THE TRANSITION TO A NEW, HSA-BASED HEALTHCARE SYSTEM
by
Julio Gonzalez, M.D., J.D.
 
In my last incarnation, I told you how the United States only haphazardly came to adopt an insurance-based system of healthcare funding.  Although doing so allowed employers to better attract new employees in the highly competitive, government-restricted, World War II labor market, the move was not based on healthcare policy or on a push to develop an optimal system for healthcare delivery in the United States. Now, the American people are stuck with the burdens of such a dysfunctional system and dealing with the ramifications of an historical accident gone wild.  In the face of the system's weaknesses, the Progressives are aiming to make the situation even worse by pushing for the further centralization of healthcare as the solution to our nation's challenges, and the Right is refusing to tout an alternative solution that makes sense.  The Center for Healthcare Policy Solutions aims to change that. 
 
There are indeed a number of interventions that need be undertaken to improve our healthcare delivery system, but it all begins with the abandonment of the dysfunctional, insurance-based system for one where healthcare funding is primarily based on health savings accounts (HSAs).  

An HSA is a tax-deductible savings account managed by the patient and implemented to pay for the costs of healthcare.  With an HSA, the patient is in complete control of his or her care, from the treatment he or she accepts to the amount paid for it.  No other system of healthcare payment offers a greater degree of autonomy and independence to the patient than the HSA.
 
Why aren't HSAs more frequently employed in paying for healthcare?  The answer to that question, once again, is government interference.  Presently, the tax code recognizes HSA eligibility only for those who are not enrolled in Medicare and possess a high deductible health plan (HDHP).[i]  An HDHP is a healthcare insurance policy covering preventive services before the deductible and carrying a minimum deductible of $1,400 for an individual or $2,800 for a family.[ii]  Under such circumstances, the taxpayer is allowed to contribute up to $3,550 to his individual HSA, or up to $7,100 for family coverage.[iii]  When not used, the funds are allowed to roll over and earn interest, which is also not taxable.
 
The present model for HSA regulation is nowhere near ideal. Linking HSAs to specific insurance products only allows for the insurance company to benefit by favoring the sale of HDHPs and allowing them to become involved in a patient's decision-making process.  Additionally, because HDHPs cover preventive medicine services before applying a deductible, the power of HSAs to curtail expenses is repressed.  The advocate for this restrictive arrangement argues that HSAs discourage the taxpayer/beneficiary from spending money and therefore from seeking preventive medicine services, but it is not the government's role to either encourage or coerce the people into seeking preventive healthcare services.  Additionally, the requirement of purchasing an HDHP before being eligible to fund an HSA robs valuable capital from the individual making decisions about her budget.
 
Another nonsensical and unproductive provision in the present HSA legislation is the exclusion of Medicare recipients from participating in HSAs. This restriction is particularly nonsensical as it targets the nation's principal healthcare consumers. Medicare enrollees have the greatest power to bend the spending curve and have the greatest resources available to spend on healthcare.  They should be employed in the national effort to curb prices and make providers accountable to their patients.
 
And why would a person who is 65 years of age or older contribute to an HSA? Divisibility!  The ability of the HSA's owner to will his funds to subsequent generations is the key factor in the long-term development of intergenerational financial independence in healthcare.  
 
Indeed, the beneficial effects of HSAs to healthcare cost containment and efficiency is so great that shifting America's dependence away from health insurance and to HSAs should be a national priority.  In fact, one estimate holds that shifting half of America's employer insurance policies to HSAs would result in cost savings of $57 billion per year![iv]  And another concluded that a complete transition to HSA based healthcare funding could save up to $400 billion per year.[v]   After all we have seen and experienced with third-party directed healthcare, isn't it time we demanded this change from our policymakers?
 
Think about it.  When you're young and pay your approximately $800.00 premium to an insurance company for coverage while not claiming benefits, the money disappears.  It is exactly as if you had thrown your money into the ocean without ever seeing it again.  Of course, when you're young and healthy, you will rarely need to use health insurance, so practically every check you cut to your insurer is wasted.  But when you apply those same moneys to your HSA, it stays with you forever, waiting for you to use it.  What's more, when you do deploy your funds, you will be the sole determiner of how it will be used.  No insurance. No government.  No pre-existing conditions.  Just your doctor and you having a conversation about the care you need.  That's the situation the Center for Healthcare Policy Solutions is striving to implement for every American.  This is not to say that you could not continue with health insurance as your principal choice of healthcare funding.  You could still do that, but let the HSA option compete with the insurance option on even footing.  If this were to take place, particularly amongst the young, the increasing use of HSAs would eventually transform the system from an insurance-based one to another where the patient is in charge.  
 
The challenge in making this immensely logical and common sense change lies only in the fight.  There is a lot of money invested in propagating the inefficiency and dysfunctionality of an insurance-based system, and this is what the Center for Healthcare Policy Solutions aims to combat.  And of course, it needs funding to combat such an outdated but deeply entrenched system.  
 
Could you please help by contributing $20, $50, $100, or more to help us fight this battle?  Any amount is greatly appreciated.  And all assistance is welcomed. 
 
Please visit healthcarepolicysolutions.com to learn more and contribute. 
 
Dr. Julio Gonzalez is an orthopaedic surgeon and lawyer living in Venice, Florida.  He served in the Florida House of Representatives.  He is the author of numerous books including The Federalist Pages, The Case for Free Market Healthcare, and Coronalessons.  He is available for appearances and book signings, and can be reached through www.thefederalistpages.com.
 
[i]Rhine, Russell, "Potential for Health Care Savings:  Can Health Savings Accounts (HSAs) bend the Cost Curve?" United States Senate Joint Economic Committee, Dec. 13, 2018, https://www.jec.senate.gov/public/_cache/files/baceddcc-39ef-4dae-a216-3da872a738ae/hsa-3.0.pdf.  

[ii]"Health Savings Account (HSA)," HealthCare.gov, accessed Oct. 11, 2019, https://www.healthcare.gov/glossary/health-savings-account-hsa/.  

[iii]"Health Savings Account (HSA)," HealthCare.gov,  accessed Oct. 11, 2019, https://www.healthcare.gov/glossary/health-savings-account-hsa/.  

[iv]Amelia M. Haviland, Susan Marquis, et al. "Growth of consumer-directed health plans to one-half of all employer-sponsored insurance could save $57 billion annually." Health Affairs (blog) May 2012, accessed Jan 25, 2020, https://www.healthaffairs.org/doi/full/10.1377/hlthaff.2011.0369.

[v]  Theodore McDowell, "Mandatory Health Savings Accounts and the Need for Consumer-Driven Healthcare, "The Georgetown Journ. of Law & Pub. Pol.," 2018Vol. 16, No pp. 315-337, accessed on Jan. 25, 2020, https://www.law.georgetown.edu/public-policy-journal/wp-content/uploads/sites/23/2018/05/16-1-Mandatory-Health-Savings-Accounts-and-the-Need-for-Consumer-Driven-Health-Care.pdf.

THE HAPHAZARD WAY AMERICA ADOPTED AN INSURANCE-BASED HEALTHCARE SYSTEM MAY SURPRISE YOU.
by
Julio Gonzalez, M.D., J.D.
 
Presently, the United States has an insurance-based healthcare system.  The coverage is certainly not uniform throughout the population, but nevertheless, whether it's a government-supplied insurance or private, funding for America's healthcare system funnels to insurance.  But is an insurance-based system really the best solution for our nation's healthcare challenges?  Did we really implement insurance coverage for Americans?  To get the answer to that question we would have to look at how we developed a healthcare-based insurance system in the first place.  
 
During World War II, with its colossal dependence on young men to prosecute the war against the Axis Powers, American workers were in high demand.  Salaries were increasing, and with them, the threat of runaway inflation. To keep these trends in check, Congress passed the Stabilization Act of 1942 giving the President the authority to freeze wages and salaries.[i]  Within a day of its passage, President Roosevelt froze workers' salaries.  
 
As with any external manipulation of market forces, employers found themselves having to devise new and innovative ways to attract employees since they could no longer do so through salaries alone.  Many turned to health insurance benefits.  Of course, paying for one's health insurance did not equate to a pay raise, but it did provide a benefit for which the employee no longer had to pay. Predictably, the number of insured Americans rose from a mere 9.8% in 1940 to nearly 30% six years later,[ii]and by the 1960s, 80% of Americans had some form of health insurance.[iii]
 
The transition being made, Americans were essentially made dependent on insurance for the funding of their healthcare.  But there were problems with the system.  First, not only did Americans become dependent on insurers for funding, they had unknowingly become dependent on the insurers' policies regarding the rendering of certain treatments.  If the insurer did not agree with a certain treatment, the beneficiary was not going to receive it.  Slowly but surely, in transitioning to an insurance-based healthcare system, Americans had given away a portion of their healthcare autonomy. 

In the United States, about 12% of women develop invasive breast cancer.  In 2019 alone, there were approximately 268,600 new invasive cases, 62,930 new non-invasive cases, and 41,760 deaths.[i]  Because breast cancer is so inconsistently cured, the principal effort at preventing breast-cancer-related deaths is early detection.  

Initial efforts at early detection were centered on self-examination. Women were instructed to perform breast self- examinations once a month (using the arrival of the electric bill as a reminder, for example) with the aim of detecting new or unusual lumps in their breasts.  Unfortunately, not only did such efforts suffer from inconsistency in compliance, but also the wide variety of breast densities and even density variations within a woman's gestational cycle made the exercise quite ineffective. Predictably, women were presenting to their doctors with reports of what turned out to be benign lesions while others were missing the diagnosis of malignancy entirely.  

Technological advances allowed for the use of mammography to become the principal method for the early detection of suspicious breast lesions. These low-intensity x-rays allowed pictures to be taken through a woman's breasts facilitating the identification of suspicious lesions.  The lesions could then be biopsied for definitive diagnoses as benign or malignant growths. 

Although much more effective at identifying early cancerous lesions than the breast self-examination, mammography still suffered from inaccuracies and complications.  First, the interpretations of the pictures were often subjective and dependent on a trained human eye to determine whether a lesion was worthy of being biopsied or not.  This uncertainty was exacerbated by the denseness of the underlying breast tissue, and since younger women have denser breasts, they were particularly prone to experiencing erroneous mammograms with falsely positive results. 

The radiation associated with mammograms was also a concern. This, combined with the lower incidence of breast cancer in younger women, made recommending mammography in young women unfavorable.  The competing priorities between the desire to save women's lives through the early detection and avoidance of unnecessary procedures and their complications led to a balancing act in determining the best approach for mammography.  If the recommendation was too aggressive, women were going to be unnecessarily exposed to pain, suffering, expense, worry, and confusion.  Too lax, and women would die.  

Various medical groups studied the issue and published their opinions regarding the best ways of detecting the appearance of breast cancer. Initial recommendations were that women undergo baseline mammography at some point between the ages of 35 and 40 years of age followed by yearly mammograms beginning at age 40.  Some recommended biennial mammograms in women between 40 and 50 years of age followed by yearly mammograms for those 51 and older.  And presently, the National Comprehensive Cancer Network, the American Congress of Obstetricians and Gynecologist, and the American College of Radiology each recommend yearly mammographic screening for breast cancer starting at 40 years of age.[ii]  
Enter the federal government and the United States Preventive Services Task Force (USPSTF).  The USPSTF is a "volunteer panel of national experts in prevention and evidence-based medicine"[iii]created in 1984 by the United States Public Health Service.[iv]  Originally, its purpose was to provide " evidence-based recommendations about clinical preventive services and health promotion."[v]  Generally, the USPSTF provides approval or disapproval of certain preventive services and procedures by assigning each a grade.  An "A" or "B" grade meant that the practice had sufficient scientific support in the panel's opinion to recommend that the service be offered to the public.[vi]  Grade "C," "D," or "I" recommendations carried varied implications, but shared a commonality in the lack of enthusiasm for it by the USPSTF.[vii]
In 2002, in keeping with the prevailing positions of the nation's leading physician organizations, the USPSTF awarded a B grade to the recommendation that women 40 years old and older should undergo mammography every one to two years.[viii]  

That changed in 2009.  

Although biennial mammography was awarded a B grade in women 50 to 74 years of age, a C grade was given to the practice of routinely performing screening mammograms in women aged 40-49 years.[ix]  In contraposition to the opinions of most national physician and patient organizations, the USPSTF did not support mammography in 40 to 50-year-old women and abandoned the practice of screening women older than 74 years of age.  In defending its position to abandon screening of women in their fifth decade of life, the USPSTF simply and offensively averred, "While screening mammography in women aged 40 to 49 years may reduce the risk of breast cancer death, the number of deaths averted is smaller than that in older women and the number of false-positive results and unnecessary biopsies is larger."[x]  But in 2017 alone, 49,360 thousand women between the ages of 40-and 49 years were diagnosed with breast cancer (36,920 of those invasive) and 3,480 women in that age group died from it.[xi]  These are women at the height of their productivity who were raising families and making invaluable contributions to society.  

The USPSTF's change in recommendations regarding women aged 75 and older is just as perplexing since the risk of developing breast cancer is known to increase exponentially with age.  The chances of developing breast cancer in women between 7- and 80 years of age are one in 26.[xii]  Moreover, in 2017, there were 92,070 new cases of breast cancer (77,940 of them invasive) and 19,130 deaths in women who were 75 years of age or older. 

 
If it weren't for the ACA, however, this would only be a story about internal disagreements among physician groups.  But in a move screaming of unconstitutionality, Congress included a provision within the ACA requiring insurers to cover any preventive services awarded a grade of A or B by the USPSTF without copays or deductibles.[xx]  It also gave the SecHHS, the authority to allow Medicare to cover preventive measures only if they carried an A or B rating from the USPSTF.[xxi] In light of the USTPSF's decisions, many insurers opted to no longer cover mammography in 40 to 50 year-olds, and Medicare discontinued its coverage for mammograms in women 75 years of age and older.

Why did Congress pick the USPSTF's position as the "official" harbinger of recommendations regarding preventive health over the other professional groups?  Because the USPSTF is part of the machinery of government.  It is an official government agency, and therefore the legislature could reasonably conclude that it ought to serve as the official voice of the federal government on issues of disease prevention. 

Suddenly, the panel of "volunteers" serving on the USPSTF went from being a relatively obscure group delivering just another set of opinions on how the nation should approach its preventive medicine efforts to being the object of intense lobbying efforts by a variety of interests with millions of dollars at stake.[xxii],[xxiii]

And just who are these volunteers?  They are a group of sixteen "members who are nationally recognized experts in prevention, evidence-based medicine, and primary care. . . with expertise in behavioral health, family medicine, geriatrics, internal medicine, pediatrics, obstetrics and gynecology, and nursing."[xxiv]  For the record, thirteen of the sixteen members are physicians.[xxv]  These members are assigned by the Director of the Agency for Healthcare Research and Quality,[xxvi]who, in turn, is appointed by the SecHHS.[xxvii]  So, although the USPSTF likes to think of itself as a scientific, apolitical group, the fact that it is composed of members whose assignments can be traced back to a hierarchy ending at the President of the United States negates that view.  
Predictably, the USPSTF's decision to not affirmatively recommend screening mammograms for women in their fifth decades of life and for those older than 74 was fraught with controversy, particularly in light of the newly created funding and access implications the decision carried.  The fallout from the recommendations was so bad that Congress overruled it, first temporarily and then, in 2015, permanently.[xxviii]     And although Congress can nullify the effects of the USPSTF decision as it relates to Medicare, its authority does not extend to private insurers such that nonfederal programs are still free to honor USPSTF's 2009 recommendations. Incidentally, in its obstinacy, the USPSTF reaffirmed its 2009 recommendations in 2016. 

The story of the USPSTF and mammography brings up a number of issues regarding the interplay between government and medicine.  First is the overarching question we have previously visited regarding the pinnacle of a democratic state's authority.  Is it we the people who stand at that pinnacle with government at our service, or is it government that crowns it?  If government is allowed to take its place at the apex, then it is totally appropriate for it to determine what interventions are appropriate for the sake of prolonging our lives and which are not.  Can one have a mammogram, and if so at what age?  When is someone no longer allowed to have a mammogram?  Should they even be tested?  These questions may validly fall upon government only if it were the ultimate purveyor of power, and we, its servants. 
If, however, each human being has an inestimable value and government exists to facilitate the peaceful coexistence of men, then the concept of government deciding whose life to prolong and whose not is nonsensical and unacceptable.  

We may question how it is that things progressed to such an extent that Congress felt compelled to intercede.  But it was Congress that created this mess in the first place.  Until the Obama administration, with the Democrats' zeal to centralize healthcare, the USPSTF was a mere think tank, albeit one under the umbrella of the fourth branch of government, but still, a mere think tank.  Whether the federal government should even be running such a think tank is subject to debate, but regardless, before 2010 and certainly in 2009 when the USPSTF's position on mammography became more restrictive, its opinion on mammography was simply that, an opinion.  It was not until Congress decided to dictate healthcare prevention policy through one of its agencies that things went awry.

Also, consider how deeply enmeshed within the recesses of bureaucratic layers the USPSTF is.  This is an agency whose members are appointed by a Director, who is himself appointed by a Secretary who is appointed by the President of the United States.  At least three levels of unaccountability exist between the American people and the persons making decisions on preventive medicine resources, with each level cloaked in increasing anonymity.  

Who are the actual members of the USPSTF?  From what parts of the country do they proceed?  What are their political views and inclinations?  What are their philosophies on government and its role in healthcare?  The public does not know the answers to these questions, yet those individuals are the ones making life and death decisions for our nation.  

Their apologists claim this is not a political body, as it is made up of scientists.  But here, the observations made by Thomas Jefferson regarding judges are equally as applicable to the members of the USPSTF: "[They] are as honest as other men, and not more so.  They have, with others, the same passions for party, for power, and the privilege of their corps. . . and their power the more dangerous as they are. . . not responsible, as the other functionaries are, to the elective control."[xxix]

Finally, there is the inherent contradiction of having Congress intervene in a decision made by one of its agencies.  By its very assignment of a matter to an agency, Congress has acknowledged that it does not possess the expertise or the political will to handle the matter directly.  If it did, Congress itself would have passed the necessary law.  

So what does it say about Congress that after it handed the ball on a matter to an unelected band of experts it should have to overrule it? Do we believe it appropriate for Congress to be deciding whether any one of us ought to be ineligible for mammography as an insurance benefit?  Yet this situation, and hundreds of thousands like it, would flourish if we adopt a government-run system of healthcare.  

The issue with all of this is that it is apt to happen again.  The same people that ran these agencies are the ones who are preparing to take control again.  We must fight back against their misguided views of public policy and of their role in administering their healthcare system.

Please help us by contributing $20, $50, $100, or more to the Center for Healthcare Policy Solutions to fight this battle.  

Any amount is greatly appreciated.  And all assistance is welcomed.  We cannot allow these missteps to take place again.  
 


[i]"U.S. Breast Cancer Statistics," Breastcancer.org, accessed Sept. 18, 2019, https://journalofethics.ama-assn.org/article/medical-ethics-and-media-value-story/2014-05.  

[ii]Gradishar, William J., "USPSTF Breast Cancer Screening Recommendations Remain Unchanged Despite Controversy," Healio(blog), Jan. 11, 2016, accessed Sept. 21, 2019, https://www.healio.com/hematology-oncology/breast-cancer/news/online/%7B4e79de36-911d-41ef-bed3-3ad171be2f26%7D/uspstf-breast-cancer-screening-recommendations-remain-unchanged-despite-controversy.

[iii]"About the USPSTF," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Name/about-the-uspstf.

[iv]"Section 1.  Overview of the U.S. Preventive Services Task Force Structure and Processes," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Name/section-1-overview-of-us-preventive-services-task-force-structure-and-processes.

[v]"Section 1.  Overview of the U.S. Preventive Services Task Force Structure and Processes," U.S. Preventive Services Task Force, accessed Sept. 21, 2019,https://www.uspreventiveservicestaskforce.org/Page/Name/section-1-overview-of-us-preventive-services-task-force-structure-and-processes.

[vi]  "Grade Definitions," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions.

[vii]"Grade Definitions," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Name/grade-definitions.

[viii]"Archived: Breast Cancer: Screening, 2002," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening-2002.

[ix]"Archived: Breast Cancer: Screening Original Release Date: November 2009," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Document/UpdateSummaryFinal/breast-cancer-screening.  

[x]"Final Recommendation Statement Breast Cancer: Screening," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Document/RecommendationStatementFinal/breast-cancer-screening1#table-of-contents.    

[xi]"Breast Cancer Facts and Figures 2017-2018," American Cancer Society, Table 1, accessed Sept. 21, 2019, https://www.cancer.org/content/dam/cancer-org/research/cancer-facts-and-statistics/breast-cancer-facts-and-figures/breast-cancer-facts-and-figures-2017-2018.pdf.

[xii]"Risk of Developing Breast Cancer," Breastcancer.org, accessed Jan. 18, 2020, https://www.breastcancer.org/symptoms/understand_bc/risk/understanding

[xiii]A.L Siu, Screening for Breast Cancer; U.S. Preventive Services Task Force Recommendation Statement," Annals of Internal Medicine, 2016; (164):279-296.

[xiv]K. C. Oeffinger, E. T. Fontham, et al., "Breast Cancer Screening for Women at Average Risk: 2015 Guideline Update from the American Cancer Society," JAMA,2015;314(15):1599-1614.

[xv]American College of Obstetricians-Gynecology, "Practice Bulletin No. 122: Breast Cancer Screening, Obstetrics and Gynecology 2011;118(2 Pt 1):372-382

[xvi]B. Lauby-Secretan, D. loomis, and K. Straif, "Breast Cancer Screening-Viewpoint of the IARC Working Group," New England Journal of Medicine, 2015;373(15):1478-1479.

[xvii]C. H. Lee, D. D. Dershaw, et al., "Breast Cancer Screening with Imaging: Recommendations from the Society of Breast Imaging and the ACR on the USe of Mammography, Breast MRI, Breast Ultrasound, and Other Techniques for the Detection of Clinically Occult Breast Cancer," Journal of the American College of Radiology, 2010;7(1):18-27.

[xviii]T. J. Wilt, R. P. Harris, et al., "Screening for Cancer: Advice for High-Value Care from the American College of Physicians," Annals of Internal Medicine, 2015;162(10):718-725.

[xix]American Academy of Family Physician, "Summary of Recommendations for Clinical Preventive Services. July 2017," accessed on Feb. 1, 2020, https://www.aafp.org/dam/AAFP/documents/patient_care/clinical_recommendations/cps-recommendations.pdf.

[xx]Roubein, Rachel, "Preventive Task Force Facing Influx of Lobbying," The Hill(blog), Oct. 13, 2016, accessed Sept. 21, 2019, https://thehill.com/policy/healthcare/300922-preventive-task-force-facing-influx-of-lobbying.  

[xxi]Wehrwein, Peter, "Has the ACA Put the USPSTF in Over Its Head?" Managed Care (blog), Nov. 3, 2016, accessed Sept. 21, 2019, https://www.managedcaremag.com/editorsdesk/has-aca-put-uspstf-over-its-head.  

[xxii]Rachel Roubein, "Preventive Task Force Facing Influx of Lobbying," The Hill(blog), Oct. 13, 2016, accessed Sept. 21, 2019, https://thehill.com/policy/healthcare/300922-preventive-task-force-facing-influx-of-lobbying.

[xxiii]Villani J, Ngo-Metzger Q, Vincent IS, Klabunde CN. Sources of Funding for Research in Evidence Reviews That Inform Recommendations of the US Preventive Services Task Force. JAMA. 2018;319(20):2132–2133. doi:10.1001/jama.2018.5404.

[xxiv]"Our Members," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Name/our-members.  

[xxv]"Our Members," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Name/our-members.  

[xxvi]"Our Members," U.S. Preventive Services Task Force, accessed Sept. 21, 2019, https://www.uspreventiveservicestaskforce.org/Page/Name/our-members;

[xxvii]Bindman, Andrew B., "JAMA Forum: The Politics of AHRQ," news@JAMA (blog), Aug. 3, 2017, accessed Sept. 21, 2019, https://newsatjama.jama.com/2017/08/03/jama-forum-the-politics-of-ahrq/.  

[xxviii]Pub. L. No. 114-113 § 228 (2015).  

[xxix]Thomas Jefferson to William Charles Jarvis, Sept. 28, 1820.