NEW ERA

• Since 2010, the U.S. healthcare system has changed with the implementation of components of the Patient Protection and Affordable Care Act of 2010 (ACA 2010)
• In December 2016, the Kaiser Health Tracking Poll reported that 43% of Americans viewed the ACA 2010 favorably, while 46% of the public viewed it unfavorably
• The election of a Republican president and Congress in November 2016 has heightened expectations for significant reform and possible repeal of this legislation
• The same December 2016 Kaiser poll found that 47% of Americans do not believe that the ACA 2010 should be repealed, and another 28% of the public does not favor repeal until the details of a replacement plan are known
• In 2010, Congress passed and President Obama signed H.R. 3590, the ACA 2010, and H.R. 4872, the Health Care and Education Reconciliation Act
• THREE WAYS TO PROVIDE UNIVERSAL COVERAGE FOR A POPULATION

  • Private insurance coverage is required for all by individual or employer mandate (Bismarck model)
  • The government owns and provides all required medical services(Beveridge or National Health Service model)
  • The government provides health insurance (National Health Insurance model)
• Otto Von Bismarck


  Introduced universal health insurance in Germany in 1883
• In early 20th Century, essentially all European democracies had "sickness insurance" (either provided by government or mandated and provided by labor organizations or guilds,frequently with government subsidy)
• Sickness insurance


  Intended to protect against loss rather than pay the cost of health care
• In Britain ,Germany, and Russia, the motive of conservative governments was to co-opt political positions.
• Most European nations evolved from wage protection plans to universal insurance that pays for medical and hospital costs
• Theodore Roosevelt

  The first US president to support the concept of universal health insurance
• Roosevelt attempted to recapture the presidency as the candidate of the Progressive (Bull Moose) Party


  1912
• Roosevelt even ran for re-election in 1912 with a platform that included national health insurance - an important part of Roosevelt's presidential campaign
• The American Association of Labor Legislation (AALL) created a committee on social welfare in 1912
• The AALL recruited physicians to help draft model legislation in 1914
• The model legislation was endorsed by American Medical Association (AMA) House of Delegates in 1917
• Several states (and one Canadian province) introduced bills based on the model; it was defeated in all with intense opposition from the American Federation of Labor (AFL), state medical societies, the insurance industry, and business interests
• Reasons for the loss of the model legislation


  • Loss of income: Doctors, businesses, and insurance companies worried about a decrease in their earnings
  • Government Control: Fear of government involvement in healthcare was widespread
  • Union Control: The AFL, a powerful labor union, didn't want the government taking over health benefits negotiations
• The push for universal health insurance in the US hit a roadblock in the 1920s and 30s and efforts stalled completely during this period
• President Roosevelt specifically excluded health insurance from the Social Security Act (1935) fearing it would jeopardize the entire bill, particularly the popular pension program
• Even a separate Senate bill proposing government-run health insurance in 1935 failed to gain traction
• Senator Robert Wagner introduced S. 1620, the National Health Act, to create national compulsory health insurance for all employees and their dependents in 1939
• Reasons why the National Health Act failed


  • Comprehensive coverage: This bill aimed to cover doctor visits, hospital stays, medications, and lab tests
  • Funding: A mix of employer and employee contributions would have paid for the program
  • State-run: Each state would have been responsible for administering the plan
  • Lack of presidential backing: Roosevelt wasn't fully on board
  • Political opposition: A conservative Congress elected in 1938 strongly opposed it
  • World War II: The war shifted national priorities
• The Wagner-Murray-Dingell Bill aimed to expand healthcare access in the US and would have provided comprehensive medical insurance for people covered by the Social Security program, both working and retired, and needy persons
• Key features of the Wagner-Murray-Dingell Bill


  • Target beneficiaries: Employed and retired people covered by Social Security, plus those in need
  • Comprehensive coverage: Doctor visits, hospitalization, nursing care, lab tests, and even dental services
  • Repeated attempts: The bill was reintroduced with adjustments in following sessions of Congress
  • Ultimately unsuccessful: Despite multiple tries, the Wagner Murray-Dingell Bill never achieved passage
• President Truman proposed, in a special message to Congress, a single comprehensive, universal national health insurance plan in 1945 but it faced opposition from the Republicans-controlled Congress
• Despite strong public support, Truman's proposal for universal health insurance failed in 1948 due to opposition from the insurance industry, organized medicine, and political conservatives
• Fewer than 10% of Americans had employment-based health insurance which rose to nearly 50% by 1952
• Premiums became tax-deductible in 1954
• Employer coverage had risen to 80% by 1980
• The Kerr-Mills Act was passed in 1960 to increase uninsured coverage, with the elderly becoming allies. Medicare, covering all Americans over 65, was enacted after President Johnson's persuasive skills
• Medicare


  A federal health insurance for anyone age 65 and older, and some people under 65 with certain disabilities or conditions
• Medicaid


  Designed to provide care for needy children, was passed in the same Social Security Act of 1965
• President Nixon proposed a plan of compulsory employment-based health insurance for all workers and their dependents in 1971, but it is also opposed by business and political conservatives, and liberals
• From then until the Clinton administration, the main government healthcare agenda was cost-control, not access
• Congress introduced a few bills in 1991 and 1992 that would have enacted a single-payer universal health insurance or an all-payer system, but none received much attention, and none of the bills left the committee
• The Clinton administration rolled out the Clinton National Health Security Plan in 1993, which was supported by most of the public during the early process and development and after completion
• Key provisions of the Clinton National Health Security Plan


  • Employer coverage through purchasing alliances
  • Standard benefits package
  • Premium price competition among private health insurers to control cost
  • Subsidized premiums for low income levels
• Support on the Clinton plan dropped in April 1994 because of the insurance industry's advertising against it, and the bill died in committee in August