Health care reform in the United States

Health care reform in the United States
Latest enacted legislation
preceding legislation

Health care reform in the United States has a long history, of which the most recent results were two federal statutes enacted in 2010: the Patient Protection and Affordable Care Act (PPACA), signed March 23, 2010,[1][2] and the Health Care and Education Reconciliation Act of 2010 (H.R. 4872), which amended the PPACA and became law on March 30.[3][4]

Contents

History of national reform efforts

Main article: History of health care reform in the United States

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.

The 2010 Federal Reform Legislation

In March 2010, President Obama gave a speech 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.[9] As of 2011, the legislation remains controversial,[10] with some states challenging it in federal court and opposition from some voters.[11]

Expanding Medicaid and subsidizing insurance

The law includes health-related provisions to take effect over several years, including expanding Medicaid eligibility for people making up to 133% of the federal poverty level (FPL),[12] subsidizing insurance premiums for people making up to 400% of the FPL ($88,000 for family of 4 in 2010) so their maximum "out-of-pocket" payment for annual premiums will be on sliding scale from 2% to 9.5% of income,[13][14][15][16][17] providing incentives for businesses to provide health care benefits, prohibiting denial of coverage and denial of claims based on pre-existing conditions, establishing health insurance exchanges, prohibiting insurers from establishing annual coverage caps, and support for medical research.

Guaranteed issue, community rating, individual mandate

Starting in 2014, the law will prohibit insurers from denying coverage (see guaranteed issue) to sicker applicants, or imposing special conditions such as higher premiums or payments (see community rating). Health care expenditures are highly concentrated with the most expensive 5% of the population accounting for half of aggregate health care spending, whereas the bottom 50% of spenders account for only 3%, which means that insurers' gains to be had from avoiding the sick greatly outweigh any possible gains from managing their care.[18] As a consequence, insurers devoted resources to such avoidance at a direct cost to effective care management which is against the interests of the insured.[19] Instead of providing health security, the health insurance industry had, since the 1970s begun to compete by becoming risk differentiators, seeking to insure only those with good or normal health profiles and excluding those considered to be or likely to become unhealthy and therefore less profitable. According to a study from Cambridge Hospital, Harvard Law School and Ohio University, 62% of all 2007 personal bankruptcies in the United States "were driven by medical incidents, with [75% having had] health insurance."[20]

Also starting in 2014, the law will generally require uninsured individuals to buy government-approved health insurance — the individual mandate. Government-run exchanges may present information to facilitate comparison among competing plans, if available, but previous attempts at creating similar exchanges “produced only mixed results."[21] This requirement is expected to reduce the number of the uninsured from 19% of all residents in 2010 to 8% by 2016.[22] Some analysts believe that the 8% figure of uninsured are expected to be mostly illegal immigrants (5%), with the rest paying the fine unless exempted.[22][23] Whether or not this is true remains unclear based on presently available data.

Some analysts have argued that the insurance premium structure may shift more costs onto younger and healthier people.[24] Approximately $43 billion was spent in 2008 providing unreimbursed emergency services for the uninsured[19] and the Act's supporters argued that increased the average family's insurance premiums.[25] Other studies claim the opposite: "The argument for reduced ER visits has been shown to be largely a canard...insuring the uninsured will lead to, very approximately, a doubling of health expenditures for the currently uninsured."[26] The studies suggest that making insurance mandatory rather than voluntary will tend to bring younger, healthier people into the insurance pool, shifting the cost of the Act's increased spending onto them.[27]

Efficacy of health insurance

The 2010 Acts require insurers to cover more costs, requiring that at least 80% of premiums must be spent on medical care or "quality improvement"[28] (see loss ratio) and requiring full coverage for screenings and immunizations, and by prohibiting lifetime and annual caps. Some insurance schemes had been considered inadequate.[29]

Some argue that expanding insurance coverage may lead to better health, while other studies claim the opposite. A 2009 Harvard study published in the American Journal of Public Health found more than 44,800 excess deaths annually in the United States associated with lack of insurance.[30][31] Other studies found less correlation,[32]; see also [33] More broadly, a 1997 analysis estimated the number of people in the United States—insured and uninsured—who die per year because of lack of medical care was nearly 100,000.[34] Recent reports have found that expanding coverage for psychiatric drugs has worsened the health of many children, who incur costly and lifelong side effects such as diabetes.[35][36][37] However, many of these studies fail to disclose that such examples of "expanded coverage" focus on narrow, non-representative subpopulations and do not, for example, reflect the likely large net benefit for the much larger subpopulations that have diabetes, hypertension, and resulting chronic kidney disease, all of whom would likely benefit from expanded coverage.

Some opponents to the Act have claimed that "80,000 people a year are killed just by “nosocomial infections”—infections that arise as a result of medical treatment." These claims however are tenuous at best since the incidence of nosocomical infections is not causally linked to expanded insurance coverage, especially when preventative measures are a key component of the new proposed regime, includiing numerous measures aimed to reduce the rate of hospitalization and re-hospitalization and improve primary prevention efforts in the outpatient setting. Opponents to the Act also point to a randomized study of almost 4,000 subjects done by Rand and concluded in 1982, which purportedly found that increasing the generosity of people’s health insurance caused them to use more health care, but made almost no difference in their health status."[33] The actual summary of the Rand study by Rand itself is quite different: "The poorest and sickest 6 percent of the sample at the start of the experiment had better outcomes under the free plan for 4 of the 30 conditions measured. Specifically, •Free care improved the control of hypertension. The poorest patients in the free care group who entered the experiment with hypertension saw greater reductions in blood pressure than did their counterparts with cost sharing. The projected effect was about a 10 percent reduction in mortality for those with hypertension. •Free care marginally improved vision for the poorest patients. •Free care also increased the likelihood among the poorest patients of receiving needed dental care.•Serious symptoms[2] were less prevalent for poorer people on the free plan. •Cost sharing also had some beneficial effects. Participants in cost sharing plans worried less about their health and had fewer restricted-activity days (including time spent in seeking medical care)." See http://www.rand.org/pubs/research_briefs/RB9174/index1.html.

Reduce the deficit

Reducing the deficit was another driver in health care reform. The reform legislation that passed was estimated by the Congressional Budget Office to reduce the deficit by $143 billion over 10 years.[38] However, the CBO numbers are the subject of some debate.[39]

Eliminate overpayment in Medicare Advantage

Medicare Advantage plans are offered by private insurers and provide benefits over and above coverage in Medicare Parts A and B and receive funding from the Medicare fund for taking on Part A and B coverage. However, under a revised contract made during the previous Bush presidency, Medicare was overpaying the private insurers. MedPAC estimated the overpayment as being approximately $12 billion a year.[40] This meant that the average person in traditional Medicare was paying $90 a year as a subsidy to private insurers for which they received zero benefit and eliminating this overpayment would save $177 billion over ten years.[41]

Political positions of the main parties

The Democratic Party supports the amended 2010 legislation. The Act aims to ensure health insurance is available to all citizens; to make more employers responsible for their workers' health insurance; to extend subsidies to middle income persons who have no employer insurance; and extend Medicaid to more people than had been the case previously. The Act directs federal spending to community health centers and to computerize health care records to encourage accurate sharing of data between health providers and reduce errors. The Act taxes expensive insurance plans and adjusts the split of Medicare funding between traditional Medicare and Medicare Advantage plans. The Act reforms payment systems and Medicare, which may reduce the perverse incentive system that pays hospitals with poor recovery records more than hospitals with better recovery records. The Act increases Medicare prescription drug coverage. President Obama said he had heard from Americans with pre-existing conditions whose lives depend on getting insurance coverage; stories of patients being denied coverage, and of families with insurance who are just one illness away from financial ruin. He said that the Act would protect people from the worst practices of the insurance industry. He said it would give small businesses and uninsured Americans a chance to choose an affordable health care plan in a competitive market. He claimed that if they did nothing, millions of Americans would lose their health care and the deficit would grow. He said that premiums would increase and patients would be denied the care they need, and that small business owners would continue to drop coverage altogether. He said he would not walk away from those Americans, and he urged others in Congress not to do so either. He highlighted that the American Medical Association considers the Act an improvement over the status quo. He challenged anyone, from either party, with a better plan that would bring down premiums, bring down the deficit, cover the uninsured, strengthen Medicare for seniors, and stop insurance company abuses, to let him know.[42]

The GOP's official current position as represented by the House majority is that the Affordable Care Act should simply be repealed, leaving the law as it was previously. The House of Representatives voted for this in January 2011, though it is unlikely that the Senate would pass it and some expect that the President would veto any attempt at repeal. The Republicans' previous proposal for health care reform in 2009 would have placed people with pre-existing conditions who are unable to get affordable coverage into high risk insurance pools and would have continued the previous practice of allowing insurers to discriminate against them in terms of coverage and premiums. Republicans opposed the Affordable Care Act during passage. Not a single representative in the House or Senate voted in favor of the bill.[43] This opposition was broadly based on objections to rises in taxation, especially of the so-called "Cadillac insurance plans" and the corollary increase in government spending on affordability subsidies. The GOP also objected to a new Health Insurance Rate Authority that would determine whether rate increases were "unreasonable" and to enforced rebates or premium reductions, and to any proposal that might have allowed government funds to subsidize abortion.[44] The opposition declared the law to be a "government takeover of health care". One version of an original draft prepared in the House of Representatives did call for a "public option" (a public insurer as one extra choice for consumers, competing against private insurers). Some Republicans have contested the constitutionality of the individual health insurance mandate (a requirement to have medical insurance or else pay a fine). Both the government and the insurance industry have argued that this is a necessary prerequisite to achieve universality and equity for other insurance payers and to prevent people buying insurance only in time of need. The government argues that its constitutionality is covered under the Commerce Clause, whereas detractors argue that this is wrong. As of 2010, this matter is still before the courts and so far 3 out of five federal court decisions have ruled in favor of it being constitutional and two against. Mitt Romney has said that the new law does not resemble the Massachusetts health care plan and did not support it. Some Republicans (for example Charles Grassley[45]) as well as the conservative think tank Heritage Foundation previously supported an individual mandate, but no longer do.[46] The same is true of the concept of the insurance exchanges which the bill sets up, which some Republicans and the Heritage Foundation once supported.[47]

Betsy McCaughey, a health care analyst who came to political prominence after she helped defeat the Clinton health care plan of 1993,[48] "got the ball rolling" in July and August 2009 when she called the bill "a vicious assault on elderly people" that will "cut your life short". McCaughey was joined in spreading the idea by other pundits and conservative media that had had helped defeat the Clinton era legislation, including The Washington Times and The American Spectator.[49][50] According to The New York Times, McCaughey also falsely claimed that presidential advisor Dr. Ezekiel Emanuel thought that the disabled should not be entitled to medical care, which helped inspire Palin's warnings about "death panels".[51] Both McCaughey and Palin's remarks about what Palin called an alleged 'death panel' were based on opinions about Ezekiel Emanuel[52][53][54][55][56] and previous page 425 legislation.[54][55][57][58]

Emanuel is an opponent of legalization of doctor-assisted suicide or euthanasia. FactCheck.org said, "We agree that Emanuel’s meaning is being twisted. In one article, he was talking about a philosophical trend, and in another, he was writing about how to make the most ethical choices when forced to choose which patients get organ transplants or vaccines when supplies are limited."[51] An article on Time.com said that Emanuel "was only addressing extreme cases like organ donation, where there is an absolute scarcity of resources ... 'My quotes were just being taken out of context.'"[59] Regarding page 425 of a health care bill, Congressman Earl Blumenauer (who sponsored the legislation) said the measure would block funds for counseling that presents suicide or assisted suicide as an option, and called references to death panels or euthanasia "mind-numbing". Page 425 of this legislation is similar to end-of-life counseling that became law when George W. Bush was president.[60]

A lot of the political debate centered on the prevention of the Federal funding of abortion with some groups claiming that abortion would become easier or would be financed by the government. In the legislation that was finally passed the existing law preserved the principle of no federal funding for abortion (except in cases of rape, incest, or to preserve the life of the mother).[61] The law requires people to pay for that element of coverage with a separate check to create a specific fund which is not subsidized and which is used to fund these services. State insurance commissioners are charged with policing this “segregation of funds”. Whether insurers in the exchanges can offer abortion coverage at all was left as a matter for individual States to decide. The default is that insurers will be allowed to offer abortion coverage as they do now unless a State passes legislation to the contrary.

Lobbying

According to Obama, America's health insurance industry has spent hundreds of millions of dollars to block the introduction of public medical insurance and stall other proposed legislation.[62] There are six registered health care lobbyists for every member of Congress.[63] The campaign against health care reform has been waged in part through substantial donations to key politicians. The single largest recipient of health industry political donations and chairman of the Senate Committee on Finance that drafted Senate health care legislation is Senator Max Baucus (D-MT).[64] A single health insurance company, Aetna, has contributed more than $110,000 to one legislator, Senator Joe Lieberman (ID-CT), in 2009.[65]

America's Health Insurance Plans, a lobby group funded by American private health insurance companies published its plans for health care reform in December 2008.[66] The key elements called for co-ordinated national strategy for health care with insurance regulation set in a national framework but enforced by the states.[66] It also called for a personal health care mandate requiring every American to have health insurance or face penalties. This, it said, was a necessary pre-requisite for guaranteed issue policies to prevent insurers from having to pre-screen applicants and set limits on coverage for pre-existing conditions, otherwise healthy people would put off buying insurance until they get sick.[66] It also called for the establishment of body to reform the payment system (including a shift from fee-for-service to fee-for-quality-outcomes), and a body to undertake Comparative effectiveness research because it admitted that the current system was not effective at providing value for money or even best practice and computerization and standardization of health care records and claims processing.[66] Most of the issues which AHIP called for in its plans have been implemented by the Obama administration and Congress in the reform process with the exception of a completely national framework for health care insurance regulation. Though the bill does place certain national rules for insurance to qualify as being "coverage" acceptable within the meaning of the individual mandate, states have retained the power under the reforms to regulate the industry and this was not put in a national framework.

Possible future reforms

The Patient Protection and Affordable Health Care Act 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.

Universal health care

See also: Universal health care#United States

The universal health care proposal pending in Congress is called the United States National Health Care Act (H.R. 676, formerly the "Medicare for All Act.") The Congressional Budget Office and related government agencies scored the cost of a universal health care system several times since 1991, and have uniformly predicted cost savings,[67] probably because of the 40% cost savings associated with universal preventative care[68] and elimination of insurance company overhead costs.[69]

Balancing doctor supply and demand

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

Bundled payments

A key project is one that could radically change the way the medical profession is paid for services under Medicare and Medicaid. The current system, which is also the prime system used by medical insurers is known as fee-for-service because the medical practitioner is paid only for the performance of medical procedures which, it is argued means that doctors have a financial incentive to do more tests (which generates more income) which may not be in the patients' best long term interest. The current system encourages medical interventions such as surgeries and prescribed medicines (all of which carry some risk for the patient but increase revenues for the medical care industry) and does not reward other activities such as encouraging behavioral changes such as modifying dietary habits and quitting smoking, or follow-ups regarding prescribed regimes which could have better outcomes for the patient at a lower cost. The current fee-for-service system also rewards bad hospitals for bad service. Some have noted that the best hospitals have fewer re-admission rates than others, which benefits patients, but some of the worst hospitals have high re-admission rates which is bad for patients but is perversely rewarded under the fee-for-service system.

Projects at CMS are examining the possibility of rewarding health care providers through a process known as "bundled payments"[70] by which local doctors and hospitals in an area would be paid not on a fee for service basis but on a capitation system linked to outcomes. The areas with the best outcomes would get more. This system, it is argued, makes medical practitioners much more concerned to focus on activities that deliver real health benefits at a lower cost to the system by removing the perversities inherent in the fee-for-service system.

Though aimed as a model for health care funded by CMS, if the project is successful it is thought that the model could be followed by the commercial health insurance industry also.

2010 Patient Protection and Affordable Care Act details

Main articles: Patient Protection and Affordable Care Act and Health Care and Education Reconciliation Act of 2010

Key provisions of the health-care legislation passed in March 2010 are:[3]

Within one year of enactment (2010–2011)

Effective during 2011

Effective as of 2012

Effective as of 2013

Effective as of 2014

Main article: Patient Protection and Affordable Care Act#Effective by January 1, 2014

Effective 2015

Effective 2018

Legal challenges

Main article: Patient Protection and Affordable Care Act: Legal challenges

As Congressional approval neared, opponents of health care reform shifted from parliamentary and procedural opposition to challenge the constitutionality of the legislation. The Virginia General Assembly passed the Virginia Health Care Freedom Act before Congress completed action on its bill. Governor Robert F. McDonnell signed that law on March 24, prior to House approval of the reconciliation bill.[86] The Virginia law prohibits any individual from being required to purchase health insurance. On March 17, 2010, Virginia Attorney General Ken Cuccinelli sent House Speaker Nancy Pelosi a letter threatening constitutional challenge to the enactment of the bill if the House used a self-implementing rule and deemed the bill, which had begun in the Senate, to pass.[87] On March 23, 2010, Cuccinelli filed Commonwealth v. Sebelius in the Federal District Court for the Eastern District of Virginia challenging the Constitutionality of the insurance requirement.[88] Also on March 23, 2010, the Attorney General of Florida, together with the States of South Carolina, Nebraska, Texas, Utah, Louisiana, Alabama, Michigan, Colorado, Pennsylvania, Washington, Idaho and South Dakota filed a joint law suit in a Florida district court also challenging the new law.[89]

Some Constitutional law professors and commentators in the press have opined that the lawsuits and state laws are unlikely to succeed.[90][91][92][93] However, other Constitutional law professors and other legal experts maintain that the health insurance mandate (the requirement that individuals purchase insurance, or face a penalty) is, in fact, unconstitutional.[94][95]

On August 2, 2010, District Court Judge Henry Hudson, presiding over Virginia's lawsuit challenging the Obama administration's health care reform package, denied the Justice Department's attempt to have that lawsuit dismissed, stating that Virginia's case raises Constitutional issues - mainly whether Congress has the right under the Commerce Clause to regulate and tax a person's decision not to participate in interstate commerce.[96]

On December 13, 2010, U.S. District Judge Henry E. Hudson struck down part of the health care law. "In his 42-page opinion, Hudson concluded that requiring most people to get insurance or pay a fine - as the law mandates starting in 2014 - is an unprecedented expansion of federal power and cannot be justified under Congress's authority to regulate interstate commerce." .[97][98]

Health reform and the 2008 presidential election

Main article: Health care reform in the United States presidential election, 2008

See also

United States portal
Health and fitness portal
Politics portal

References

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