative, and billing personnel ininsurance companies, doctors offices, hospitals, nursing acilities, and otheracilities whose jobs are eliminated due to reduced administration. One percent ohealth spending is set aside or unemployment and retraining annually.7. In Section 103, HR 676 provides that over a fifeen year period, investor-ownersshall be compensated or the actual appraised value o converted acilities usedin the delivery o care. A reserve und o $20 billion annually is created or thispurpose.8. Congressional Budget Office, February 2013 Estimate o the Effects o theAffordable Care Act on Health Insurance Coverage.

9. Dante Morra et al., US Physician Practices Versus Canadians: SpendingNearly Four imes As Much Money Interacting With Payers, Health Affairs 30,no. 8 (2011): 1443 1450, doi:10.1377/hlthaff.2010.0893; Also see, Lawrence P.Casalino et al., What Does It Cost Physician Practices o Interact With HealthInsurance Plans?, Health Affairs 28, no. 4 (July 1, 2009): w533w543, doi:10.1377/hlthaff.28.4.w533; Woolhandler, Campbell, and Himmelstein, Cost o HealthCare Administration in the United States and Canada; David Himmelstein, SteffieWoolhandler, and Sidney Wole, Administrative Waste in the U.S. Health CareSystem in 2003: Te Cost to the Nation, the States, and the District o Columbia,with State-Specific Estimates o Potential Savings, International Journal o HealthServices 34, no. 1 (2004): 7986.10. McKinsey Global Institute, Accounting or the Cost o Health Care in theUnited States, January 2007, http://www.mckinsey.com/mgi/rp/healthcare/accounting_cost_healthcare.asp; Te magnitude o excessive pricing or drugs isindicated by the 80% drop in drug prices when they come out o patent protectionand are produced as generics; see Center or Devices and Radiological Health,

About the Center or Drug Evaluation and Research - Generic Competitionand Drug Prices, WebContent, accessed December 27, 2012, http://www.da.gov/AboutFDA/CentersOffices/OfficeoMedicalProductsandobacco/CDER/ucm129385.htm.11. No savings have been assumed rom reduced raud despite the great capacity oa single-payer system to reduce or even to eliminate raudulent billing. Fraudulentbilling, including duplicate billing and billing or services not rendered, accountsor between 3% and 10% o health care spending in the United States, including anerror rate in ederal programs o over 9%. See estimony o the National HealthCare Anti-Fraud Association (Harrisburgh, PA., House Insurance Committee,Hourse o Representatives, Commonwealth o Pennsylvania, January 28, 2010),http://www.legis.state.pa.us/cdocs/legis/R/transcripts/2010_0017_0014_SMNY.pd; General Accounting Office, Medicare and Medicaid Fraud, Waste,and Abuse: Effective Implementation o Recent Laws and Agency Actions CouldHelp Reduce Improper Payments (Washington D.C., March 9, 2011), http://www.

Appendix 2: ext o unding sectiono HR 676 in the 113th Congress

1st SessionH. R. 676o provide or comprehensive health insurance coverage or

all United States residents, improved health care delivery, andor other purposes.

C. 211. OVERVIEW: FUNDING HE MEDICARE FOR ALLPROGRAM.

(a) In General. Te Medicare For All Program is to be undedas provided in subsection (c)(1).

(b) Medicare For All rust Fund. Tere shall be established aMedicare For All rust Fund in which unds provided underthis section are deposited and rom which expenditures underthis Act are made.

(c) Funding.(1) IN GENERAL. Tere are appropriated to the Medicare For

All rust Fund amounts sufficient to carry out this Act rom the

ollowing sources:(A) Existing sources o Federal Government revenues or

health care.(B) Increasing personal income taxes on the top 5 percent

income earners.(C) Instituting a modest and progressive excise tax on payroll

and sel-employment income.(D) Instituting a modest tax on unearned income.(E) Instituting a small tax on stock and bond transactions.(2) SYSEM SAVINGS AS A SOURCE OF FINANCING.

Funding otherwise required or the Program is reduced as aresult o--

(A) vastly reducing paperwork;(B) requiring a rational bulk procurement o medicationsunder section 205(a); and

(C) improved access to preventive health care.(3) ADDIIONAL ANNUAL APPROPRIAIONS O

MEDICARE FOR ALL PROGRAM. Additional sums areauthorized to be appropriated annually as needed to maintainmaximum quality, efficiency, and access under the Program.

SEC. 212. APPROPRIAIONS FOR EXISING PROGRAMS.Notwithstanding any other provision o law, there are hereby

transerred and appropriated to carry out this Act, amounts rom

the reasury equivalent to the amounts the Secretary estimateswould have been appropriated and expended or Federal publichealth care programs, including unds that would have beenappropriated under the Medicare program under title XVIIIo the Social Security Act, under the Medicaid program undertitle XIX o such Act, and under the Childrens Health InsuranceProgram under title XXI o such Act.



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gao.gov/new.items/d11409t.pd; William Hsiao, Steven Kappel, and JonathanGruber, Act 128: Health System Reorm Design. Achieving Affordable UniversalHealth Care in Vermont, January 21, 2011, 34, http://www.leg.state.vt.us/jo/healthcare/FINAL%20V%20Draf%20Hsiao%20Report.pd.12. Te MLR or Medicaid is under 95%, lower than or Medicare because othe more complicated eligibility criteria. April Grady, State Medicaid ProgramAdministration: A Brie Overview (Congressional Research Service, May 14,2008), http://aging.senate.gov/crs/medicaid3.pd; ibid.; Earl Hoffman, BarbaraKlees, and Catherine Curtis, itle XVIII and itle XIX o the Social Security Actas o November 1, 2005 (Washington D.C.: Centers or Medicare and MedicaidServices, November 2005), http://www.cms.gov/Research-Statistics-Data-and-Systems/Statistics-rends-and-Reports/MedicareProgramRatesStats/downloads/

MedicareMedicaidSummaries2005.pd I assume the same administrative savingsrate or other government health programs.13. Since Canada established a single-payer system in 1971, real health carecosts have risen by 1.1 percentage points less per year than in the UnitedStates. Over hal o this difference can be explained by the greater inflation inadministrative costs in the United States. Karen Davis et al., Slowing the Growtho U.S. Health Care Expenditures: What Are the Options, CommonwealthFund Commission on a High Perormance Health System (CommonwealthFund, January 2007), http://www.commonwealthund.org/usr_doc/Davis_slowinggrowthUShltcareexpenditureswhatareoptions_989.pd; Woolhandler SHimmelstein DU, Cost Control in a Parallel Universe: Medicare Spending in theUnited States and Canada, Archives o Internal Medicine (October 29, 2012): 12,doi:10.1001/2013.jamainternmed.272; McKinsey Global Institute, Accounting orthe Cost o Health Care in the United States.14. Originally proposed by the Yale economist and Nobel-laureate James obin,the United States taxed financial transactions rom 1914 till 1966. A financial

transactions tax has been endorsed by 11 Eurozone member states where it isscheduled to go into effect in 2014. Te National Nurses United is campaigningor such a tax in the United States. Called the Robin Hood ax, a proposal or afinancial transactions tax has been sponsored in Congress by Representative KeithEllison in HR 6411; see the discussion at http://robinhoodtax.org/latest/robin-hood-tax-bill-introduced-congress; James obin, A Proposal or InternationalMonetary Reorm, Eastern Economic Journal 4, no. 34, Eastern EconomicJournal (1978): 153159; Dean Baker et al., Te Potential Revenue rom Financialransactions axes, Political Economy Research Institute Working Paper Series(Amherst, MA.: Political Economy Research Institute, University o Massachusettsat Amherst, December 2009).15. Over the next decade, savings rom excess revenue, reduced health-carespending because o a slowing in the rate o health-care inflation, and interestsavings will produce total deficit reduction o almost $3 trillion.16. Tomas Piketty and Emmanuel Saez, Income Inequality in the United States,1913-1998, Te Quarterly Journal o Economics 118, no. 1 (February 1, 2003):139.17. Internal Revenue Service, Te 400 Individual Income ax Returns Reportingthe Highest Adjusted Gross Incomes Each Year, 1992-2007, 2012, http://www.irs.gov/pub/irs-soi/07intop400.pd.18. Himmelstein DU, Cost Control in a Parallel Universe; Gerald Friedman,Universal Health Care: Can We Afford Anything Less?, Dollars and Sense, June29, 2011, http://dollarsandsense.org/archives/2011/0711riedman.html.19. Health care expenditures or the next decade have been calculated underthe assumption that HR 676 is implemented in 2014 and the rate o growtho expenditures slows by 1.1% a year afer that. Te $1.8 trillion figure is thedifference between the annual growth in expenditures projected by the CMS or2015-24 and the growth projected under these assumptions.

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