Health care reform in the United States

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Healthcare reform in the United States of America
History Debate
Legislation Preceding Social Security Amendments of 1965 EMTALA (1986) HIPAA (1996) Medicare Modernization Act (2003) PSQIA (2005) Superseded Affordable Health Care for America (H.R. 3962) America's Affordable Health Choices (H.R. 3200) Baucus Health Bill (S. 1796) Proposed United States National Health Care Act (2009, H.R. 676) Healthy Americans Act (2007, 2009) Health Security Act (H.R. 3600) Latest enacted Affordable Care Act (H.R. 3590) Health Care and Education Reconciliation Act (H.R. 4872)
Reforms Recent legislative proposals Public opinion Reform advocacy groups Rationing Insurance coverage
Systems Free market Health insurance exchange Nationalized insurance Publicly-funded Single-payer Canadian vs. American Two-tier Socialized
Third-party payment models All-payer rate setting Capitation Fee-for-service Global payment
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Health care reform in the United States has a long history.

History of national reform efforts

Here is a summary of reform achievements at the national level in the United States. For failed efforts, state-based efforts, native tribes services and more details generally, see the main article History of health care reform in the United States.

• 1965 President Lyndon Johnson enacted legislation that introduced Medicare, covering both hospital (Part A) and supplemental medical (Part B) insurance for senior citizens. The legislation also introduced Medicaid, which permitted the Federal government to partially fund a program for the poor, with the program managed and co-financed by the individual states.^[1][2]
• 1985 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.^[3]
• 1996 The Health Insurance Portability and Accountability Act (HIPAA) not only protects health insurance coverage for workers and their families when they change or lose their jobs, it also made health insurance companies cover pre-existing conditions. If such condition had been diagnosed before purchasing insurance, insurance companies are required to cover it after patient has one year of continuous coverage. If such condition was already covered on their current policy, new insurance policies due to changing jobs, etc... have to cover the condition immediately.^[4]
• 1997 The Balanced Budget Act of 1997 introduced two new major Federal healthcare insurance programs, Part C of Medicare and the State Children's Health Insurance Program, or SCHIP. Part C formalized longstanding "Managed Medicare" (HMO, etc.) demonstration projects and SCHIP was established to provide health insurance to children in families at or below 200 percent of the federal poverty line. Many other "entitlement" changes and additions were made to Parts A and B of fee for service (FFS) Medicare and to Medicaid within an omnibus law that also made changes to the Food Stamp and other Federal programs.^[5]
• 2000 The Medicare, Medicaid, and SCHIP Benefits Improvement and Protection Act (BIPA) effectively reversed some of the cuts to the three named programs in the Balanced Budget Act of 1997 because of Congressional concern that providers would stop providing services.
• 2003 The Medicare Prescription Drug, Improvement and Modernization Act (also known as the Medicare Modernization Act or MMA) introduced supplementary optional coverage within Medicare for self-administered prescription drugs and as the name suggests also changed the other three existing Parts of Medicare law.
• 2010 The Patient Protection and Affordable Care Act, called PPACA or ACA but also known as Obamacare, was enacted, providing for the phased introduction over multiple years of a comprehensive system of mandated health insurance reforms designed to eliminate "some of the worst practices of the insurance companies"—pre-existing condition screening and premium loadings, policy cancellations on technicalities when illness seems imminent, annual and lifetime coverage caps. It also sets a minimum ratio of direct health care spending to premium income, and creates price competition bolstered by the creation of three standard insurance coverage levels to enable like-for-like comparisons by consumers, and a web-based health insurance exchange where consumers can compare prices and purchase plans. The system preserves private insurance and private health care providers and provides subsidies in the form of income tax reductions to enable lower income Americans to buy insurance. PPACA also made many changes to the 1997, 2000 and 2003 laws that had previously changed Medicare and further expanded eligibility for Medicaid (that expansion was later ruled by the Supreme Court to be at the discretion of the states)
• 2015 The Medicare Access & CHIP Reauthorization Act (MACRA) made significant changes to the process by which many Medicare Part B services are reimbursed and also extended SCHIP

Quality of care

There is significant debate regarding the quality of the U.S. healthcare system relative to those of other countries.

Patient Protection and Affordable Care Act

After campaigning on the promise of health care reform, President Barack Obama gave a speech in March 2010 at a rally in Pennsylvania explaining the necessity of health insurance reform and calling on Congress to hold a final up or down vote on reform.^[6] The result of his efforts was the Patient Protection and Affordable Care Act. Because Obama's party did not have a filibuster-proof majority in the Senate, the law was amended by the Health Care and Education Reconciliation Act of 2010 using the reconciliation process in which debate in the Senate is limited and the filibuster is therefore not permitted.

The legislation remains controversial,^[7][8][9] with some states challenging it in federal court^[10] and opposition from some voters.^[11] In June 2012, in a 5–4 decision, the U.S. Supreme Court found major portions of the law to be constitutional.^[12] However, the law continues to face legal challenges. The latest attempt at reversing the Affordable Care Act occurred during the Government Shutdown on October 1, 2013. Government officials that oppose the ACA tried to make approval of a bill to reopen the government contingent on the demise of the ACA. This attempt met with failure and the government reopened on November 16, 2013.^[13]

Uninsured Americans, with the numbers shown here from 1987 to 2008, are a major driver for reform efforts

As a result of the law, insurance companies can no longer charge members based on gender, burdening men with the health care costs of women. A study by the National Institutes of Health reported that the lifetime per capita expenditure at birth, using year 2000 dollars, showed a large difference between health care costs of females ($361,192) and males ($268,679). A large portion of this cost difference is in the shorter lifespan of men, but even after adjustment for age (assume men live as long as women), there still is a 20% difference in lifetime health care expenditures.^[14]

The act's provisions become effective over time. The most significant changes, particularly affecting the availability and terms of insurance become effective January 1, 2014. These include an expansion of Medicaid (at the option of each state) to those without dependent children and subsidized healthcare exchanges. Changes which occur earlier include allowing dependents to remain on their plan until 26, limitations on rescission (dropping insureds when they get sick), removal of lifetime coverage limits, mandates that insurers fully cover certain preventative services, high-risk pools for uninsureds, tax credits for businesses to provide insurance to employees, an insurance company rate review program, and minimum medical loss ratios.^[15]

The law creates the Patient-Centered Outcomes Research Institute to study comparative effectiveness research funded by a fee on insurers per covered life (starting at $1, increasing to $2 and thereafter adjusted according to an index^[16]). It also allowed the FDA to approve generic biologic drugs and specifically allows for 12 years of exclusive use for newly developed biologic drugs.

In addition, the law explores some programs intended to increase incentives to provide quality and collaborative care, such as accountable care organizations. The Center for Medicare and Medicaid Innovation was created to fund pilot programs which may reduce costs;^[17] the experiments cover nearly every idea healthcare experts advocate, except malpractice/tort reform.^[18] The law also requires for reduced Medicare reimbursements for hospitals with excess readmissions and eventually ties physician Medicare reimbursements to quality of care metrics.

The law is also designed to complement the 2009 HITECH Act which encourages the "meaningful use" of electronic health records; for example, the law directs the government to make use of these records for analyzing healthcare provider quality.^[19]

The Affordable Care Act also aims to promote access to preventative healthcare. Through providing access to screenings for diseases like breast cancer, promoting health in the workplace, and community preventative health, the Affordable Care Act contains sections that advance and promote preventative health initiatives.^[20]

Alternatives and research directions

There are alternatives to the exchange-based market system which was enacted by the Patient Protection and Affordable Care Act which have been proposed in the past and continue to be proposed, such as a single-payer system and allowing health insurance to be regulated at the federal level.

In addition, the Patient Protection and Affordable Health Care Act of 2010 contained provisions which allows the Centers for Medicare and Medicaid Services (CMS) to undertake pilot projects which, if they are successful could be implemented in future.

Single-payer health care

A number of proposals have been made for a universal single-payer healthcare system in the United States, most recently the United States National Health Care Act, (popularly known as H.R. 676 or "Medicare for All") but none have achieved more political support than 20% congressional co-sponsorship. Advocates argue that preventative health care expenditures can save several hundreds of billions of dollars per year because publicly funded universal health care would benefit employers and consumers, that employers would benefit from a bigger pool of potential customers and that employers would likely pay less, and would be spared administrative costs of health care benefits. It is also argued that inequities between employers would be reduced.^[21][22][23] Also, for example, cancer patients are more likely to be diagnosed at Stage I where curative treatment is typically a few outpatient visits, instead of at Stage III or later in an emergency room where treatment can involve years of hospitalization and is often terminal.^[24][25] Others have estimated a long-term savings amounting to 40% of all national health expenditures due to preventative health care,^[26] although estimates from the Congressional Budget Office and The New England Journal of Medicine have found that preventative care is more expensive.^[27]

Any national system would be paid for in part through taxes replacing insurance premiums, but advocates also believe savings would be realized through preventative care and the elimination of insurance company overhead and hospital billing costs.^[28] An analysis of a single-payer bill by Physicians for a National Health Program estimated the immediate savings at $350 billion per year.^[29] The Commonwealth Fund believes that, if the United States adopted a universal health care system, the mortality rate would improve and the country would save approximately $570 billion a year.^[30]

Recent enactments of single-payer systems within individual states, such as in Vermont in 2011, may serve as living models supporting federal single-payer coverage.^[31] The plan in Vermont, however, has failed.^[32]

Public option

In January 2013, Representative Jan Schakowsky and 44 other U.S. House of Representatives Democrats introduced H.R. 261, the "Public Option Deficit Reduction Act" which would amend the 2010 Affordable Care Act to create a public option. The bill would set up a government-run health insurance plan with premiums 5% to 7% percent lower than private insurance. The Congressional Budget Office estimated it would reduce the United States public debt by $104 billion over 10 years.^[33]

Balancing doctor supply and demand

The Medicare Graduate Medical Education program regulates the supply of medical doctors in the U.S.^[34] By adjusting the reimbursement rates to establish more income equality among the medical professions, the effective cost of medical care can be lowered.

See also

• Health care reform
• Health care system § International comparisons
• Health economics
• Health policy
• List of healthcare reform advocacy groups in the United States
• McCarran–Ferguson Act
• Medicare Sustainable Growth Rate

References

Further reading

• Christensen, Clayton Hwang, Jason, Grossman, Jerome, The Innovator's Prescription, McGraw Hill, 2009. ISBN 978-0-07-159208-6
• Terry L. Leap, Phantom Billing, Fake Prescriptions, and the High Cost of Medicine: Health Care Fraud and What to do about It (Cornell University Press, 2011).
• Mahar, Maggie, Money-Driven Medicine: The Real Reason Health Care Costs So Much, HarperCollins, 2006. ISBN 978-0-06-076533-0
• Morrisey, Michael A. (2008). "Health Care". In David R. Henderson (ed.). Concise Encyclopedia of Economics (2nd ed.). Indianapolis: Library of Economics and Liberty. ISBN 978-0865976658. OCLC 237794267. 
• Starr, Paul, The Social Transformation of American Medicine, Basic Books, 1982. ISBN 0-465-07934-2
• Reid, T.R. (2009). The Healing of America: A Global Quest for Better, Cheaper and Fairer Health Care. Penguin Books. ISBN 978-1-59420-234-6. 

External links

• Health care reform in the United States at DMOZ