Background
The issue of health insurance reform in the United States has been the subject of political debate since the early part of the 20th century. Recent reforms remain an active political issue. Alternative reform proposals were offered by both of the two major candidates in the 2008 presidential election and President Obama's plan for universal health care was challenged in the 2012 presidential election.
Clinton Initiative
Health care reform was a major concern of the Bill Clinton administration, headed by First Lady Hillary Clinton; however, the 1993 Clinton health care plan was not enacted into law.
The Health Security Express was a bus tour that started in late July of 1994. It involved supporters of President Clinton's national health care reform. Several buses leaving from different points in the United States stopped in many cities along the way to the final destination of the White House. During these stops, each of the bus riders would talk about personal experiences, health care disasters, and why they felt it was important for all Americans to have health insurance. When the bus tour ended on August 3rd, the riders were greeted by President Clinton and the First Lady on the White House South lawn for a rally that was broadcast all over the world.
Changes under George W. Bush
In 2003 Congress passed the Medicare Prescription Drug, Improvement, and Modernization Act , which President George W. Bush signed into law on December 8, 2003. Part of this legislation included filling gaps in prescription-drug coverage left by the Medicare Secondary Payer Act that was enacted in 1980. The 2003 bill strengthened the Workers' Compensation Medicare Set-Aside Program (WCMSA) that is monitored and administered by CMS.
Debate in the 2008 Presidential Election
Barack Obama called for universal health care and the creation of a National Health Insurance Exchange that would include both private insurance plans and a Medicare-like government run option. Coverage would be guaranteed regardless of health status and premiums would not vary based on health status. Obama's plan required that parents cover their children, but did not require that adults buy insurance.
In 2010, the Patient Protection and Affordable Care Act (PPACA) was enacted by President Obama, providing for the introduction, over four years, of a comprehensive system of mandated health insurance with reforms designed to eliminate some of the least-desirable practices of the insurance companies (such as precondition screenings, rescinding policies when illness seemed imminent, and annual and lifetime coverage caps). The PPACA also set a minimum ratio of direct health care spending to premium income, created price competition bolstered by the creation of three standard insurance coverage levels to enable like-for-like comparisons by consumers, and also created 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 more subsidies to enable the poor to buy insurance.
Effective as of 2013
- A national pilot program is established for Medicare on payment bundling to encourage doctors, hospitals, and other care providers to better coordinate patient care. The threshold for claiming medical expenses on itemized tax returns is raised from 7.5% to 10% of adjusted gross income. The threshold remains at 7.5% for the elderly through 2016.
- The Federal Insurance Contributions Act tax (FICA) is raised to 2.35% from 1.45% for individuals earning more than $200,000 and married couples with incomes over $250,000. The tax is imposed on some investment income for that income group.
- A 2.9% excise tax is imposed on the sale of medical devices. Anything generally purchased at the retail level by the public is excluded from the tax
Effective as of 2014
- State health insurance exchanges open for small businesses and individuals.
- Individuals with income up to 133% of the federal poverty level qualify for Medicaid coverage.
- Healthcare tax credits become available to help people with incomes up to 400 percent of poverty purchase coverage on the exchange.
- Premium cap for maximum "out-of-pocket" pay will be established for people with incomes up to 400 percent of the Federal Poverty Line.
- Most people will be required to obtain health insurance or pay a tax.
- Health plans can no longer exclude people from coverage due to preexisting conditions.
- Employers with 50 or more workers who do not offer coverage face a fine of $2,000 for each employee if any worker receives subsidized insurance on the exchange. The first 30 employees are not counted for the fine.
- Effects on insurance premiums
- The Associated Press reported that, as a result of PPACA's provisions concerning the Medicare Part D coverage gap (between the initial coverage limit and the catastrophic coverage threshold in the Medicare Part D prescription drug program), individuals falling in this "donut hole" would save about 40 percent. Almost all of the savings came because, with regard to brand-name drugs, PPACA secured a discount from pharmaceutical companies. The change benefited more than two million people, most of them in the middle class