The long, long road to national health reform (A short history)
1883 Germany enacts Chancellor Otto von Bismarck’s Sickness Insurance Law, the world’s first national healthcare system. 1912 Former President Theodore Roosevelt runs again for the presidency on the Progressive Party ticket and a platform endorsing national health insurance. 1932 The Committee on the Cost of Medical Care issues a report stating that medical care has become too expensive for many Americans. It recommends an expansion of group physician practices organized around hospitals and an expansion of health insurance. The American Medical Association and other critics denounce the report as advocating “socialized medicine.” 1934 President Franklin D. Roosevelt creates an advisory Committee on Economic Security, which considers including national health insurance in its model bill. An insurance proposal in the Social Security Act is dropped after intense lobbying by the AMA. 1935 The Social Security Act is adopted without a national health insurance provision. 1943 Sen. Claude Pepper (D-Fla.) moves to establish the Subcommittee on Wartime Health and Education. It surveys needs around the country and later issues a report concluding that national health insurance is the only way to ensure access to care. 1944 President Franklin D. Roosevelt in his State of the Union address proposes an economic “Second Bill of Rights” to secure prosperity for the future after World War II. This includes “the right to adequate medical care and the opportunity to achieve and enjoy good health.” 1945 Roosevelt dies in April before he can fulfill his promise of a national health insurance program. He is succeeded by Harry S. Truman, who proposes national health insurance as well as funding for hospital construction and providing grants to states for public health. His proposals are blasted by Republicans, who call them biggovernment schemes. 1946 Congress passes the Hospital Survey and Construction Act, also known as Hill-Burton, which subsidizes a wave of hospital construction. It also requires hospitals to provide charity care. 1947 Truman again calls for a national health plan. The AMA blasts the insurance proposal as “socialized medicine,” and the U.S. Chamber of Commerce and other groups also oppose the initiative. 1948 The United Kingdom’s National Health Service is launched, providing medical care to all citizens who want it. 1962 President John F. Kennedy backs health coverage for senior citizens. The Medicare proposal runs into opposition from commercial insurers and the medical profession, most notably the AMA. 1965 In the wake of Kennedy’s assassination and a Democratic sweep of the 1964 congressional elections, President Lyndon B. Johnson pushes an aggressive domestic agenda. He persuades Congress to approve creation of the Medicare and Medicaid programs. Johnson signs the Medicare bill into law in Independence, Mo., with former President Truman at his side. 1966 Canada sets up a national Medicare system, building on health insurance programs that had been under way in provinces since the 1940s, most notably Saskatchewan.
1971 Sen. Edward Kennedy (D-Mass.) assumes chairmanship of the Senate Health Subcommittee and proposes a national single-payer program. President Richard Nixon also introduces a plan to bolster private insurance, impose an employer mandate to provide benefits and offer federal subsidies for low-income workers. Other events overwhelm the debate; neither plan is enacted. 1973 Nixon signs into law an experimental program to create health maintenance organizations, a proposal backed by corporations alarmed by rising healthcare costs. 1974 Kennedy begins negotiations with the Nixon White House that nearly achieve an agreement on health reform. Opposition from the AMA, small businesses, unions and outside events undermine the effort. 1979 Two political rivals, President Jimmy Carter and Kennedy, offer competing reform proposals, but the issue is sidelined by other events. 1986 Congress approves the Emergency Medical Treatment and Labor Act, requiring hospitals to screen and stabilize all emergency room patients, and the Consolidated Omnibus Budget Reconciliation Act, known as COBRA, allowing employees to continue group coverage for 18 months after losing their jobs. 1988 President Ronald Reagan signs the Medicare Catastrophic Coverage Act to shield seniors from ruinous long-term health costs. It is financed by a surtax on Medicare beneficiaries. 1989 Congress repeals the catastrophic coverage law after protests by senior citizens upset about the surtax. 1993 President Bill Clinton launches a universal coverage reform effort, spearheaded by his wife, Hillary Rodham Clinton. The “managed competition” plan would have private insurers compete in a regulated market. 1994 The Clinton plan dies in Congress, the result of partisan politics, lobbying by provider and insurance interests and poor White House handling. 1996 Congress approves the Health Insurance Portability and Accountability Act, sponsored by Kennedy and Sen. Nancy Kassebaum (R-Kan.). The legislation is touted as a remedy for pre-existing condition bans and other insurance problems, but it has only a minor effect on coverage. 1997 President Clinton signs legislation creating the State Children’s Health Insurance Program, designed to increase funds to states to expand coverage of low-income children. 2003 President George W. Bush signs legislation creating the Medicare Part D prescription drug benefit program. Critics contend the program isn’t properly financed, relies on private insurers and leaves a “doughnut hole” coverage gap for seniors facing high drug costs. 2007 The race for the White House gets under way, with a raft of Democratic and GOP hopefuls promising to increase healthcare access and control costs. 2008 Barack Obama wins the Democratic nomination and faces GOP opponent Sen. John McCain. Obama favors a sweeping health overhaul, while McCain backs a more modest approach of allowing insurers to sell across state lines and taxing employee health benefits. Obama wins and begins selecting a team to shepherd reform initiatives.
Obama’s choice for HHS secretary and leader on reform issues, former Democratic Senate Leader Tom Daschle, withdraws his nomination in the wake of revelations over taxes and interest from a consulting firm and use of a car service. He is replaced by former Kansas Gov. Kathleen Sebelius. Nancy-Ann DeParle, a former Clinton administration official, becomes director of a newly created White House Office on Health Reform.
In May, Obama lauds promises by segments of the healthcare industry to cut $2 trillion in spending over a decade.
The AMA, which historically opposed reform, indicates in June that it will back reform legislation.
In July, House Democratic leaders unveil their reform proposal, America’s Affordable Health Choices Act. The measure—estimated to cost $871 billion—is approved by Democrats on three House committees. Also in July, the Senate Health, Education, Labor and Pensions Committee on a party-line vote approves a healthcare reform plan.
Congress adjourns for its August recess and anti-reform protesters flock to lawmakers’ “town hall” constituent 2010
Republican Scott Brown on Jan. 19 wins the special election in Massachusetts to fill the Senate seat long held by Ted Kennedy, who died in August 2009. The victory sends shock waves through the ranks of Democratic lawmakers because Brown made a point of opposing reform and because it deprives them of the 60th vote needed to break Senate filibusters.
Obama on Jan. 27 again touts healthcare reform in his State of the Union address.
Anthem Blue Cross, a unit of WellPoint, tells subscribers on Feb. 13 that it intends to raise premiums for individual insurance plans by an average of 25%. The Obama administration seizes on the announcement as proof that insurance reform is needed, and launches a series meetings. The gatherings sometimes turn chaotic and feature denunciations of Obama as a socialist and a fascist. Some Republicans contend the House reform plan would create “death panels” to withdraw medical care from senior citizens.
Obama addresses a joint session of Congress in September to argue in favor of reform. He tells lawmakers: “I am not the first president to take up this cause, but I am determined to be the last.” He denounces what he terms a “partisan spectacle” and “scare tactics.”
In October, the Congressional Budget Office estimates the $829 billion Senate Finance Committee reform bill would meet spending targets and reduce the federal deficit by more than $81 billion over a decade. The committee later votes 14-9 to approve the legislation, with one Republican, Sen. Olympia Snowe of Maine, joining Democrats to advance the measure.
Later in October, House Democrats unveil a compromise $894 billion reform package that would provide additional coverage by expanding Medicaid and offering subsidies to moderate-income Americans to buy insurance either from private carriers or a government-run plan.
of attacks on the insurance industry.
The Obama administration on Feb. 22 issues it own reform proposal, which mirrors the Senate-approved package with some changes designed to appeal to House Democrats.
Obama hosts a bipartisan televised healthcare summit Feb. 25. Despite hours of talk, Republicans show no signs of compromise and Democrats appear resolved to push on with legislation.
On March 20, final debate on the reform legislation opens in the House. Obama comes to Capitol Hill to encourage skittish House lawmakers to vote for the bills. Quoting Abraham Lincoln, who said, “I am not bound to win, but I am bound to be true. I am not bound to succeed, but I am bound to live by the
The House narrowly approves its reform measure in early November. Lawmakers vote 220-215 to OK the legislation with only one Republican joining Democrats.
Senate Majority Leader Harry Reid of Nevada unveils a 10-year, $848 billion overhaul package that melds components of two previously approved Senate bills.
The Senate in November votes 60-39 along party lines to begin debate on the reform package.
Senior Senate Democrats reach a deal to drop the government-run insurance plan from their reform package. Instead, people 55 and older would be permitted to buy into Medicare. That deal is torpedoed when Sen. Joseph Lieberman (I-Conn.) threatens to filibuster any legislation with a Medicare expansion.
The Senate rejects Republican filibuster attempts and 60 Democrats vote to approve that chamber’s health reform package on Christmas Eve. The vote marks the first time in history that both chambers of Congress had approved comprehensive health reform legislation. Lawmakers look to a reconciliation of the House and Senate bills. light that I have,” Obama urges them to pursue the goal of the public good.
Tensions soar on March 21 as the House nears final votes on two pieces of legislation to enact reform. Protesters outside the Capitol taunt members of Congress. Meanwhile, a small group of anti-abortion Democrats win a statement from the White House affirming that no public money under the reform bill will be used to fund abortions. The House finally votes on the bill passed by the Senate and a second bill to make corrections in the Senate measure. Both pass on party-line roll calls, with no Republican support.
On March 23, Obama signs the Senate bill into law during a White House ceremony.
Even before passage of the reform package, Republicans vow to repeal the legislation. Some politically conservative and business interests join in the congressional and legal battles against the law. Florida’s attorney general, joined by 12 other attorneys general, files the first suit in federal court challenging the act shortly after Obama signs it into law.
Republican candidates running in the midterm elections campaign hard against the reform law.
In the November elections, Republicans reclaim the U.S. House of Representatives for the first time since 2006, although Democrats retain control of the Senate. GOP leaders immediately launch plans for a reform repeal effort and state Republicans promise to impede the law’s state insurance exchanges.
The government in November issues final rules under the reform law regarding the treatment of patients, including those who are same-sex domestic partners, by Medicare and Medicaid participating hospitals. 2011
In the first major act of the new Congress, House Republicans in January vote to repeal the reform law. The roll call is 245-189, with only three Democrats siding with GOP opponents. Senate Democratic leaders say they will block a similar vote in that chamber.
U.S. District Judge Roger Vinson in Pensacola, Fla., rules shortly after the House vote in January that the entire reform law is unconstitutional because Congress exceeded its authority under the commerce clause in forcing nearly all Americans to purchase insurance. The most famous of the three dozen lawsuits challenging the reform law, the lawsuit eventually comes to include officials from 26 states as plaintiffs.
Senate Republicans come up short on a vote to attach an ACA repeal amendment to an air traffic control modernization measure.
In April, the Senate passes the House version of a bill to overturn the reform law’s contentious Form 1099 provision that would have required businesses to report to the Internal Revenue Service payments of goods totaling $600 or more. Obama signs the bill into law the same month.
The House in May votes 238183 to eliminate federal funding for states to establish health insurance exchanges; the Senate promises the legislation is “dead on arrival.” Also in May, the House votes 235191 for a measure to eliminate funding for construction of school-based health centers.
The government in May issues final rules requiring health insurers to explain double-digit premium increases.
The 11th U.S. Circuit Court of Appeals in Atlanta in August strikes down the mandate for individuals to buy health insurance, which emerges as the most controversial aspect of the law. The court says the rest of the law can stand without the mandate, and becomes the only appeals court to strike down any part of the law. All four questions related to the law’s legality before the U.S. Supreme Court stem from aspects of this decision.
In August, after a months-long battle, Obama signs a bill creating a “supercommittee” of lawmakers to find $1.5 trillion in deficit reductions. By Thanksgiving, the panel fails in the effort, setting the stage for automatic cuts of $1.2 trillion split between domestic and defense spending to begin in January 2013. The bill caps Medicare cuts, which are limited to providers, at 2%.
The Obama administration in October issues final rules for Medicare accountable care organizations, amending controversial rules in March that came under industry fire. The new rules drop requirements that all ACOs face potential penalties, and they increase potential bonuses.
HHS suspends the Community Living Assistance Services and Supports Act, known as the CLASS Act. The reform law provision was intended to provide coverage of longterm care, but HHS Secretary Kathleen Sebelius says, “We have not identified a way to make CLASS work at this time.”
In November, the influential U.S. Court of Appeals for the District of Columbia Circuit upholds, by a 2-1 majority, the individual mandate to purchase health insurance, saying it was a “political judgment” that was legal under precedents including
Wickard (1942) and Raich (2005).
More implementation rules are issued in November, including ones regarding incentive payments under the hospital valuebased purchasing program.
The government in December issues final rules requiring insurance plans to spend minimum percentages of premium dollars on paying for healthcare services or refund the difference to customers. 2012
In January, the administration issues a rule requiring employers to cover birth control without out-ofpocket payments. After strong protest by Roman Catholic clergy, the government promises religious employers that insurers—not the employers—would cover contraceptives.
Obama signs a legislative package passed in February that averts a 27.4% Medicare physician pay cut and uses about $5 billion from the law’s public health and prevention fund to pay for it.
In March, the House votes 223181 to repeal the ACA’s Independent Payment Advisory Board, which was intended to control Medicare cost growth.
The U.S. Supreme Court in March holds three days of oral arguments on challenges to the reform law. Conservative justices—and Anthony Kennedy, a perceived swing vote—pepper the government’s attorney with pointed questions about the law, alarming reform proponent lawyers who previously saw little chance the court would overturn the act. The law’s individual mandate comes in for particular scrutiny; justices question whether the whole law can stand if the mandate is struck down.
The House in April passes a bill to cut nearly $6 billion from the reform law’s prevention and public health fund to offset the cost of preventing a doubling of student loan interest rates.
The House votes 270-146 in June to repeal a tax on medical devices that was included in the reform law. The 2.3% excise tax applies to the sale of medical devices by manufacturers and importers. The tax came under fire from device manufacturers and business groups. The Senate has no plans to take up the measure, and the White House threatens to veto the bill if it reaches Obama’s desk.
In June, the Supreme Court ruled that the insurance provisions of the Patient Protection and Affordable Care Act are constitutional. The court in a 5-4 ruling with Chief Justice John Roberts in the majority says Congress has the power to compel individuals to purchase insurance as a tax on people who do not have health insurance. The court strikes down part of the law’s Medicaid expansion provisions. Republicans vow to continue trying to dismantle the ACA.
1883—Chancellor Otto von Bismarck
1912—President Theodore Roosevelt
1944—President Franklin D. Roosevelt
1947—President Harry S. Truman
1962—President John F. Kennedy
1965—President Lyndon B. Johnson
1973—President Richard Nixon
1974—Sen. Edward Kennedy
1997—President Bill Clinton
2012—U.S. Supreme Court
2010—President Barack Obama