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Health care reform in the United States
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Specific bills
Lead Proposal(s)
Superseded Proposal(s)


Reform advocacy groups

Health care in the United States

The issue of health insurance reform in the United States has been the subject of political debate since the early part of the 20th century. It remains an active issue. Alternative reform proposals were offered by both of the two major candidates in the last presidential election, and reform measures have been introduced during the current Congressional session.


Federal reform efforts


First plans

U.S. efforts to achieve universal coverage began with Theodore Roosevelt, who had the support of progressive health care reformers in the 1912 election but was defeated.[1] During the Great Depression in 1933, Franklin D. Roosevelt, asked Isidore S. Falk and Edgar Sydenstricter to help draft provisions to Roosevelt's pending Social Security legislation to include publicly funded health care programs. These reforms were attacked by the American Medical Association as well as state and local affiliates of the AMA as "compulsory health insurance." Roosevelt ended up removing the health care provisions from the bill in 1935. Fear of organized medicine's opposition to universal health care became standard for decades after the 1930s.[2]

The Medicare program was established by legislation signed into law on July 30, 1965, by President Lyndon B. Johnson. Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are either age 65 and over, or who meet other special criteria. The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) amended the Employee Retirement Income Security Act of 1974 (ERISA) to give some employees the ability to continue health insurance coverage after leaving employment.

Former President Jimmy Carter wrote in 1982 that Kennedy’s disagreements with Carter's proposed approach thwarted Carter’s efforts to provide a comprehensive health-care system for the country.[3]

Clinton initiative and Bush era debate

Health care reform was a major concern of the Bill Clinton administration headed up by First Lady Hillary Clinton; however, the 1993 Clinton health care plan was not enacted into law. The Health Insurance Portability and Accountability Act of 1996 (HIPAA) made it easier for workers to keep health insurance coverage when they change jobs or lose a job[citation needed], and also provided national standards for protecting personal health information.

In 2000 the Health Insurance Association of America (HIAA) partnered with Families USA and the American Hospital Association (AHA) on a "strange bedfellows" proposal intended to seek common ground in expanding coverage for the uninsured.[4][5][6]

In 2001, a Patients' Bill of Rights was debated in Congress, which would have provided patients with an explicit list of rights concerning their health care. This initiative was essentially taking some of ideas found in the Consumers' Bill of Rights and applying it to the field of health care. It was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the health care industry.[7] Standardizing the nature of health care institutions in this manner proved rather provocative. In fact, many interest groups, including the American Medical Association (AMA) and the pharmaceutical industry came out vehemently against the congressional bill. Basically, providing emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the biggest stumbling blocks for this bill.[8] As a result of this intense opposition, the Patients' Bill of Rights initiative eventually failed to pass Congress in 2002.

As president, Bush signed into law the Medicare Prescription Drug, Improvement, and Modernization Act which included a prescription drug plan for elderly and disabled Americans.[9]

During the 2004 presidential election, both the George Bush and John Kerry campaigns offered health care proposals. Bush's proposals for expanding health care coverage were more modest than those advanced by Senator Kerry.[10][11][12] Several estimates were made comparing the cost and impact of the Bush and Kerry proposals. While the estimates varied, they all indicated that the increase in coverage and the funding requirements of the Bush plan would both be lower than those of the more comprehensive Kerry plan.[13][14]

In 2006 the HIAA's successor organization, America's Health Insurance Plans (AHIP), issued another set of reform proposals.[15]

In January 2007 Rep. John Conyers, Jr. (D-MI) has introduced The United States National Health Care Act (HR 676) in the House of Representatives. As of October 2008, HR 676 has 93 co-sponsors.[16] Also in January 2007, Senator Ron Wyden introduced the Healthy Americans Act (S. 334) in the Senate. As of October 2008, S. 334 had 17 cosponsors.[17]

Also in 2007, AHIP issued a proposal for guaranteeing access to coverage in the individual health insurance market and a proposal for improving the quality and safety of the U.S. health care system.[18][19]

"Economic Survey of the United States 2008: Health Care Reform" by the Organisation for Economic Co-operation and Development, published in December 2008, said that:[20]

  • Tax benefits of employer-based insurances should be abolished.
  • The resulting tax revenues should be used to subsidize the purchase of insurance by individuals.
  • These subsidies, "which could take many forms, such as direct subsidies or refundable tax credits, would improve the current situation in at least two ways: they would reach those who do not now receive the benefit of the tax exclusion; and they would encourage more cost-conscious purchase of health insurance plans and health care services as, in contrast to the uncapped tax exclusion, such subsidies would reduce the incentive to purchase health plans with little cost sharing."

In December 2008, the Institute for America's Future together with the chairman of the Ways and Means Health Subcommittee Pete Stark launched a proposal from Jacob Hacker who is co-director of the U.C. Berkeley School of Law Center on Health that in essence said that the government should offer a public health insurance plan to compete on a level playing field with private insurance plans.[21] This was said to be the basis of the Obama/Biden plan. The argument is based on three basic arguments. Firstly public plans success at managing cost control (Medicare medical spending rose 4.6% p.a. compared 7.3% for private health insurance on a like-for-like basis in the 10 years from 1997-2006). Secondly public insurance has better payment and quality-improvement methods based on its large databases, new payment approaches, and care-coordination strategies. Thirdly it can set a standard against which private plans must compete which would help unite the public around the principle of broadly shared risk while building greater confidence in government over the long term.[22]

Also in December 2008, America's Health Insurance Plans (AHIP) announced a set of proposals which included setting a national goal to reduce the projected growth in health care spending by 30%. AHIP said that if this goal were achieved, it would result in cumulative five-year savings of $500 billion. Among the proposals was the establishment of an independent comparative effectiveness entity that compares and evaluates the benefits, risks, and incremental costs of new drugs, devices, and biologics.[23] An earlier "Technical Memo" published by AHIP in June 2008 had estimated that a package of reforms involving comparative effectiveness research, health information technology (HIT), medical liability reform, "pay-for-performance" and disease management and prevention could reduce U.S. national health expenditures "by as much as 9 percent by the year 2025, compared with current baseline trends."[24]

Debate in the 2008 presidential election

Both of the major party presidential candidates offered positions on health care.

John McCain's proposals focused on open-market competition rather than government funding. At the heart of his plan were tax credits - $2,500 for individuals and $5,000 for families who do not subscribe to or do not have access to health care through their employer. To help people who are denied coverage by insurance companies due to pre-existing conditions, McCain proposed working with states to create what he called a "Guaranteed Access Plan."[25]

Barack Obama called for universal health care. His health care plan called for the creation of a National Health Insurance Exchange that would include both private insurance plans and a Medicare-like government run option. Coverage would be guaranteed regardless of health status, and premiums would not vary based on health status either. It would have required parents to cover their children, but did not require adults to buy insurance.

The Philadelphia Inquirer reported that the two plans had different philosophical focuses. They described the purpose of the McCain plan as to "make insurance more affordable," while the purpose of the Obama plan was for "more people to have health insurance."[26] The Des Moines Register characterized the plans similarly.[27]

A poll released in early November, 2008, found that voters supporting Obama listed health care as their second priority; voters supporting McCain listed it as fourth, tied with the war in Iraq. Affordability was the primary health care priority among both sets of voters. Obama voters were more likely than McCain voters to believe government can do much about health care costs.[28]

2009 reform debate

In March 2009 AHIP proposed a set of reforms intended to address waste and unsustainable growth in the current health care market. These reforms included:

  • Updates to the Medicare physician fee schedule;
  • Setting standards and expectations for safety and quality of diagnostics;
  • Promoting care coordination and patient-centered care by designating a "medical home" that would replace fragmented care with a coordinated approach to care. Physicians would receive a periodic payment for a set of defined services, such as care coordination that integrates all treatment received by a patient throughout an illness or an acute event. This would promote ongoing comprehensive care management, optimizes patients’ health status and assist patients in navigating the health care system
  • Linking payment to quality, adherence to guidelines, achieving better clinical outcomes, giving better patient experience and lowering the total cost of care.
  • Bundled payments (instead of individual billing) for the management of chronic conditions in which providers would have shared accountability and responsibility for the management of chronic conditions such as coronary artery disease, diabetes, chronic obstructive pulmonary disease and asthma, and similarly
  • A fixed rate all-inclusive average payment for acute care episodes which tend to follow a pattern (even though some acute care episodes may cost more or less than this).[29]

On May 5, 2009, US Senate Finance Committee held hearings on Health care reform. On the panel of the "invited stakeholder", no supporter of the Single-payer health care system was invited.[30] The panel featured Republican senators and industry panelists who argued against any kind of expanded health care coverage.[31] The preclusion of the single payer option from the discussion caused significant protest by doctors in the audience.[31]

There is one bill currently before Congress but others are expected to be presented soon. A merged single bill is the likely outcome.[citation needed] The Affordable Health Choices Act is currently before the House of Representatives and the main sticking points at the markup stage of the bill have been in two areas; should the government provide a public insurance plan option to compete head to head with the private insurance sector, and secondly should comparative effectiveness research be used to contain costs met by the public providers of health care.[citation needed] Some Republicans have expressed opposition to the public insurance option believing that the government will not compete fairly with the private insurers. Republicans have also expressed opposition to the use of comparative effectiveness research to limit coverage in any public sector plan (including any public insurance scheme or any existing government scheme such as Medicare), which they regard as rationing by the back door.[citation needed] Democrats have claimed that the bill will not do this but are reluctant to introduce a clause that will prevent, arguing that it would limit the right of the DHHS to prevent payments for services that clearly do not work.[citation needed] America's Health Insurance Plans, the umbrella organization of the private health insurance providers in the United States has recently urged the use of CER to cut costs by restricting access to ineffective treatments and cost/benefit ineffective ones. Republican amendments to the bill would not prevent the private insurance sectors from citing CER to restrict coverage and apply rationing of their funds, a situation which would create a competition imbalance between the public and private sector insurers.[citation needed] A proposed but not yet enacted short bill with the same effect is the Republican sponsored Patients Act 2009.[citation needed]

On June 15, 2009, the U.S. Congressional Budget Office (CBO) issued a preliminary analysis of the major provisions of the Affordable Health Choices Act.[32] The CBO estimated the ten-year cost to the federal government of the major insurance-related provisions of the bill at approximately $1.0 trillion.[32] Over the same ten-year period from 2010 to 2019, the CBO estimated that the bill would reduce the number of uninsured Americans by approximately 16 million.[32] At about the same time, the Associated Press reported that the CBO had given Congressional officials an estimate of $1.6 trillion for the cost of a companion measure being developed by the Senate Finance Committee.[33] In response to these estimates, the Senate Finance Committee delayed action on its bill and began work on reducing the cost of the proposal to $1.0 trillion, and the debate over the Affordable Health Choices act became more acrimonious.[34][35] Congressional Democrats were surprised by the magnitude of the estimates, and the uncertainty created by the estimates has increased the confidence of Republicans who are critical of the Obama Administration's approach to health care.[36][37]

However, in a June New York Times editorial, economist Paul Krugman argued that despite these estimates universal health coverage is still affordable. "The fundamental fact is that we can afford universal health insurance--even those high estimates were less than the $1.8 trillion cost of the Bush tax cuts."[38]

In contrast to earlier advocacy of a publicly-funded health care program, in August 2009 Obama administration officials announced they would support a health insurance cooperative in response to deep political unrest amongst Congressional Republicans and amongst citizens in town hall meetings held across America.[39][40][41] However, in a June 2009 NBC News/Wall Street Journal survey, 76 percent said it was either "extremely" or "quite" important to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance."[42]

During the summer of 2009, members of the "Tea Party" protested against proposed health care reforms.[43][44][45] Former insurance PR executive Wendell Potter of the Center for Media and Democracy- whose funding comes from groups such as the Tides Foundation-[46] argue that the hyperbole generated by this phenomenon is a form of corporate astroturfing, which he says that he used to write for CIGNA.[47] Opponents of more government involvement, such as Phil Kerpen of Americans for Prosperity- whose funding comes mainly from the Koch Industries corporation-[48] counter-argue that those corporations oppose a public-plan, but some try to push for government actions that will unfairly benefit them, like employer mandates forcing private companies to buy health insurance.[49] Journalist Ben Smith has referred to mid-2009 as "The Summer of Astroturf" given the organizing and co-ordinating efforts made by various groups on both pro- and anti-reform sides.[45]

State and city reform efforts

A few states have taken serious steps toward universal health care coverage, most notably Minnesota, Massachusetts and Connecticut, with recent examples being the Massachusetts 2006 Health Reform Statute[50] and Connecticut's SustiNet plan to provide quality, affordable health care to state residents.[51] The influx of more than a quarter of a million newly insured residents has led to overcrowded waiting rooms and overworked primary-care physicians who were already in short supply in Massachusetts.[52] Other states, while not attempting to insure all of their residents, cover large numbers of people by reimbursing hospitals and other health care providers using what is generally characterized as a charity care scheme; New Jersey is perhaps the best example of a state that employs the latter strategy.

Several single payer referendums have been proposed at the state level, but so far all have failed to pass: California in 1994,[53] Massachusetts in 2000, and Oregon in 2002.[54] The state legislature of California has twice passed SB 840, The Health Care for All Californians Act, a single-payer health care system. Both times, Governor Arnold Schwarzenegger (R) vetoed the bill, once in 2006 and again in 2008.[55][56][57]

The percentage of residents that are uninsured varies from state to state. Texas has the highest percentage of residents without health insurance at 24%.[58] New Mexico has the second highest percentage of uninsured at 22%.[58]

States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans,[59] which give them multiple opportunities to try to improve how it functions. While states are actively working to improve the system in a variety of ways, there remains room for them to do more.[60]

One municipality, San Francisco, California, has established a program to provide health care to all uninsured residents (Healthy San Francisco).

In July 2009, Connecticut passed into law a plan called SustiNet, with the goal of achieving health-care coverage of 98% of its residents by 2014.[51] The SustiNet law establishes a nine-member board to recommend to the legislature, by January 1, 2011, the details of and implementation process for a self-insured health care plan called SustiNet. The recommendations must address (1) the phased-in offering of the SustiNet plan to state employees and retirees, HUSKY A and B beneficiaries, people without employer-sponsored insurance (ESI) or with unaffordable ESI, small and large employers, and others; (2) establishing an entity that can contract with insurers and health care providers, set reimbursement rates, develop medical homes for patients, and encourage the use of health information technology; (3) a model benefits package; and (4) public outreach and ways to identify uninsured citizens.[61] The board must establish committees to make recommendations to it about health information technology, medical homes, clinical care and safety guidelines, and preventive care and improved health outcomes. The act also establishes an independent information clearinghouse to inform employers, consumers, and the public about SustiNet and private health care plans and creates task forces to address obesity, tobacco usage, and health care workforce issues. The effective date of the SustiNet law was July 1, 2009 for most provisions.[62].

See also


  1. ^ Lee Igel (May-June, 2008), "The history of health care as a campaign issue", Physician Executive, 
  2. ^ Jan Coombs (2005), The rise and fall of HMOs, ISBN 0299202402,,M1 
  3. ^ Carter, Keeping Faith: Memoirs of a President, 1982, p. 86-87.
  4. ^ "Strange Bedfellow" Join Forces on Agreement for Uninsured Americans, Families USA, Press Release, November 20, 2000
  5. ^ Charles N. Kahn III and Ronald F. Pollack, "Building A Consensus For Expanding Health Coverage," Health Affairs, January/February 2001; 20(1): 40-48
  6. ^ Conrad F. Meier, "HIAA and Families USA Seek More Government," Health Care News, The Heartland Institute, April 1, 2001
  7. ^ Summary of the McCain-Edwards-Kennedy Patients' Bill of Rights
  8. ^ Ibid.
  9. ^
  10. ^ Robin Toner , "THE 2004 CAMPAIGN: POLITICAL MEMO; Biggest Divide? Maybe It's Health Care," The New York Times, Tuesday, December 18, 2007
  11. ^ "CAMPAIGN 2004: THE BIG ISSUES - Kerry vs. Bush on Health Care," The New York Times, October 3, 2004
  12. ^ Ceci Connolly, "Bush Health Care Plan Seems to Fall Short," The Washington Post, August 22, 2004
  13. ^ John Sheils, "Lewin Presents an Independent Comparison of the Bush and Kerry Health Proposals," The Lewin Group, September 21, 2004
  14. ^ Joseph Antos, Roland (Guy) King, Donald Muse, Tom Wildsmith and Judy Xwhta , "Analyzing the Kerry and Bush Health Proposals: Estimates of Cost and Impact," The American Enterprise Institute, September 13, 2004
  15. ^ "We Believe Every American Should Have Access to Affordable Health Care Coverage: A Vision for Reform," America's Health Insurance Plans, November 13, 2006
  16. ^ "H.R. 676". Library of Congress THOMAS. Retrieved 2007-08-28. 
  17. ^ "S. 334". Library of Congress THOMAS. Retrieved 2008-05-05. 
  18. ^ "Guaranteeing Access to Coverage for All Americans," America's Health Insurance Plans, December 19, 2007
  19. ^ "Setting a Higher Bar: We Believe There is More the Nation Can Do to Improve Quality and Safety in Health Care,"America's Health Insurance Plans, April 19, 2007
  20. ^ "Economic Survey of the United States 2008: Health Care Reform". OECD. 9 December 2008.,3343,en_2649_34117_41809843_1_1_1_1,00.html. 
  21. ^</ref News conference of IAF on benefits of having a public insurance plan to compete with private plans
  22. ^
  23. ^ Now is the Time for Health Care Reform: A Proposal to Achieve Universal Coverage, Affordability, Quality Improvement and Market Reform, Board of Directors’ Statement, America's Health Insurance Plans, December 2008
  24. ^ Jim Capretta, Jack Rodgers, Michael Thompson and Tom Wildsmith, Technical Memo: Estimates of the Potential Reduction in Health Care Costs from AHIP’s Affordability Proposals, America's Health Insurance Plans, June 2008
  25. ^ Robert E. Moffit and Nina Owcharenko, "The McCain Health Care Plan: More Power to Families," The Heritage Foundation, October 15, 2008
  26. ^ Stacey Burling, "Rivals' prescriptions for an ailing system," The Philadelphia Inquirer, September 28, 2008
  27. ^ Tony Leys, "Health plans pit low-cost vs. public coverage," The Des Moines Register, September 29, 2008
  28. ^ Robert J. Blendon, Drew E. Altman, John M. Benson, Mollyann Brodie,Tami Buhr, Claudia Deane, and Sasha Buscho, "Voters and Health Reform in the 2008 Presidential Election," New England Journal of Medicine 359;19, November 6, 2008
  29. ^|44|26308 AHIP: Improving the U.S. Health Care System. Rethinking the Delivery and Payment Structures
  30. ^
  31. ^ a b Single-payer advocates protest Senate hearing The Real News, May 7 2009
  32. ^ a b c U.S. Congressional Budget Office, Preliminary Analysis of Major Provisions Related to Health Insurance Coverage Under the Affordable Health Choices Act, June 15, 2009
  33. ^ DAVID ESPO, "Dems seek to trim health bill as estimates soar," The Associated Press, Wednesday, June 17, 2009; 1:47 AM
  34. ^ RICARDO ALONSO-ZALDIVAR, "Lawmakers clash over cost of health care overhaul," The Associated Press, Wednesday, June 17, 2009; 9:48 PM
  35. ^ Lori Montgomery, "Debate on Health Care Hits Snags At the Start," The Washington Post, Thursday, June 18, 2009
  36. ^ CHARLES BABINGTON, "Obama may need firmer hand on health care debate," The Associated Press, Saturday, June 20, 2009; 10:14 AM
  37. ^ Ceci Connolly, "Obama Initiatives Hit Speed Bumps On Capitol Hill: High Price Tag For Reform Bill Prompts Sparring And a Delay," The Washington Post, Friday, June 19, 2009
  38. ^ Paul Krugman, "Health Care Showdown," Op Ed, The New York Times, June 22, 2009
  39. ^ "White House appears ready to drop 'public option'" Retrieved on August 17, 2009
  40. ^ "President Obama Considering Insurance Co-Op" Retrieved on August 17th, 2009
  41. ^ "Town Halls Having an Impact? White House Bends on Health Care Provision in Face of Discontent" Retrieved on August 18th, 2009
  42. ^ HART/McINTURFF, NBC News/Wall Street Journal Survey, Study #6095, Jun 12-15, 2009
  43. ^ Bowser, Andre (August 22, 2009). "TEA Party protests health care reform plan". East Valley Tribune. Retrieved August 26, 2009. 
  44. ^ Copeland, Mike (August 15, 2009). "Local Tea Party members protest Obama health care plan at Chet Edwards' Waco office". Waco Tribune. Retrieved August 26, 2009. 
  45. ^ a b Ben Smith (August 21, 2009). "The Summer of Astroturf". Politico. Retrieved August 28, 2009. 
  46. ^ "Financial Supporters". Center for Media and Democracy. Retrieved 2008-06-03. 
  47. ^ Wendell Potter. "Commentary: How insurance firms drive debate". CNN. Retrieved August 26, 2009. 
  48. ^ Secret Money Project. By Will Evans. National Public Radio. Published October 6, 2008. Accessed September 1, 2009.
  49. ^ "The Grass Is AstroTurf-er on the Other Side". Fox News. August 12, 2009. Retrieved August 26, 2009. 
  50. ^'s Pros & Cons of Massachusetts' Mandatory Health Insurance Program
  51. ^ a b
  52. ^ Moore, Pamela "Voting for Healthcare Reform"|journal=Physicians Practice|volume=18|number=7|pages=26-40|year=2008|accessdate=2009-01-07
  53. ^ The California Single-Payer Debate, The Defeat of Proposition 186 - Kaiser Family Foundation
  54. ^ Free-Market Reformers Are Winners in Election 2002 - by Joe Moser - The Heartland Institute
  55. ^ California Healthcare for All
  56. ^ California
  57. ^ [1]
  58. ^ a b Total Population - Kaiser State Health Facts
  59. ^ Managed Care & Health Insurance - Kaiser State Health Facts
  60. ^ Catherine Hess, Sonya Schwartz, Jill Rosenthal, Andrew Snyder, and Alan Weil, "States’ Roles in Shaping High Performance Health Systems," The Commonwealth Fund, April 2008
  61. ^ Connecticut General Assembly, Office of Legislative Research, "OUR Acts Affecting Insurance," July 21, 2009
  62. ^ Connecticut General Assembly, Office of Legislative Research, "OLR Acts Affecting Insurance," July 21, 2009


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