Review: Rand Paul’s Obamacare Replacement Act

January 2017 is Obamacare hunting season and Sen. Rand Paul decided to throw his replacement plan proposal into the mix of Republican ideas on the discussion table. Finally we have something concrete and serious from the Republicans to work with. The summary can be found here and law nerds can find the entire 149 page bill on Capitol Hill here. So how does it look? Well, it’s not great. It’s actually pretty bad for a variety of reasons rooted in poor understanding of economics and human behavior, but let’s go over the summary section by section.

Repealing Obamacare

  • Effective as of the date of enactment of this bill, the following provisions of Obamacare are repealed: Individual and employer mandates, community rating restrictions, rate review, essential health benefits requirement, medical loss ratio, and other insurance mandates.

Alright, repealing the individual mandate is an immediate reprieve for the 6.5 million poor taxpayers whom the government was forcing to pay $3.0 billion in penalties because they valued having money for things like food and rent more highly than subsidized health insurance. Repealing the employer mandate is a benefit more broadly to the working class by making it easier for employers to hire above the 50 person boundary imposed by Obamacare. Repealing the insurance regulations and requirements allows them to revisit their plans and deliver a greater diversity of products that better match consumers needs. We’re doing well so far, let’s see what’s next.

Protecting Individuals with Pre-Existing Conditions

  • Provides a two-year open-enrollment period under which individuals with pre-existing conditions can obtain coverage.
  • Restores HIPAA pre-existing conditions protections. Prior to Obamacare, HIPAA guaranteed those within the group market could obtain continuous health coverage regardless of preexisting conditions.

Another good change. The patient protection portions of the Patient Protection and Affordable Care Act were popular for obvious reasons, but they’re also the reason why it should be called the Patient Protection and Unaffordable Insurance Act. The Obamacare regulations give far too much protection to individuals and open up the insurance market to abuse by patients who take advantage of their information asymmetry by signing up for insurance only when they anticipate heavy usage of the healthcare system. Rolling back the regulations to the 1996  HIPAA pre-existing condition rules restores to insurance companies ways to protect themselves from such manipulation. These are good changes so far, but unfortunately this is the repeal portion of the bill. The rest is the replace portion, and it’s all downhill from here.

Equalize the Tax Treatment of Health Insurance

  •  Individuals who receive health insurance through an employer are able to exclude the premium amount from their taxable income. However, this subsidy is unavailable for those that do not receive their insurance through an employer but instead shop for insurance on the individual market.
  • Equalizes the tax treatment of the purchase of health insurance for individuals and employers. By providing a universal deduction on both income and payroll taxes regardless of how an individual obtains their health insurance, Americans will be empowered to purchase insurance independent of employment. Furthermore, this provision does not interfere with employer provided coverage for Americans who prefer those plans.

This is very bad economics. For those not familiar with this issue, there is a massive loophole in the tax code where health insurance benefits provided by the employer are not subject to taxation. The rule is rooted in World War II wage controls where employers were not allowed by the government to give employees salary increases because of the war effort, but the worker unions negotiated to be allowed to receive health insurance benefits instead of additional wages. Except the tax code did not have any provisions for these health insurance benefits. By the time that Congress realized this loophole, the unions had also realized that  they were effectively receiving a subsidy from the government on every dollar that they got paid in health insurance as opposed to wages, and the practice became so widespread that politicians were not able to muster the courage to go through with the fix. The result is that 60% of Americans receive insurance through their employer. This is an enormous economic problem, because it completely distorts the insurance market. The employer does not know your preferences, willingness to pay, and healthcare needs. Therefore making the employer  the primary purchaser of health insurance guarantees sub-optimal insurance selection and decreases market competition. If your employer provides only one or two insurance plan choices, did you as a consumer really participate in the insurance marketplace? By tying the insurance to the employer rather than the individual, it makes insurance less portable and forces the individual to renegotiate their insurance every time that they get a new job or move between state which makes people less likely to do so if they do develop a condition. In addition, the tax loophole results in an effective market distortion of the pricing signals (if they existed, more on that later) that the economy creates. By giving health insurance an effective 20-30% subsidy, this guarantees that people will purchase more insurance than they need and that providers, knowing that there is an excess of insurance protection in the marketplace, increase their prices in order to take advantage of this fact. This doesn’t make healthcare easier to pay for the insured, and makes it MORE difficult to afford for the uninsured. Expanding this loophole to insurance premiums for the sake of “equality” only makes the problem worse!

Expansion of Health Savings Accounts

  • Provides individuals the option of a tax credit of up to $5,000 per taxpayer for contributions to an HSA. If an individual chooses not to accept the tax credit or contributes in excess of $5,000, those contributions are still tax-preferred.
  • Removes the maximum allowable annual contribution, so that individuals may make unlimited contributions to an HSA.
  • Eliminates the requirement that a participant in an HSA be enrolled in a high deductible health care plan. Currently, in order to be eligible to establish and use an HSA, an individual must be enrolled in a high-deductible health plan. This section removes the HSA plan type requirement to allow individuals with all types of insurance to establish and use an HSA.

In addition to the above changes, there is a very long list of HSA deregulation giving people more freedom in how they can spend their HSA accounts and how they can transfer that money between people and funds if necessary. This is the core of the new Republican healthcare agenda, trying to move people off unlimited premium driven insurance plans and to a more cash based healthcare market. It’s a great idea, but it’s necessary to be critical and skeptical about this bill’s implementation. Critical because these changes further expand the tax loophole described above to cash based purchases of healthcare, which further inflates healthcare prices. This hurts the uninsured more than everybody else, because the insured are loss protected after their deductible limit is reached. It’s also necessary to be skeptical, because promoting health savings accounts implies that people are able to take their cash and use it to make purchases in a transparent competitive free market. No such thing exists.You can’t go to your local hospital’s website, navigate to the orthopedics section, and find out the cost of a hip replacement. Healthcare is the only industry where there are no publicly available prices and it’s acceptable to quote a price after the service has been delivered. Imagine airlines billed you for a transcontinental flight AFTER you arrived at your destination. Would you be surprised if they tried to overcharge you? Without transparent prices it’s completely irrational for consumers to try purchasing their healthcare on a cash basis. It’s safer to stick with your insurance than risk it with the HSA. Providers, for their part, will never be the first to provide prices because doing so would mean that they would have to actually compete for business and innovate, instead of generating profits by overcharging your insurance behind the scenes. Despite all the changes proposed by Sen. Rand, HSA’s in this bill are a non-starter without provider side reforms.

Charity Care and Bad Debt Deduction for Physicians

  • Amends the Internal Revenue Code to allow a physician a tax deduction equal to the amount such physician would otherwise charge for charity medical care or uncompensated care due to bad debt. This deduction is limited to 10% of a physician’s gross income for the taxable year.

Is this real? Somebody pinch me. Besides the obvious critique that this is a physician senator peddling to the physician special interest, here’s why this is a terrible idea. In Brazil health expenditure is a limitless tax deduction. So what do people do? They go to their friendly neighborhood physician and have him write out receipts for a large amount of fake healthcare which they use to reduce their taxable income while giving the physician a kickback for his cooperation in the scheme. Every single physician will max out this Sen. Paul tax deduction. Physicians  who did not have enough uncompensated care during the year will go to their friendly neighborhood uninsured patients to “provide” charity care until they reach 10% of gross income. In addition, this rule encourages physicians to increases the cost of their services, because Increasing their billing to insured patients increases their gross income, which in turn increases the allowed net amount of the 10% tax deduction.

Pool Reform for the Individual Market

  • Establishes Independent Health Pools (IHPs) in order to allow individuals to pool together for the purposes of purchasing insurance.
  • Amends the Public Health Service Act (PHSA) to allow individuals to pool together to provide for health benefits coverage through Individual Health Pools (IHPs). These can include nonprofit organizations (including churches, alumni associations, trade associations, other civic groups, or entities formed strictly for establishing an IHP) so long as the organization does not condition membership on any health status-related factor.

Sure, deregulation is good, but this won’t go anywhere as long as employers provide insurance. Businesses will always have more negotiating power against insurers than self-organized groups of individuals, so people will always get a better deal from their job than their individual group.

Interstate Market for Health Insurance

  • Increases access to individual health coverage by allowing insurers licensed to sell policies in one state to offer them to residents of any other state.
  • Exempts issuers from secondary state laws that would prohibit or regulate their operation in the secondary state. However, states may impose requirements such as consumer protections and applicable taxes, among others.
  • Gives sole jurisdiction to the primary state to enforce the primary state’s covered laws in the primary state and any secondary state.
  • Allows the secondary state to notify the primary state if the coverage offered in the secondary state fails to comply with the covered laws in the primary state.

In addition to HSA’s, this is the other major tent pole of the new Republican health insurance agenda. Trump especially emphasized deregulation of state barriers on insurance as a major fix to the health insurance market. That’s probably not the case. The problem is that insurers trying to move into new states do not have a provider network in the target state, and therefore have no negotiating power which results in plans that are more expensive and networks that are smaller than the incumbent insurers. Even Kaiser ended up fumbling when they tried expanding to the east coast. The idea is good, and the changes are a move in the right direction, but it likely won’t be meaningful except for cases where insurers are especially abusive in their relationship with the local providers.

Association Health Plans

  • Association Health Plans (AHPs) allow small businesses to pool together across state lines through their membership in a trade or professional association to purchase health coverage for their employees and their families. AHPs increase the bargaining power, leverage discounts, and provide administrative efficiencies to small businesses while freeing them from state benefit mandates

More bad policy. We discussed already how employer sponsored health insurance is bad because it limits individual participation in the insurance marketplace and results in suboptimal health insurance utilization. While this change has the understandable goal of increasing small business bargaining power against insurers, it only expands the employer’s presence in the insurance marketplace when we need less of it. In the words of American philosopher Donald Trump, “Bad!”

Anti-Trust Reform for Healthcare

  • Provides an exemption from Federal antitrust laws for health care professionals engaged in negotiations with a health plan regarding the terms of a contract under which the professionals provide health care items or services.
  • This section applies only to health care professionals excluded from the National Labor Relations Act. It would also not apply to contracts or care provided under Medicare, Medicaid, SCHIP, the FEHBP, or the IHS as well as medical and dental care provided to members of the uniformed services and veterans.

Hold on. Full stop. What? So if a health insurance company tries to negotiate a rate with an independent specialist, the Sherman anti-trust act is waived and he is allowed to collude with all the other independent specialists in an area in order to push up his negotiated rates? In an economy where physicians are generally overpaid compared to their counterfactuals? From an economic perspective that’s fine, cartels fall apart because there’s always an incentive for members to cheat and eventually one of the colluders will independently agree to lower rates in exchange for more referrals. But Anti-Trust Reform? Let’s at least be honest Sen. Rand “Physician Special Interest” Paul that this will only increase cost of care and call it Trust Empowerment.

Increasing State Flexibility to Conduct Medicaid Waivers

  • Provides new flexibilities to states in their Medicaid plan design, through existing waiver authority in current law.

The final tent pole in Republican healthcare policy, giving power back to the states, a tale as old as time. This is guaranteed to be part of the final policy, regardless of whose plan is passed. Innovation and decentralization is good and I look forward to what the states will create.

Self-Insurance Protections

  • Amends the definition of “health insurance coverage” under the Public Health Service Act (PHSA), and parallel sections of ERISA and the Tax Code, to clarify that stop-loss insurance is not health insurance.
  • This provision is designed to prevent the federal government from using rule-making to restrict the availability of stop-loss insurance used by self-insured plans.

This is interesting. Some of these regulations are decent, like requiring stop-loss insurance to cover unpaid claims if the small business plan terminates. Others, like requiring a certain amount of healthcare spending before stop-loss is allowed to kick in, are very invasive. That being said, it is completely correct to say that stop-loss insurance is not health insurance. If it were, every single financial product that insurance companies use to manage their risk profile could be construed as health insurance.

Conclusion

What’s the verdict? It’s pretty disappointing. The only good thing it achieves is the repeal itself, because the replacement is mediocre. A mixture of decent changes that aren’t going to reduce costs significantly (interstate sale, individual pool reform) and well-intentioned bad policy (tax treatment equalization, association health plans).

In fact, it’s embarrassing that people claim Sen. Rand Paul is libertarian leaning when this bill engages in such heavy manipulation of the tax code and obvious  pandering to the physician special interest. The biggest problem with the bill is that it focuses entirely on health insurance reform and does nothing with respect to  regulation on the provider side of the equation. Obamacare proved that you can’t reduce health care costs through financial engineering, but even Obamacare tried to address provider behavior with bundled payments and the accountable care organizations. Healthcare COSTS will not be reduced until providers have to quote prices, until incumbents are no longer protected by certificates of need, and until the physician trade union is no longer protected by scope of practice and licensing restrictions.

Failing to push any provider side change(except for empowering their cartel powers!), or provide any evidence based insurance reforms, the bill gets a C+. Why not an F? There’s a fringe case where it could work out. The tax treatment equalization section means that there will be no tax treatment difference between employer sponsored health insurance premiums being paid directly by the employer or by the employee. Therefore some employers may opt to increase employee wages and not pay directly for health insurance in order to appear more competitive in the job market. Healthy employees then could choose to opt out of health insurance and keep the money instead of buying through their employer. This would result in an employer sponsored insurance death spiral due to increasing average costs, which would ultimately increase the uninsured population and could force providers to compete on price. That’s a lot of ifs, however. A simple “providers must quote a real price on their website for every episode of care that they provide” bill is much more reliable.

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Rare diseases are the great case for UHC

The Economist’s article reporting on developments in gene therapy for rare diseases mentions something important:

The lessons from Glybera, the first gene therapy to be sold in Europe, still loom large. It cures a genetic condition that causes a dangerously high amount of fat to build up in the blood system. Priced at $1m, the product has only been bought once since 2012 and stands out as a commercial disaster.

Incredibly high need for the patient, but high development costs, essentially non-existent consumer base, no competition, no economies of scale, and no consumer bargaining power. Any one of those can destroy a market, but all at once? The only thing that would make it worse is if the patients can’t pay. Oh, right. They can’t. Because it costs $1m. If I’ve ever heard of a perfect government job, then this is it.

In the US, rare disease treatments will need to be covered by CMS and the associated costs spread across the entire tax base, because the free market will quite literally never be able to find a humane solution for this problem. Good luck using charity, vouchers or tax credits to cover a $1m treatment.

Health Fail – ACA Smoking Surcharges

Sometimes people’s behavior triggers, surprises and pleases me all at once. The ACA contains a provision enabling insurance providers to add a surcharge on the premiums of smokers, hoping to incentivize smokers to quit. Yale researchers report in Health Affairs how the smokers reacted to these incentives:

That’s right. Smokers dropped insurance coverage. I can’t even anymore.

The administration managed to put through a measure penalizing smoking without using the word that shall not be spoken in congress (tax) and got outsmarted (outdumbed?) by the smokers. I napped through most of my college macro economics course, but the one thing I took away from that class was that if you encounter a market failure that you want to correct, you tax it directly and never tangentially.

This is exactly why.

By the way, this is also why we desperately need to #MakeTaxesGreatAgain in U.S. politics. Treating the taxman as a pariah is tying down policymakers hands with foolish and disastrous consequences.

Lessons from Primary Care Reform in Iran

The organization and effectiveness of the rural primary health care reforms in Iran, focusing on the behvarz health workers and health homes, are reviewed and the potential for implementation in the Mississippi delta is analyzed. Review indicates that Iranian health houses are effective and clinically relevant to the health challenges faced by Mississippi, but currently not replicable due to political barriers. Recommendation is to develop health worker training curricula in preparation for a political event that removes these barriers. 

Background

In 1979 the Islamic Republic of Iran inherited from the Shah regime a dysfunctional rural health care system created by years of neglect. The rural maternal mortality ratio was 370 per 100,000 live births and the rural infant mortality rate was 120 per 1000 live birthsi. In addition, the rural physician to population ratio was only 1:18000.ii The new government, however, was determined to fulfill the promises of the revolution to its rural supporters, and as part of the Reconstruction Jihad decided on the creation of a network of health houses staffed by minimally trained local health workers. Physicians criticized this as a collapse in the quality of care,iii but the government arrested hundreds of them and moved forward with the plans.

Organization

OrganizationThirty years after the revolution, these plans have grown into a network of 17,000 rural health houses staffed by 30,000 salaried behvarz (community health workers) that provide primary care services to 23 million Iranians, or 95% of the rural population.iv Each health house is generally staffed by 1 male and 1 female behvarz, who are responsible on average for 1500 people in their village and surrounding communities.v The behvarz is required to have 11 years of education and be elected by their community before receiving 2 years of community health worker training at a district facility. The community selection is an intentional policy design meant to increase community engagement, ensure cultural competence and decrease personnel turnover. Behvarz duties include collecting census information, maintaining family health records, maternal and child care, family planning, immunization, home visits, simple curative care, administration of medicines, and sanitation.vivii As the first point of contact, they are also responsible for basic triage and referring cases to one of 2300 primary care clinics at the district level, who provide ambulatory care for approximately 10,000 people.viii These clinics provide referrals for secondary care at district hospitals or tertiary care at provincial hospitals.

Schedule

Access to primary care services in public facilities is free and is financed through federal budget transfers.ix In 1995 the Medical Services Insurance Organization funded by a general tax was created to provide insurance to civil servants, self-employed and special groups. In 2005 the Rural Health Insurance Program (RHIP) expanded this coverage to all rural citizens, which resulted in 95% rural insurance coverage.x Importantly, RHIP also formalized the family practice (FP) specialty in an attempt to improve quality of rural care. This has resulted in friction with the behvarz system, as the FPs don’t always provide superior care.xi

Achievements

Twenty years of primary care reform in Iran resulted in significant advancements, including reduction of the fertility rate from 6.5 to 1.92, reduction of the rural infant mortality rate from 71 per 1000 live births to 30.2 per 1000 live births, reduction of rural maternal mortality ratio from 370 per 100,000 live births to 35 per 100,000 live births, and achievement of over 96% immunization coverage for DPT, MMR and Polio vaccinesxii. Most importantly, there was significant convergence towards the urban infant mortality rate and maternal mortality ratio, which had improved to 27.7 per 1000 live births and 22.0 per 100,000 live births respectively. By 2015 the expansion of the family practice specialty under RHIP further reduced the overall infant mortality rate to 13 per 1000 live births and the maternal mortality ratio to 25 per 100,000 live birthsxiii xiv. Avoidable death rates for rural and urban areas have also converged (37.40% and 36% respectively).xv In some areas the reforms have even enabled rural communities to surpass urban ones. Rural hypertension and diabetes prevalence, 17.2% and 5.6% respectively, are lower than in urban communities, where they are 18.4% and 8.5% respectively.xvi

Comparison to Mississppi

Mississippi is selected for comparison with Iran because the state was rated as the worst health system in the U.S. eight years in a rowxvii and a pilot program at Jackson State University is experimenting with Iranian-style health homes.xviii In 2012 the maternal mortality rate in Mississippi was 39.7 per 100,000xix, and in 2014 the infant mortality rate was 8.2 per 1,000 live births, ranking last in the U.S.xx Full immunization at age 2 was only 80.5% in 2007. Also, 67.8% of Mississippi adults were obesexxi, 11.6% were diagnosed with diabetesxxii and 22.7% smoked in 2009.xxiii Prevention and treatment is complicated by the worst physician shortage in the U.S.xxiv (159 physicians per 100,000) and only 82% of the population having insurance coverage.xxv

Takeaways for U.S. Policy

Mississippi’s challenges are similar to those faced by Iran and make the behvarz model important for local policy due to Iran’s superior performance on many of these metrics when compared to Mississippi. The success of the behvarz reveals two lessons that are critical for future primary care reforms in the state. The first is that dedicating funding to primary care and public health results in significant health gains for the population. However, this is nothing new and has been argued for decades by public health officials. The success of the Family Health Program in Brazil is another current example of this. The most important lesson, and the point where the Iranian behvarz differentiate themselves from the Family Health Program, is that the program is primarily administrated by non-physicians. Iran reveals that it is possible to have effective basic primary care with limited physician involvement. This has important implications for the way we should approach health system capacity building in rural areas and developing countries, a key U.N. goal after the recent ebola outbreak. Delegating basic and routine primary care tasks to minimally trained behvarz allows for highly trained physicians’ time to be allocated to more serious cases. In addition to the efficiency gains, physicians are likely to have improved job satisfaction due to decreased stress on their time and more meaningful utilization of their unique skills.

However, the political environment in the U.S. is poorly aligned to implement this model. The behvarz reforms were a conscious top-down commitment by the Iranian government to a primary care based health care system. In the U.S., on the other hand, Congress only committed $1billion per year to the Prevention and Public Health Fund – far short of the $12 billion per year level recommended by the Institute of Medicinexxvi. In addition, only 30% of Iranian government revenue is from taxation and 70% is derived from the sale of natural resources.xxvii This makes Iran’s generous primary health care transfers difficult to replicate. Finally, Iran was able to bypass the protests of the medical community against the behvarz through authoritarian oppression. This is not an option in the U.S. and the physician community is likely to lobby against behvarz as they do against nurse practitioners.xxviii This may even be happening in Iran, where the 2015 reform expanded FP and specialist financing, but did little for the behvarz.xxix

Facing these realities, the recommendation for policymakers in the U.S. is to prepare for a future political crisis that could be used as an opportunity to implement health homes by developing health worker certification curricula that could be quickly adopted.

References

[i] Mehryar, Amir. “Primary Health Care and the Rural Poor in the Islamic Republic of Iran.” (2004): n. pag. Web. 16 Feb. 2016.

[ii] Marandi, S. (2009). The Integration of Medical Education and Healthcare Services in the I.R. of Iran and its Health Impacts. Iranian Journal of Public Health, 38, 4-12.

[iii] Elizabeth A. Willis MA DHMSA & Jahangir Taghipour MD MRCS LRCP DThMed (1992) Effects of prolonged war and repression on a country’s health status and medical services: Some evidence from Iran 1979–90, Medicine and War, 8:3, 185-199, DOI: 10.1080/07488009208409045

[iv] Statistical Center of Iran. Databases Government of the Islamic Republic of Iran, SCI. Available from http://www.sci.org.ir/portal/faces/public/sci_en/sci_en.search.

[v] World Bank. 2008. Main report. Washington, DC: World Bank. http://documents.worldbank.org/curated/en/2008/06/16262698/islamic-republic-iran-health-sector-review-vol-1-3-main-report

[vi] Mehryar, 2004.

[vii] Rahbar, M., & Ahmadi, M. (2015). Lessons Learnt From the Model of Instructional System for Training Community Health Workers in Rural Health Houses of Iran. Iranian Red Crescent Medical Journal, 17(2), e2145. http://doi.org/10.5812/ircmj.2145

[viii] World Bank, 2008. Main Report.

[ix] World Bank. 2008. Background Sections. Washington, DC: World Bank. http://bit.ly/28MMdcb

[x] Lankarani, K.B., Ghahramani, S., Zakeri, M., Joulaei, H. (2015)
Lessons learned from national health accounts in Iran: Highlighted evidence for policymakers
Shiraz E Medical Journal, 16 (4), art. no. e27868, 3 p.

[xi] Motlagh, M. E., Heidarzadeh, A., Hashemian, H., & Dosstdar, M. (2012). Patterns of Care Seeking During Episodes of Childhood Diarrhea and its Relation to Preventive Care Patterns: National Integrated Monitoring and Evaluation Survey (IMES) of Family Health. Islamic Republic of Iran.International Journal of Preventive Medicine3(1), 60–67.

[xii] Mehryar, 2004.

[xiii] Infant Mortality Rate. World Bank, n.d. Web. 18 Mar. 2016. <http://data.worldbank.org/indicator/SH.XPD.TOTL.ZS?order=wbapi_data_value_2013+wbapi_data_value+wbapi_data_value-last&sort=desc&gt;.

[xiv] Ministry of Health and Medical Education (MOHME). Annual report of rural insurance & family physician programs. MOHME, Tehran; 2007 ((in Persian).)

[xv] Omranikhoo H, Pourreza A, Eftekhar Ardebili H, Heydari H, Rahimi Forushani A. Avoidable mortality differences between rural and urban residents during 2004–2011: a case study in Iran. International Journal of Health Policy and Management 2013; 1: 287–293.

[xvi] Kelishadi R, Alikhani S, Delavari A, et al. Obesity and associated lifestyle behaviours in Iran: fi ndings from the fi rst national non-communicable disease risk factor surveillance survey. Public Health Nutr 2008; 11: 246–51.

[xvii] Joulaei H, Lankarani KB, Shahbazi M. Iranian and American Health Professionals working together to Address Health Disparities in Mississippi Delta based on Iran’s Health House Model. Arch Iran Med. 2012; 15(6): 378 – 380.

[xviii] Hansen, Suzy. “What Can Mississippi Learn From Iran?” The New York Times. The New York Times, 28 July 2012. Web. 03 Mar. 2016. <http://www.nytimes.com/2012/07/29/magazine/what-can-mississippis-health-care-system-learn-from-iran.html&gt;.

[xix] “Pregnancy Related Maternal Mortality.” (n.d.): n. pag. Web. 17 Apr. 2016. <http://msdh.ms.gov/msdhsite/_static/resources/5631.pdf&gt;

[xx] “Infant Mortality Report 2015.” Mississippi State Department of Health (2015): n. pag. Web. 17 Apr. 2016. <http://msdh.ms.gov/msdhsite/_static/resources/6435.pdf&gt;

[xxi] Kaiser Family Foundation, statehealthfacts.org. Data source: Centers for Disease Control and Prevention, Behavioral Risk Factor Surveillance System Survey Data, 2009, unpublished data, at http://www.statehealthfacts. org/profileind.jsp?ind=91&cat=2&rgn=26.

[xxii] Kaiser Family Foundation, 2009

[xxiii] Kaiser Family Foundation, 2009

[xiv] “MS Worst in the Nation for Doctor Shortage.” – WLOX.com. N.p., n.d. Web. 05 Apr. 2016. <http://www.wlox.com/story/19918160/ms-worst-in-the-nation-for-doctor-shortage&gt;.

[xv] The Kaiser Family Foundation, statehealthfacts.org. Data source: Urban Institute and Kaiser Commission on Medicaid and the Uninsured estimates based on the Census Bureau’s March 2009 and 2010 Current Population Survey (CPS: Annual Social and Economic Supplements) , at http://www.statehealthfacts.org/profileind. jsp?cat=3&sub=39&rgn=26.

[xvi] “Issue Brief: The Prevention and Public Health Fund.” APHA, June 2012. Web. 14 Apr. 2016. <https://www.apha.org/~/media/files/pdf/factsheets/apha_prevfundbrief_june2012.ashx&gt;.

[xvii] Hajizadeh M, Connelly LB. Equity of health care financing in Iran. http://mpra.ub.uni-muenchen.de/14672. Accessed August 21, 2015. Published 2009.

[xviii] “AMA RESPONDS TO IOM REPORT ON FUTURE OF NURSING.”FierceHealthcare. N.p., n.d. Web. 28 Apr. 2016. <http://www.fiercehealthcare.com/press-releases/ama-responds-iom-report-future-nursing-0&gt;.

[xix] Moradi-Lakeh M, Vosoogh-Moghaddam A. Health sector evolution plan in Iran; equity and sustainability concerns.” Int J Health Policy Manag. 2015;4(10):637–640. doi:10.15171/ijhpm.2015.160