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They say a picture is worth a thousand words. Well, data visualization is worth at least that much. Paragon Pic makes health policy easier to see and understand by demonstrating with images what researchers would normally try to explain with a lecture or text. Check for a new figure every week.

They say a picture is worth a thousand words. Well, data visualization is worth at least that much. Check for a new figure every week.

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April 15, 2026

Improper Exchange Enrollment Remains High in 2026

This Paragon PIC demonstrates continued problems with the integrity of the Obamacare exchanges, namely an increase in the percentage of enrollees claiming income between 100 and 150 percent federal poverty level (FPL). In 2026, a staggering 56 percent of all sign-ups in states using the federal exchange—and 46 percent of all sign-ups nationally—claimed income in this narrow range. This is the income range in which enrollees qualify for the largest subsidies.

We estimated that 6.4 million more enrollees claimed income in this range than had such income in 2025. Improper enrollment soared with COVID-era subsidy boosts that made 94 percent actuarial value plans fully subsidized for individuals claiming income in this category. Insurers received massive subsidy payments on behalf of people improperly enrolled, many of whom were phantom enrollees—individuals without knowledge of their enrollment or fictitious creations of unscrupulous brokers. Weak program integrity measures—as evidenced by the Government Accountability Office enrolling 96 percent of fictitious applicants into fully subsidized coverage—compounded the problem.

Improper enrollment existed before the COVID-era subsidy boosts due to incentives to misreport income, which benefited insurers, brokers, and enrollees aware of their enrollment. The misreporting of income to claim more subsidies grew substantially with the COVID-era subsidy boosts, as demonstrated by the increase in the percentage of federal exchange enrollees claiming income between 100 and 150 percent FPL during open enrollment. (The data is presented for federal exchange states because the FPL grouping data was not available for state-based exchange states last decade.)

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April 15, 2026

Federal Health Program Spending Consumes 62 Percent of Relevant Federal Taxes

As this Paragon PIC shows, federal spending on health care programs consumed roughly 62 percent of all individual federal income, corporate federal income, and Medicare payroll tax revenue in 2025 — up from 29 percent 25 years ago (in 2000) and 17 percent 50 years ago (in 1975). According to the Centers for Medicare and Medicaid Services, total national health expenditures reached $5.3 trillion in 2024, or 18 percent of GDP, with federal health care spending at $1.7 trillion. Federal policies affect most of the remainder, too.

In this PIC, Medicare spending is shown net of premiums, since those premiums are paid by enrollees, not taxpayers. Medicare Part A (Hospital Insurance) payroll tax revenue is included in the revenue line because it is dedicated by law to finance Part A and represents taxes on current workers. Part A payroll taxes cover only a fraction of total Medicare costs as Parts B and D are funded primarily through general revenue. While Medicare costs continue to escalate, so do costs in other programs, particularly Medicaid and the Affordable Care Act subsidies to insurers.

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April 8, 2026

New ACA Data—Improper Enrollment Barely Changed while Out-of-Pocket Premiums Remain Very Low

While the share of enrollees in zero-premium plans has declined—from 41 percent of sign-ups to 29 percent—it remains a central feature of the program. Subsidies continue to be extremely generous. The median enrollee pays approximately $42 per month after advanced subsidies to their insurer, with the federal government covering 94 percent of total premium costs.

Enrollment has shifted significantly away from silver plans (down from 56 percent to 43 percent) toward bronze and gold plans, reflecting intensified silver loading and likely continued enrollment fraud as brokers switch people out of zero-premium silver plans and into zero-premium bronze and gold plans with the expiration of the COVID-era subsidy boosts. At the same time, 87 percent of enrollees continue to receive subsidies, and average subsidized premiums increased only modestly—about $22 per month—despite large increases in underlying premiums.

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March 31, 2026

How States Use IGTs to Shift Medicaid Costs to Federal Taxpayers

This Paragon PIC illustrates how states and government-owned or affiliated providers use intergovernmental transfers (IGTs) to fund Medicaid payments without any actual state expenditure.

Medicaid is supposed to be jointly funded by the federal government and the states. The federal government reimburses each state for a share of its Medicaid expenditures based on the federal medical assistance percentage (FMAP), which ranges from 50 to about 77 percent for traditional Medicaid populations and is 90 percent for the ACA expansion population. States are responsible for the remainder (the “non-federal share”). Federal law permits states to fund a portion of that non-federal share through IGTs in which local governments or government-owned providers send funds to the state.

As the figure shows, the IGT mechanism works in three steps:

First, a government-owned or affiliated provider transfers funds to the state. In this example, the provider sends the state $30 million.
Second, the state uses those transferred funds as its nonfederal share and makes a Medicaid payment to the provider — in this case, $100 million.
Third, because the state has made a $100 million Medicaid expenditure, it draws federal matching funds. At a 70 percent FMAP, the federal government reimburses the state $70 million.

The result: the state pays the provider $100 million without spending any of its own general fund dollars. The provider receives a net gain of $70 million (accounting for the IGT), and the entire cost is borne by federal taxpayers.

These schemes distort Medicaid’s financing structure, shift costs from states to the federal government. They are also fundamentally unfair because they give public providers a significant advantage over private providers. If private providers tried to similarly transfer large sums of money, such transfers would be scrutinized as provider-related donations, and likely shut down. As a result, IGT schemes lead to much larger payments for government providers over private providers — for delivering the exact same service.

As Paragon has documented, the federal share of total Medicaid spending has risen from about 60 percent to roughly three-quarters of the total bill, driven in large part by financing gimmicks like provider taxes and IGTs. With Congress having enacted important limits to the provider tax schemes in the One Big Beautiful Bill, states may increasingly turn to IGT schemes to draw down even more federal funds.

Federal policymakers should close this loophole. As Paragon has recommended, Congress and the Centers for Medicare and Medicaid Services (CMS) should prohibit states from paying government providers more than private providers for the same services, impose upper payment limit caps to all provider types, and rigorously scrutinize state IGT proposals.

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March 31, 2026

The Medi-Cal Gold Rush: California’s Projected Medicaid Spending Growth is Twice the National Average

California was once a destination for those seeking fortunes in gold and Hollywood fame. Some are still striking it rich—this time, through medical welfare programs. Spending on Medi-Cal, California’s Medicaid program, has exploded. In nominal terms, it is projected to grow nearly four-fold since the Affordable Care Act’s Medicaid expansion took effect—twice the national average among all other states. This new spending diverges from the original purpose of Medicaid to serve the poor, the disabled, and pregnant mothers, with much of the spending increase going to the wealthy; undocumented immigrants; and able-bodied, working-age adults instead.

This rapid increase in spending was initially driven by California enrolling far more people in the Medicaid expansion than expected. By October 2016, more than 3.7 million expansion enrollees had been added. As of federal fiscal year 2023, 5.7 million able-bodied, working-age adults are enrolled in the program—representing 36 percent of total enrollees. These figures far outpace original projections of only 910,000 Californians originally projected to enroll in expansion.

Beyond Medicaid expansion-driven costs, California recently implemented new programs covering undocumented immigrants with Medicaid and eliminating the program’s asset test for long-term care. These initiatives were supported through a legalized money-laundering scheme involving taxes on managed care organizations (MCOs) to draw down $9.5 billion in federal funds without any state contributions. Such schemes fueled spending growth, as both the elimination of the asset test and coverage for undocumented immigrants are projected to cost twice initial estimates. With the passage of the One Big Beautiful Bill last year, the MCO tax scheme was prohibited.

Managed care organizations are among those benefitting from the excess. One analysis notes that California’s MCOs collected $5.4 billion between 2014 and 2016. These corporations benefit even more by participating in the MCO tax scheme above as they get a cut of the looted federal dollars.

California continues to pursue other strategies that shift more costs onto federal taxpayers. The state is leveraging intergovernmental transfers (IGTs) with state-owned ambulance systems to increase Medicaid spending and pull in additional federal matching funds. This scheme, if approved, would set the rates for government ambulance providers five times higher than the rates for private providers for the exact same services. The result will be inflated costs for patients and for federal taxpayers.

This combination of elevated spending and a reduced state share of the cost creates a huge and ongoing incentive for waste, fraud, and abuse. A 2018 audit by the Health and Human Services Office of Inspector General found that half of the 125 non-expansion enrollees they sampled had improper eligibility determinations. They estimate that California made $959 million in payments on behalf of 803,000 ineligible enrollees between 2014 and 2015.

Medi-Cal’s focus on collecting federal funds over cost containment, and enrollment over program integrity drove its significant growth over the last 13 years. Ultimately, taxpayers and the truly vulnerable are the ones who bear the cost.

March 25, 2026

A Growing Majority of States Are Restricting Cell Phones in Schools

Kansas recently became the latest state to enact a cell phone ban for the entire school day. It joins a growing majority of states restricting student phone use in schools to combat the negative effects of screen time on academic performance, classroom focus, and well-being. As more states pursue these policies, they appear to be learning from one another: newer legislation increasingly favors stricter, bell-to-bell bans.

As of March 24, 2026, 35 states and Washington, D.C., have adopted some form of phone restriction for at least K–8th graders, with most state actions occurring in 2025 and early 2026.

Twenty states and D.C. require bell-to-bell bans for all grades (prohibiting phones from arrival to dismissal), and three more apply bell-to-bell bans only to grades K–8. Seven states have statewide instructional-time bans for all grades (prohibiting phones during class only), and five more states require districts to adopt a policy limiting phone use. Most state policies set a minimum standard and require districts to develop and implement their own policies that meet or exceed it.

Fifteen states have not yet enacted meaningful statewide restrictions on cell phone use. Six states require districts to adopt some policy regulating phone use without specifying limits, five have statewide guidance recommending but not requiring restrictions on phone use, and four have no statewide policy requirement at all. In states without statewide bans, districts may choose to adopt their own policies, though it is not required.

The strongest state policies are those that implement full bell-to-bell bans with inaccessible storage requirements. A Paragon Bill Spotlight showcased legislation enacted in June 2025, which requires every public school to adopt a policy prohibiting students from having physical access to cell phones throughout the entire school day—including non-instructional periods like lunch and passing time. Other similarly strong state approaches include North Dakota, Indiana, and most recently Kansas.

A recent Paragon policy brief reviewing the literature on cell phone bans in schools found that bell-to-bell bans show the best results, and are associated with meaningful academic gains, particularly for low-achieving students, and reductions in behavioral problems and bullying. One New York City school reported a 50 percent increase in after-school activity attendance following a ban, suggesting that phone-free school days restore in-person social habits. Partial restrictions such as instructional-time bans provide more limited benefits—when phones remain accessible during lunch or between classes, their pull on student minds persists during the school day.

A recent Paragon PIC reinforces why storage requirements matter. When phones are stored away and inaccessible, just 28 percent of educators report classroom disruption, compared to nearly half when students can keep phones on their person, even when prohibited from using them. This share rises to nearly three-quarters when phones are permitted between classes. Disruption peaks when teachers set their own rules rather than following a uniform school policy, with nearly eight in ten educators reporting at least some disruption. The data make clear that instructional-time bans alone are insufficient to improve classroom performance and student attention; full-day phone ban policies with inaccessible storage requirements—consistently enforced across every classroom—are most effective.

Several states without statewide bans are actively considering new legislation, including Pennsylvania and Maryland, which have bell-to-bell ban proposals moving through their legislatures. States with partial bans are also looking to expand: Georgia is advancing legislation that would extend its bell-to-bell ban to high school, and Wisconsin is considering legislation to upgrade its instructional-time ban to a full bell-to-bell ban.

As states continue to act, Paragon recommends following the lead of states like Rhode Island and North Dakota and implementing policies that prohibit student access to cell phones for the entire school day.

March 18, 2026

HSA Adoption Has Steadily Grown Over the Past 15 Years

Despite ongoing concerns about rising health insurance premiums, hospital price growth, and limited consumer control over their health care decisions, one notable success is the continued expansion of Health Savings Accounts (HSAs).

An HSA is a tax-advantaged account that allows individuals enrolled in a high-deductible health plan (HDHP) — now including bronze and catastrophic plans available in the individual market — to set aside funds for qualified medical expenses. Contributions are made with tax-free dollars, balances grow tax-free, and withdrawals remain tax-free when used for eligible medical costs. Unlike flexible spending accounts and health reimbursement arrangements, HSA funds roll over indefinitely and are fully owned by the individual.

HSAs are paired with HDHPs, including bronze and catastrophic plans, which typically carry lower monthly premiums but higher upfront deductibles. This structure gives individuals greater control over how their health care dollars are spent and encourages shopping for lower cost items and services.

Figure 1 shows the growth in total HSA accounts. Accounts increased from just 6.3 million in 2011 to nearly 40 million by 2025. The number of Americans covered by an HSA account as of 2024 was almost 60 million, roughly 33 percent of privately insured individuals.

HSA Adoption Has Steadily Grown Over The Last 15 Years.

Figure 2 illustrates the growth in total HSA assets. Combined deposits and investments have grown from just $3.4 billion in 2007 to over $200 billion projected by 2027. Deposits represent funds contributed by individuals and employers, while investment balances reflect account holders choosing to invest their savings for long-term growth. Notably, investment assets have expanded rapidly in recent years, signaling that HSAs are increasingly serving as long-term savings.

Figure 2: Consumer-Owned Health Savings Are Rapidly Expanding

Recent policy improvements in the One Big Beautiful Bill have strengthened HSAs by expanding eligibility, modernizing telehealth rules, and integrating Direct Primary Care arrangements. Paragon has developed a variety of options to further expand consumer choice and reinforce personal ownership in health care through HSAs, including the HSA Option (which would provide most Affordable Care Act enrollees with the option of redirecting part of the subsidy from the insurer to an HSA-like account under their control) and a proposal to expand the types of plans that could be integrated with HSAs.

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March 11, 2026

New York’s Medicaid Spending Per Resident is $4,800—85 Percent Higher Than the National Average in the Rest of the Country, 2024

The Trump administration has begun scrutinizing New York’s Medicaid program—an overdue step given the state’s long history of excessive spending, weak oversight, and fraud. CMS Administrator Dr. Mehmet Oz recently sent a letter to Governor Kathy Hochul raising concerns about program integrity in several high-risk service areas, including personal care services, home health, adult day care, non-emergency medical transportation, and behavioral health services. These services are particularly vulnerable because they are delivered outside traditional clinical settings, where verification is difficult and billing for services that were never delivered is a persistent risk. A recent policy brief I coauthored with Chris Medrano identified four areas of Medicaid particularly vulnerable to fraud and abuse and recommended stronger CMS enforcement.

Medicaid is a joint federal-state program in which the federal government reimburses states for a large share of their spending. Because federal funding is open-ended—states receive additional federal dollars whenever spending increases—the program is highly vulnerable to waste, fraud, and abuse. CMS therefore has a critical responsibility to safeguard the program both for the vulnerable individuals who rely on Medicaid and for the taxpayers who finance it.

New York’s Medicaid program is disproportionately large, even for the state’s size. As the figure below shows, New York’s Medicaid spending per resident is nearly $4,800—a staggering 85 percent higher than the national average of roughly $2,600 excluding New York. New York’s per-resident Medicaid spending is 23 percent higher than that of the next highest state, Kentucky.

Medicaid waste, fraud, and abuse are rampant in New York—and have been for almost the entire 60-year history of the program. In March 2013, the House Oversight and Government Reform Committee released a bipartisan report following a year-long investigation into New York’s Medicaid program. The report documented extensive problems, including weak eligibility controls, poor oversight of long-term care services, excessive administrative costs, and political corruption. The investigation also highlighted how Medicaid had become deeply embedded in the state’s fiscal and political structure—so much so that officials referred to the practice of “Medicaiding it,” referring to the state tactic of shifting as many services and costs as possible into the Medicaid program to maximize federal funding.

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March 4, 2026

Banning Cell Phone Use in Class Is Not Enough to Prevent Classroom Disruptions

Teachers report phones are disruptive during class time even when school policy restricts smartphone and personal device use to between classes only.

According to a survey of 2,889 educators in the spring of 2024, disruption during instructional time is lowest when schools require phones to be stored away. Disruptions rise with each step toward less restrictive or less consistent policy, peaking when the policy permits individual teachers to set their own rules.

When phones are stored away and inaccessible, just 28 percent of educators report disruption during class time, and only 12 percent report phones are very disruptive.

When students can keep their phones but are not allowed to use them, nearly half of educators still report disruption during class time.

Disruption rises sharply when students are permitted to use phones between classes—almost three-quarters of educators report disruption during instructional time, even though phone use is restricted during class.

Educators are most likely to report disruption when teachers set their own rules. Without a uniform school policy, enforcement falls disproportionately on individual teachers, leading to inconsistency across classrooms and more opportunities for students to use phones during instructional time. Nearly eight out of ten educators in these schools report at least some classroom disruption, and nearly half report phones are very disruptive.

These survey findings support Paragon’s recommendation that statewide, bell-to-bell smartphone bans requiring phones to be stored away and inaccessible are the most effective policy for reducing classroom disruption. In a new bill spotlight, Paragon highlights Rhode Island as a model for bell-to-bell smartphone legislation, noting that comprehensive storage policies outperform less restrictive approaches. Less restrictive bans, including instructional time bans and bell-to-bell bans that don’t require phones to be stored away, still result in meaningful disruption during class time.

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