Satvat Healthcare: The Truth Behind Universal Healthcare
Past American Efforts At Universal Coverage (Failed)
Got to love that Insurance Lobby...
Source: Wikipedia, Other Sources and Personal Contributions and Editing
Roosevelt Passes Social Security in the 1930s But Fails On Care Universality
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. 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.
The Wagner-Murray-Dingell Bill of 1943
National health insurance was but one of several provisions of this bill. Other provisions, such as extension of Social Security, the nationalization of unemployment compensation, and federal aid for general relief, are beyond the scope of this discussion.
The bill provided that health insurance would be established by the creation of a national medical care and hospitalization fund, to which employers and employees would each contribute 1.5 percent of the first $3,000 of annual wages, making 3 percent in all. Self-employed would contribute the entire 3 percent themselves. Contributions amounting to an additional 4.5 percent of wages would be made by employers and employees, 9 percent in all, to pay for the other benefits of the bill. Two of these latter provisions have an important bearing on health, namely, those providing for cash payments during temporary and permanent disability.
For every insured person and his family, the. medical care and hospitalization fund would pay for unlimited doctors’ care including specialists, for hospitalization up to 30 days, X rays, and laboratory tests. Dental care, nursing, medicines and drugs would not be paid for.
Patients would be free to choose their physicians from among those participating in the program, whether engaged in individual or group practice. Standards of competence for specialists and hospitals would be established by the Surgeon General of the United States Public Health Service. Any licensed physician could participate in the program as a general practitioner.
The national fund would pay physicians for the services rendered to patients covered by the system through any of several methods-fee-for-service, capitation, part-time or full-time salaries, or by a combination of these methods. The physicians of each area would choose by majority vote the method of payment to be adopted in that area. Hospitals would be paid up to $6 per day for each day of care they furnished.
The 1943 Wagner-Murray-Dingell Bill never came to a vote in Congress. Nevertheless it caused a storm of comment. Backed enthusiastically by organized labor and some farm organizations, it was considered by them “so enormous an improvement over our present social security provisions that no responsible person, deeply concerned with the welfare of our country, can fail to support it.”
At the same time, it was vigorously opposed by representatives of organized physicians, in those minds it was “socialized medicine.” The opposition groups said that the bill implied that sick people would have to depend on a doctor paid by the government to work only eight hours daily-emergency cases would have to wait until the doctor checked in. Patients would have to go to the doctor assigned to them by political bureaucrats, and doctors would become incompetent because methods and remedies would be fixed by bureaucratic superiors. Largely to oppose this bill, physicians and drug houses raised and spent over a quarter of a million dollars in giving out “information” of this nature. Extremes were reached with statements like, “It is doubtful if even Nazidom confers on its gauleiters the powers which this measure would confer on the Surgeon-General of the U. S. Public Health Service.”
One group of physicians attempted to promote a national movement to boycott any legislative program such as the Wagner-Murray-Dingell Bill, giving physicians this advice: “If such legislation as the Wagner-Murray-Dingell Bill passes and your patients come to you for services under the plan, tell them you don’t serve the politicians, you serve there. If they want to know what they are going to get for the money deducted from their pay checks for health insurance, you don’t know.”
It is of course debatable whether an insurance scheme such as that proposed in the bill would in fact have the disastrous effects predicted by its opponents. Certainly the bill itself had no provisions for assigning patients to doctors, for regulating physicians’ hours of work, income, or methods of practice, except for the elementary requirement that specialists meet national standards of competence in their particular fields. Many persons in favor of federal legislation for health and medical care felt, however, that the first Wagner-Murray-Dingell Bill fell far short of providing a truly adequate health program for the nation. They pointed out that it included, for example, no provision for the construction of hospitals and health centers. It contained nothing to encourage the expansion of preventive health services. It offered nothing to induce physicians to modernize their methods of practice by joining together in groups instead of continuing in the traditional solo practice of the old-time family physician.
Some felt, too, that the whole population should be protected under the plan, rather than merely employed persons and their families. For this reason, and to promote preventive health services, support from general taxes as well as from the pay-roll contributions of employer and employee was urged.
Finally, disinterested critics generally felt that the bill permitted too centralized an administration of the program. They said that the program did not require sufficient participation by state and local governments nor by local representatives of the professions and the public. The American Bar Association made the additional point that it failed to provide for court review of administrative decisions.
1965 Medicare and 1974 COBRA Bills - Finally Some Passage
On July 30, 1965, The Medicare program was established by legislation signed into law on 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.
1993 Clinton Health Reform Plan
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 Clinton health care plan was a package proposed by the administration of President Bill Clinton and closely associated with the chair of the task force devising the plan, First Lady of the United States Hillary Rodham Clinton.
Bill Clinton had campaigned heavily on health care in the 1992 U.S. presidential election. The task force was created in January 1993, but its own processes were somewhat controversial and drew litigation. Its goal was to come up with a comprehensive plan to provide universal health care for all Americans, which was to be a cornerstone of the administration's first-term agenda. A major health care speech was delivered by President Clinton to the U.S. Congress in September 1993. The core element of the proposed plan was an enforced mandate for employers to provide health insurance coverage to all of their employees through competitive but closely-regulated health maintenance organizations.
Opposition to the plan was heavy from conservatives, libertarians, and the health insurance industry. The industry produced a much-talked-about television ad, "Harry and Louise", in an effort to rally public support against the plan. Democrats, instead of uniting behind the President's original proposal, offered a number of competing plans of their own. By September 1994, the final compromise Democratic bill was declared dead by Senate Majority Leader George J. Mitchell. Opponents of the plan continued to deride it in future years as "HillaryCare".
In 1996, The Health Insurance Portability and Accountability Act (HIPAA) made it easier for workers to keep health insurance coverage when they change jobs or lose a job, 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.
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.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. As a result of this intense opposition, the Patients' Bill of Rights initiative eventually failed to pass Congress in 2002.
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. 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.
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.
In 2006 the HIAA's successor organization, America's Health Insurance Plans (AHIP), issued another set of reform proposals.
In January 2007 Rep. John Conyers, Jr. (D-MI) 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. 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 co-sponsors. Both bills are indefinitely dead as stalled legislation.
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.
"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:
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. 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.
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.An earlier "Technical Memo" published by AHIP in June of 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."
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."
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." The Des Moines Register characterized the plans similarly.
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.
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:
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.The panel featured Republican senators and industry panelists who argued against any kind of expanded health care coverage. The preclusion of the single payer option from the discussion caused significant protest by doctors in the audience.
There is one bill currently before Congress but others are expected to be presented soon. A merged single bill is the likely outcome. 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. 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. 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. 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. A proposed but not yet enacted short bill with the same effect is the Republican sponsored Patients Act 2009.
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. 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. 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. 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. 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. 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.
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."
State Reform Efforts
A few states have taken serious steps toward universal health care coverage, most notably Minnesota and Massachusetts, with a recent example being the Massachusetts 2006 Health Reform Statute. 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. 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. It is typical for most forms of general liability insurance sold in the U.S., such as home, automobile, or business insurance to have a significant premium allocation for medical damages. In the event that a third party is responsible for injury or illness (e.g., the responsible driver in an automobile accident), action can be taken in the U.S. court system to prove liability and collect the money for medical bills from the responsible party's liability insurances.
Several single payer referendums have been proposed at the state level, but so far all have failed to pass: California in 1994, Massachusetts in 2000, and Oregon in 2002. 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.
The percentage of residents that are uninsured varies from state to state. Texas has the highest percentage of residents without health insurance at 24%.New Mexico has the second highest percentage of uninsured at 22%.
States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans, 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.
One municipality, San Francisco, California, has established a program to provide health care to all uninsured residents (Healthy San Francisco).
Since 2005, Universal Health Care Foundation of Connecticut has developed relationships with several key groups that would be instrumental in creating broad change in the health system, including medical societies, hospitals, businesses, labor and clergy. In January 2009 the foundation unveiled SustiNet, a proposal for a statewide health care plan for Connecticut that would provide residents with their choice of health coverage and care regardless of their employment status, age, or pre-existing conditions. An estimated 1,000 people attended a rally at Union Station (Hartford) for the release of the plan. SustiNet would emphasize preventive care and the management of chronic illnesses. It would create a large health insurance pool by combining state employees, retirees, and people covered by state assistance programs. The pool would also be open to members of the public without insurance, those with inadequate insurance, and employers, starting with small businesses, nonprofits and municipalities. Eventually, Sustinet would be open to larger employers wishing to buy into the plan for their employees In February; the 18,500-member Connecticut Association of REALTORS announced its support for the SustiNet health care plan. REALTORS are independent contractors and are representative of the plight of many independent contractors and small business employees in Connecticut in that they do not have access to group health insurance. Also in that month, the independent statewide organization "Small Businesses for Health Care Reform" endorsed the SustiNet health care reform proposal and encouraged other business owners to review and support it. In March 2009, the foundation's SustiNet plan was formally endorsed by the Interfaith Fellowship for Universal Health Care, a group devoted to health reform, as well as by dozens of other religious leaders representing a wide range of faiths in Connecticut. Fellowship members include Rabbi Stephen Fuchs of Congregation Beth Israel in West Hartford, a co-chairman of the Interfaith Fellowship, and Bilal Ansari, a Muslim chaplain at Saint Francis Hospital & Medical Center in Hartford, where much of his counseling involves helping families cope with not just the stress of a relative's illness, but the worries about how they will pay for it.
SustiNet passed its first legislative hurdle Thursday, March 26, receiving an endorsement from the state legislature's Public Health Committee. The committee voted 22-8 to move the bill forward. On April 22, SustiNet received a favorable report from a second committee, the Human Services Committee, which voted 13-6 for the bill. On April 29, SustiNet received a favorable report from a third committee, the Labor and Public Employees Committee, which voted 8-3 for the bill. On April 29, SustiNet received a favorable report from a third committee, the Labor and Public Employees Committee, which voted 8-3 for the bill. On May 7, 2009, Sustinet received a favorable report from a fourth committee, the Insurance and Real Estate Committee, which voted 13-4 for the bill.
On May 20, 2009, the Connecticut House of Representatives voted 107-35 for SustiNet.
On May 30, 2009, the Connecticut Senate voted 23-12 for SustiNet. The bill then went to Connecticut Governor M. Jodi Rell for signature or veto.
SustiNet was vetoed by Governor Rell on July 8. On July 20 the governor's vetoes were overridden by the Connecticut House of Representatives with a vote of 102 to 40, and then by the Connecticut Senate with a vote of 24-12.
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.
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.
Roosevelt Passes Social Security in the 1930s But Fails On Care Universality
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. 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.
The Wagner-Murray-Dingell Bill of 1943
National health insurance was but one of several provisions of this bill. Other provisions, such as extension of Social Security, the nationalization of unemployment compensation, and federal aid for general relief, are beyond the scope of this discussion.
The bill provided that health insurance would be established by the creation of a national medical care and hospitalization fund, to which employers and employees would each contribute 1.5 percent of the first $3,000 of annual wages, making 3 percent in all. Self-employed would contribute the entire 3 percent themselves. Contributions amounting to an additional 4.5 percent of wages would be made by employers and employees, 9 percent in all, to pay for the other benefits of the bill. Two of these latter provisions have an important bearing on health, namely, those providing for cash payments during temporary and permanent disability.
For every insured person and his family, the. medical care and hospitalization fund would pay for unlimited doctors’ care including specialists, for hospitalization up to 30 days, X rays, and laboratory tests. Dental care, nursing, medicines and drugs would not be paid for.
Patients would be free to choose their physicians from among those participating in the program, whether engaged in individual or group practice. Standards of competence for specialists and hospitals would be established by the Surgeon General of the United States Public Health Service. Any licensed physician could participate in the program as a general practitioner.
The national fund would pay physicians for the services rendered to patients covered by the system through any of several methods-fee-for-service, capitation, part-time or full-time salaries, or by a combination of these methods. The physicians of each area would choose by majority vote the method of payment to be adopted in that area. Hospitals would be paid up to $6 per day for each day of care they furnished.
The 1943 Wagner-Murray-Dingell Bill never came to a vote in Congress. Nevertheless it caused a storm of comment. Backed enthusiastically by organized labor and some farm organizations, it was considered by them “so enormous an improvement over our present social security provisions that no responsible person, deeply concerned with the welfare of our country, can fail to support it.”
At the same time, it was vigorously opposed by representatives of organized physicians, in those minds it was “socialized medicine.” The opposition groups said that the bill implied that sick people would have to depend on a doctor paid by the government to work only eight hours daily-emergency cases would have to wait until the doctor checked in. Patients would have to go to the doctor assigned to them by political bureaucrats, and doctors would become incompetent because methods and remedies would be fixed by bureaucratic superiors. Largely to oppose this bill, physicians and drug houses raised and spent over a quarter of a million dollars in giving out “information” of this nature. Extremes were reached with statements like, “It is doubtful if even Nazidom confers on its gauleiters the powers which this measure would confer on the Surgeon-General of the U. S. Public Health Service.”
One group of physicians attempted to promote a national movement to boycott any legislative program such as the Wagner-Murray-Dingell Bill, giving physicians this advice: “If such legislation as the Wagner-Murray-Dingell Bill passes and your patients come to you for services under the plan, tell them you don’t serve the politicians, you serve there. If they want to know what they are going to get for the money deducted from their pay checks for health insurance, you don’t know.”
It is of course debatable whether an insurance scheme such as that proposed in the bill would in fact have the disastrous effects predicted by its opponents. Certainly the bill itself had no provisions for assigning patients to doctors, for regulating physicians’ hours of work, income, or methods of practice, except for the elementary requirement that specialists meet national standards of competence in their particular fields. Many persons in favor of federal legislation for health and medical care felt, however, that the first Wagner-Murray-Dingell Bill fell far short of providing a truly adequate health program for the nation. They pointed out that it included, for example, no provision for the construction of hospitals and health centers. It contained nothing to encourage the expansion of preventive health services. It offered nothing to induce physicians to modernize their methods of practice by joining together in groups instead of continuing in the traditional solo practice of the old-time family physician.
Some felt, too, that the whole population should be protected under the plan, rather than merely employed persons and their families. For this reason, and to promote preventive health services, support from general taxes as well as from the pay-roll contributions of employer and employee was urged.
Finally, disinterested critics generally felt that the bill permitted too centralized an administration of the program. They said that the program did not require sufficient participation by state and local governments nor by local representatives of the professions and the public. The American Bar Association made the additional point that it failed to provide for court review of administrative decisions.
1965 Medicare and 1974 COBRA Bills - Finally Some Passage
On July 30, 1965, The Medicare program was established by legislation signed into law on 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.
1993 Clinton Health Reform Plan
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 Clinton health care plan was a package proposed by the administration of President Bill Clinton and closely associated with the chair of the task force devising the plan, First Lady of the United States Hillary Rodham Clinton.
Bill Clinton had campaigned heavily on health care in the 1992 U.S. presidential election. The task force was created in January 1993, but its own processes were somewhat controversial and drew litigation. Its goal was to come up with a comprehensive plan to provide universal health care for all Americans, which was to be a cornerstone of the administration's first-term agenda. A major health care speech was delivered by President Clinton to the U.S. Congress in September 1993. The core element of the proposed plan was an enforced mandate for employers to provide health insurance coverage to all of their employees through competitive but closely-regulated health maintenance organizations.
Opposition to the plan was heavy from conservatives, libertarians, and the health insurance industry. The industry produced a much-talked-about television ad, "Harry and Louise", in an effort to rally public support against the plan. Democrats, instead of uniting behind the President's original proposal, offered a number of competing plans of their own. By September 1994, the final compromise Democratic bill was declared dead by Senate Majority Leader George J. Mitchell. Opponents of the plan continued to deride it in future years as "HillaryCare".
In 1996, The Health Insurance Portability and Accountability Act (HIPAA) made it easier for workers to keep health insurance coverage when they change jobs or lose a job, 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.
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.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. As a result of this intense opposition, the Patients' Bill of Rights initiative eventually failed to pass Congress in 2002.
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. 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.
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.
In 2006 the HIAA's successor organization, America's Health Insurance Plans (AHIP), issued another set of reform proposals.
In January 2007 Rep. John Conyers, Jr. (D-MI) 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. 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 co-sponsors. Both bills are indefinitely dead as stalled legislation.
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.
"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:
- 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. 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.
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.An earlier "Technical Memo" published by AHIP in June of 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."
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."
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." The Des Moines Register characterized the plans similarly.
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.
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).
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.The panel featured Republican senators and industry panelists who argued against any kind of expanded health care coverage. The preclusion of the single payer option from the discussion caused significant protest by doctors in the audience.
There is one bill currently before Congress but others are expected to be presented soon. A merged single bill is the likely outcome. 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. 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. 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. 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. A proposed but not yet enacted short bill with the same effect is the Republican sponsored Patients Act 2009.
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. 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. 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. 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. 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. 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.
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."
State Reform Efforts
A few states have taken serious steps toward universal health care coverage, most notably Minnesota and Massachusetts, with a recent example being the Massachusetts 2006 Health Reform Statute. 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. 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. It is typical for most forms of general liability insurance sold in the U.S., such as home, automobile, or business insurance to have a significant premium allocation for medical damages. In the event that a third party is responsible for injury or illness (e.g., the responsible driver in an automobile accident), action can be taken in the U.S. court system to prove liability and collect the money for medical bills from the responsible party's liability insurances.
Several single payer referendums have been proposed at the state level, but so far all have failed to pass: California in 1994, Massachusetts in 2000, and Oregon in 2002. 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.
The percentage of residents that are uninsured varies from state to state. Texas has the highest percentage of residents without health insurance at 24%.New Mexico has the second highest percentage of uninsured at 22%.
States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans, 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.
One municipality, San Francisco, California, has established a program to provide health care to all uninsured residents (Healthy San Francisco).
Since 2005, Universal Health Care Foundation of Connecticut has developed relationships with several key groups that would be instrumental in creating broad change in the health system, including medical societies, hospitals, businesses, labor and clergy. In January 2009 the foundation unveiled SustiNet, a proposal for a statewide health care plan for Connecticut that would provide residents with their choice of health coverage and care regardless of their employment status, age, or pre-existing conditions. An estimated 1,000 people attended a rally at Union Station (Hartford) for the release of the plan. SustiNet would emphasize preventive care and the management of chronic illnesses. It would create a large health insurance pool by combining state employees, retirees, and people covered by state assistance programs. The pool would also be open to members of the public without insurance, those with inadequate insurance, and employers, starting with small businesses, nonprofits and municipalities. Eventually, Sustinet would be open to larger employers wishing to buy into the plan for their employees In February; the 18,500-member Connecticut Association of REALTORS announced its support for the SustiNet health care plan. REALTORS are independent contractors and are representative of the plight of many independent contractors and small business employees in Connecticut in that they do not have access to group health insurance. Also in that month, the independent statewide organization "Small Businesses for Health Care Reform" endorsed the SustiNet health care reform proposal and encouraged other business owners to review and support it. In March 2009, the foundation's SustiNet plan was formally endorsed by the Interfaith Fellowship for Universal Health Care, a group devoted to health reform, as well as by dozens of other religious leaders representing a wide range of faiths in Connecticut. Fellowship members include Rabbi Stephen Fuchs of Congregation Beth Israel in West Hartford, a co-chairman of the Interfaith Fellowship, and Bilal Ansari, a Muslim chaplain at Saint Francis Hospital & Medical Center in Hartford, where much of his counseling involves helping families cope with not just the stress of a relative's illness, but the worries about how they will pay for it.
SustiNet passed its first legislative hurdle Thursday, March 26, receiving an endorsement from the state legislature's Public Health Committee. The committee voted 22-8 to move the bill forward. On April 22, SustiNet received a favorable report from a second committee, the Human Services Committee, which voted 13-6 for the bill. On April 29, SustiNet received a favorable report from a third committee, the Labor and Public Employees Committee, which voted 8-3 for the bill. On April 29, SustiNet received a favorable report from a third committee, the Labor and Public Employees Committee, which voted 8-3 for the bill. On May 7, 2009, Sustinet received a favorable report from a fourth committee, the Insurance and Real Estate Committee, which voted 13-4 for the bill.
On May 20, 2009, the Connecticut House of Representatives voted 107-35 for SustiNet.
On May 30, 2009, the Connecticut Senate voted 23-12 for SustiNet. The bill then went to Connecticut Governor M. Jodi Rell for signature or veto.
SustiNet was vetoed by Governor Rell on July 8. On July 20 the governor's vetoes were overridden by the Connecticut House of Representatives with a vote of 102 to 40, and then by the Connecticut Senate with a vote of 24-12.
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.
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.