The long, long road to na­tional health re­form (A short his­tory)

Modern Healthcare - - SPECIAL FEATURE -

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.

2010 (cont.)

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

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