Requires difficult enforcement

The approach depends on checking compliance and responding when rules are ignored or evaded. Its burden is greater when oversight is weak or affected organizations can readily change their behavior to avoid the rules.

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Regulated multi-payer: everyone must have a non-profit or tightly regulated planTens of millions of people have no coverageRejected

Mandatory enrollment or automatic enrollment requires enforcement.

Stronger network adequacy rules and audited directoriesNarrow networks and out-of-network surprisesRejected

Enforcing network standards is difficult because regulators rely on insurer-reported data.

Regulate denials: reporting, penalties, and fast independent appealsClaim denialsChosen

Insurers can respond to denial penalties by slowing approvals, making enforcement difficult.

Tighter medical-loss ratios and non-profit requirementInsurer overhead and profitRejected

Vertical integration can hide profits despite premium-spending rules.

Regulate PBMs: delink pay from drug prices, ban spread pricingPharmacy benefit managers profit from opaque drug pricingChosen

PBMs may adapt to flat-fee and rebate rules by introducing new fees.

Limit private equity ownership and require disclosurePrivate equity roll-ups in medicineChosen

Owners may restructure to evade the rules.

Pre-payment analytics and auditsFraud and improper paymentsChosen

Fraudsters adapt to claims analytics, complicating detection, audits, and prosecution.

Allow supplemental only (non-covered items)Two-tier care: a private fast lane for those who can payChosen

Restricting private insurance to extras is difficult when the boundary between extras and core care blurs.

Spending-growth target tied to GDP, reviewed publiclyChronic underfunding by government budgetsChosen

Budget growth targets are often missed, and the independent board’s recommendations can be ignored.

Phase in employer taxes for small and low-wage firmsEmployer health taxes can lower wages at firms that never offered coverageChosen

Firms may split to remain eligible for the lower small-firm tax rates.

No employer tax: fund from households directlyEmployer health taxes can lower wages at firms that never offered coverageRejected

Requiring employers to pass former premium spending into wages is hard to enforce; the cited precedent describes such mandates as untested.

Require timely U.S. launch as a condition of market accessPrice limits can cause shortages, launch delays, or exitsRejected

Enforcing the link between favorable pricing and prompt launches is difficult.

Hardship waivers for shortage areasStaffing mandates raise costs and may close facilitiesChosen

Temporary staffing waivers can become permanent rather than ending as intended.