The Affordable Care Act of 2010

1. The Affordable Care Act of 2010 Henry C Powell, Professor Emeritus, University of California San Diego

2. Health care legislation in the USA • Government by crisis, laissez faire, federalism • First attempts at group health care support was local, through mutual societies, non-profit plans etc. • European models in Germany 1883, UK 1911, • First US political discussion during 1912 election when Theodore Roosevelt ran on ‘Bull Moose’ platform which included health care.

3. The Townsend Plan and Social Security • “She is helpless, suffering from Sugar Diabetes, which has affected her mind. She has to be cared for in the same manner as an infant. She is out of funds completely. Her son who she used to keep house for is in hospital in Waco, Texas – no compensation for either himself or her….I appeal to you to place your dear mother in my dear mother’s place – with no money and no place to go unless it be the poorhouse.” • Letter from a Texas widow to President Franklin D Roosevelt, 1934

4. Social insurance or health insurance? • Roosevelt considered health insurance three times, 1935, 1938 and 1945 • “The only one who can explain the medical thing is myself.” Private comment to Treasury Secretary, Henry Morgenthau in 1935 • Jan 1944 address ‘Economic bill of rights’ • Truman proposed ‘Single payer’ plan in 1949 • AMA opposed this and previous proposals

5. Medicine and health • “The art has three factors, the disease, the patient, the physician.” Hippocrates, Epidemics, I, 11 • Hospitals, professional societies, regulatory agencies, governmental and non-governmental • Pharmacists, pharmacies and ‘Big Pharma’ • Biotech companies and medical device makers • Federal, state and local government • Insurance companies

6. Two seeds planted • During the Truman years, rather than support individual health care, Congress funded hospital building, medical research and education. • 1950 A small program for medical support of states to reimburse health costs of welfare recipients: this was the ‘germ’ of Medicaid. • 1951 A presidential commission reacting to the defeat of Truman’s big health care proposal recommended just 60 days of coverage for elderly recipients of Social Security income: this was the ‘germ’ of Medicare.

7. Kennedy Johnson years, 1961-1969 • Kennedy very concerned about elderly uninsured, began to develop a plan • Johnson used his political skills and the horror of Kennedy’s assassination to advance a progressive agenda • 1965 Medicare enacted in the face of fierce AMA opposition • A mosaic of different plans and programs creates conditions for a ‘policy trap’

8. Two presidents aim for ‘universal health coverage’ • Richard M Nixon 1969-1974 reached out to significant players such as Senator Edward Kennedy in an attempt to provide broad reaching health care coverage • But ‘politics’ got in the way • Bill Clinton 1993-2001 and his team, lead by First Lady Hillary Clinton, developed a plan that engendered fierce political opposition • During this time new plans for ‘cost containment’ including ‘health maintenance organizations’

9. The ‘policy trap’ • Paul Starr described the policy trap created by the tension between ‘covered groups’, who like their health insurance and the needs of the uninsured, who, faced with big medical bills risk losing their job, their house and their marriage. • While the uninsured clamor for relief, anxiety pervades the ‘covered groups’ • Political forces fan the flames

10. Obama’s challenge • “I am a 58 year old teacher at Roslyn School in northeast South Dakota. Our school is closing in June of 2010, which means I will be losing my job and my health insurance. I am a type 1 diabetic and I had heart bypass surgery in 2005. My husband is also a teacher at Roslyn, so we will both be losing insurance. I am exploring other options and have been told that I cannot stay on our group policy or transfer to another policy after our jobs cease because of my medical condition. What am I to do after 39 years of teaching to acquire adequate health coverage?” • Letter to Senator Tim Johnson (SD) spring of 2009.

11. Who had health care in the USA in 2008? • Employed people with employer funded private insurance • Social Security recipients eligible for Medicare • Veterans who meet eligibility requirements • Active military personnel • The US Congress and Supreme Court • Private policy holders, including small business people and the very affluent

12. Whowasnot eligible for health insurance in 2008? • Workers employed by companies who did not offer this benefit • Unemployed who did not qualify for Medicaid • Patients with ‘pre-existing condition’ as defined by insurance industry • Retirees whose retirement plans failed, or were liquidated during corporate acquisition • People under 65, or ineligible for Medicare insurance

13. Affordable Care Act Titles I-V • I. Expands health insurance to many uninsured, provides subsidies to help pay for private insurance policies, establishes ‘exchanges’ in each of the states • II. Children’s Health Insurance Program and expansion of Medicaid, reform at the state level, health care guarantee for disabled • III. Quality and efficiency regulations designed to cut costs • IV. Prevention of chronic disease and improving public health • V. Healthcare workforce shortages: expanding the number of doctors, nurses and other professionals

14. Affordable Care ActTitles VI - X • VI. Increased transparency through financial disclosure requirements affecting doctors, nurses and other health care providers • VII. Biosimilar biological products and generic pharmaceuticals • VIII. Community Living Assistance Services and Supports (CLASS), includes long term care • IX. Revenue measures designed to pay for ACA • X. The Manager’s amendment. Fitting the nine titles together and reconciling objectives.

15. Obstacles in the path of the ACAFrom decision to implementation • Would health care remain an objective after the 2008 election? • Would the financial crisis of 2009 stop ACA’s momentum? • Would the US Senate allow the debate to go forward? • Would challenges in the courts delay or kill the legislation • Would elections in 2010 and 2012 kill the ACA? • Will the opposition prevail against implementation in 2014? • What next?

16. Conclusion • Legislative initiatives addressing social matters have long political gestation periods • Yesterday’s failed idea may be tomorrow’s new program • Social attitudes towards governance easily manipulated • Media reluctant to discuss policy, preferring politics • Political will, social strategy and a base of knowledge

17. Further Reading • John McDonough “Inside National Health Reform” UC Press and Millbank Memorial Fund 2011 • Paul Starr “Remedy and Reaction: The peculiar American Struggle over Health Reform” Yale University Press 2011, revised 2013. • Richard Kirsch “Fighting for our Health” Rockefeller Institute Press 2011 • David Goldhill “Catastrophic Care: How American Healthcare killed my father-and how we can fix it” Knopf 2013 • Steven Brill “Bitter Pill: Why medical bills are killing us” A special report. Time March 4th 2013 • Staff of the Washington Post. “Landmark. Inside Story of America’s New Health Care Law and what it means for us.” Public Affairs 2010 • Arnold Relman “Obamacare: How it should be fixed. New York Review of Books. Summer Issue August 15th 2013 pp-42-48