History of Reform in US

President John Adams signs into law, "An Act for the Relief of Sick and Disabled Seamen," creating the Marine Hospital Service that later evolves into the Public Health Service. Federal customs collectors tax American ships arriving from foreign ports 20 cents per sailor per month to pay for construction and mainte­nance of marine hospitals. This sum is subtracted from the wages of seamen.

National Convention of Insurance Commissioners develops first model of state law for regulating health insurance.

The American Association for Labor Legislation (AALL) publishes a draft bill for compulsory health insurance and promotes campaigns in several states. A few states show interest, but fail to enact as U.S. enters into World War I. The idea draws initial support from the AMA, but by 1920 AMA reverses their position.

Committee on the Costs of Medical Care forms to study the economic organization of medical care. Group is comprised of economists, physicians, public health specialists, and other major interest groups. Recommendations were completed by 1932. While some members would not support the recommendation for medical group practice, the majority did endorse the idea, along with voluntary health insurance.

Great Depression years begin.

FDR creates Committee on Economic Security to address old-age and unemployment issues, as well as medical care and insurance.

President Roosevelt continued to support national health reform throughout his terms. His second push for national health insurance came after the Social Security Act passed. However, the momentum from FDR’s Technical Committee on Medical Care and a National Health Conference were not enough to overcome a Congress that was no longer supportive of further government expansions.

Social Security Act passed by Congress. The Act includes grants for Maternal and Child Health. These grants restored many of the programs established under the SheppardTowner Act and extended the role of the Children’s Bureau to include not only maternal and child health services, but other child welfare services as well. In the end, President Roosevelt did not risk the passage of the Social Security Act to advance national health reform.

Technical Committee on Medical Care established under Interdepartmental Committee to Coordinate Health and Welfare Activities; publishes its report, A National Health Program in 1938.

Sen. Wagner introduces National Health Bill incorporating recommendations from the National Health Conference. Proposal dies in committee.

Department of Health and Human Services born as the Federal Security Agency bringing together federal agencies concerned with health, welfare, and social insurance.

Senators Wagner and Murray, along with Representative Dingell introduce legislation as part of a broader vision to operate health insurance as part of social security. Wagner-Murray-Dingell bill includes provisions for universal comprehensive health insurance along with other changes to social security meant to move toward a system of "cradle to grave" social insurance.

FDR outlines 'economic bill of rights' including right to adequate medical care and the opportunity to achieve and enjoy good health in his State of the Union address.

Truman sends health message to Congress. Revised Wagner-Murray-Dingell bill introduced to Congress again. An alternative Senate bill (Taft-Smith-Ball bill) authorizes grants to states for medical care of the poor. Neither bill gains traction.

Truman, in another special message to Congress calls for a National Health Program. Wagner-MurrayDingell bill and Taft bill both reintroduced.

AMA launches a national campaign against national health insurance proposals.

National Conference on Aging is convened by Federal Security Agency.

Federal Security Agency proposes enactment of health insurance for Social Security beneficiaries.

Revenue Act of 1954 excludes employers' contributions to employee's health plans from taxable income.

Military "medicare" program enacted, providing government health insurance for dependents of those in the Armed Forces.

AFL-CIO decides to support government health insurance, while the AMA reiterates opposition to national health insurance.

The groundwork for the enactment of Medicare and Medicaid began in the late 1950s and early 1960s. As employer-based health coverage grew, private plans began to set premiums based on their experience with health costs and the retired and disabled found it harder to get affordable coverage. Health reformers refocused their efforts toward the elderly.

Kerr-Mills Act passes, using federal funds to support state programs providing medical care to the poor and elderly; a precursor to the Medicaid program.

President Kennedy addresses the nation on Medicare that is televised from Madison Square Garden. AMA issues televised rebuttal.

Civil Rights Act passes.

Medicare and Medicaid were incorporated under the Social Security Act and signed by President Johnson in 1965 with Truman by his side. The combination of Johnson’s political skills, a large Congressional Democratic majority, public approval, the support of the hospital and insurance industries, and the fact that no government cost controls or physician fee schedules were enacted contributed to the passage of the most significant health reform of the century.

The Medicare and Medicaid programs are signed into law. Medicare Part A is to pay for hospital care and limited skilled nursing and home health care. Optional Medicare Part B is to help pay for physician care. Medicaid is a separate program to assist states in covering not only long-term care for the poor but also to provide health insurance coverage for certain classes of the poor and disabled.

General inflation and unchecked health care costs were a growing concern by the early 1970s. Sen. Kennedy’s proposal for national health insurance was countered by President Nixon’s own Comprehensive Health Insurance Plan (CHIP). Other Congressmen wrote more incremental plans, all of which splintered support for any one reform. Action on national health insurance was eventually overshadowed by the Watergate hearings and Nixon’s resignation. While President Ford supported national reform in 1974 and Rep. Mills drafted yet another compromise bill, its progress stalled without Mills' leadership following a personal scandal

Social Security amendments pass allowing people under age 65 with long-term disabilities and end-stage renal disease (ESRD) to qualify for Medicare coverage. Those with long-term disabilities must wait for two years before qualifying for Medicare.

Supplemental Security Income (SSI) program begins providing cash assistance to elderly and disabled. States are required to cover SSI recipients or apply their 1972 Medicaid eligibility standards for the two groups for coverage under Medicaid.

Hawaii Prepaid Health Care Act passes requiring employers to cover any employee working more than 20 hours/week. In 1989 Hawaii added their State Health Insurance Program to cover "the gap group": those not eligible for Medicaid or employer-based insurance.

Health Care Financing Administration (HCFA) established within Department of Health, Education, and Welfare (HEW).

National Medical Care Expenditure Surveys (NMCES) conducted surveying households, their physicians, and health insurers – provides first detailed data on individuals' health care costs.

Federal budget reconciliation (OBRA 81) requires states to make additional Medicaid payments to hospitals who serve a disproportionate share of Medicaid and low-income patients. It also repeals the requirement that state Medicaid programs pay hospital rates equivalent to those paid by the Medicare program. Requires states to pay nursing homes at rates that are "reasonable and adequate" under the Boren Amendment (applied to hospitals the following year).

States allowed to expand Medicaid to children with disabilities who require institutional care but can be cared for at home and would not otherwise qualify for Medicaid if not institutionalized; popularly referred to as the Katie Beckett option for the disabled child who garnered national attention on the issue.

COBRA (Consolidated Omnibus Budget Reconciliation Act) contains specific regulations that allow employees who lose their jobs to continue with their health plan for 18 months.

Emergency Medical Treatment and Active Labor Act (EMTALA) requires hospitals participating in Medicare to screen and stabilize all persons who use their emergency rooms regardless of ability to pay.

National Medical Expenditure Survey (NMES), built on the NMCES 1977, is conducted with household information supplemented by surveys of medical and health insurance providers used by respondents.

The Family Support Act requires states to extend 12 months of transitional Medicaid coverage to families leaving welfare due to earnings from work.

Making national health reform a priority early in his Presidency, Clinton proposed a "managed competition" approach, sending a detailed plan to Congress in 1993. It called for universal coverage, employer and individual mandates, competition between insurers, with government regulation to control costs. Support from key stakeholders was often limited and conditional. The opposition was led largely by two groups: the Health Insurance Association of America and the National Federation of Independent Businesses, both believing reform would create hardship for their smaller members. Congressional Democrats were divided in their support, and further splintered by a variety of alternative proposals that were then generated all of which blocked progress on the President's plan

Federal budget reconciliation (OBRA 90) legislation mandates Medicaid coverage of children age 6-18 under the poverty level, phased in one year at a time until 2002.

Health Insurance Association of America begins airing "Harry and Louise" television advertisements portraying a middle-class couple worried about health care under the Clinton health plan.

The Vaccines for Children program providing federally purchased vaccines to states is established.

Other national health reform proposals are introduced in Congress, but also fail to garner sufficient support for passage -- the McDermott/Wellstone single payer health insurance proposal and Cooper's proposal for managed competition without a guarantee of universal coverage. By mid-1994 even a bipartisan bill to expand coverage without comprehensive reform is unable to pass.

Health Insurance Portability and Accountability Act (HIPAA) restricts the use of pre-existing conditions in health insurance coverage determinations, sets standards for medical records privacy, and establishes tax-favored treatment of long-term care insurance.

Mental Health Parity Act enacted that prohibits group health plans from having lower annual or lifetime dollar limits for mental health benefits than medical or surgical benefits (except substance abuse and chemical dependency).

Also part of the Balanced Budget Act (BBA), the State Children's Health Insurance Program (S-CHIP) is enacted. Provides block grants to states allowing for coverage of low-income children above Medicaid eligibility levels. BBA also allows states to cover working disabled with incomes up to 250% of poverty, permits mandatory Medicaid enrollment in managed care and repeals the Boren amendment.

Breast and Cervical Cancer Treatment and Prevention Act of 2000 allows states to provide Medicaid coverage to uninsured women for treatment of breast or cervical cancer if they have been diagnosed through a CDC screening program, regardless of income or resources.

Maine passes the Dirigo Health Reform Act, a comprehensive health care reform plan, that creates the DirigoChoice health plan, providing subsidized coverage to individuals and small employers, expands Medicaid, and creates the Maine Quality Forum.

Medicare legislation creates Health Savings Accounts which allow individuals to set aside pre-tax dollars to pay for current and future medical expenses. The plans must be used in conjunction with a high-deductible health plan.

Medicare Part D Drug benefit goes into effect in January.

One month following Massachusetts, Vermont passes comprehensive health care reform also aiming for near-universal coverage. In addition to creating the Catamount Health Plan for uninsured residents, the plan focuses on improving the overall quality of care and the management of chronic conditions through the Blueprint for Health.

Senators Wyden and Bennett introduce the Healthy Americans Act. The proposal would require individuals to obtain private health insurance coverage through state health insurance purchasing pools. The long-standing favorable tax treatment of employer-sponsored insurance premiums would be eliminated. Legislation gains some bipartisan support.

Congress passes two versions of a bill to reauthorize the State Children’s Health Insurance Program with bi-partisan support, but President Bush vetoes both bills and Congress cannot override the veto. A temporary extension of the program is passed in December 2007.

Mental Health Parity Act amended to require full parity. Insurance companies must treat mental health conditions, including substance abuse disorders, on an equal basis with physical conditions when health policies cover both.

The Children's Health Insurance Program (CHIP) is reauthorized, providing states with additional funding, new tools land fiscal incentives to help reach and estimated 4.1 million children through Medicaid and CHIP who otherwise would have been uninsured by 2013.

White House holds a Health Reform Summit with key stakeholders.

President Obama releases FY 2010 budget which outlines eight principles for health reform and proposes a set aside of 634 billion in a health reform reserve fund.

The White House releases President Obama's proposal for health care reform that bridges elements of the House and Senate bills passed in the last months of 2009.

In a White House speech President Obama lays out his proposal and provides legislative direction indicating that if need be, the reconciliation process (requiring a Senate majority vote vs. 60 votes to pass) should be used to pass major health reform legislation.

President Obama signs the landmark legislation, the Patient Protection and Affordable Care Act (P.L. 111-148) at the White House, surrounded by legislative leaders and invited guests, including some who have suffered from the lack of health coverage. The historic health reform legislation requires that all individuals have health insurance beginning in 2014.

• The poorest will be covered under a Medicaid expansion.
• Those with low and middle incomes who do not have access to affordable coverage through their jobs will be able to purchase coverage with federal subsidies through new "American Health Benefit Exchanges."
• Employers are not mandated to provide health benefits, however large businesses whose employees receive insurance subsidies will pay penalties. Small businesses will be able to access more plans through a separate Exchange.
• Health plans will not be allowed to deny coverage to people for any reason, including their health status, nor can they charge more because of a person's health or gender. Young adults will now have the option of being covered under their parents' plan up to age 26.

 

President Obama signs the Health Care and Education Reconciliation Act of 2010 (becoming P.L. 111-152) at the Northern Virginia Community College amending P.L. 111-148.