The Changes in US Healthcare Policies and Programs

Throughout the nation's history, there have been substantial changes to the healthcare programs and policies in the United States. Between 1750 and 2000, the healthcare system in the United States saw numerous changes, evolving from a crude system of untrained doctors and herbal treatments into a varied array of health programs that utilized cutting-edge scientific technology.
The development of medical technology allowed for the adoption of the "germ theory" by authorities and medical professionals. The theory contributed to the professionalization of doctors and later the urgent need for medical technologies by illuminating the causes of diseases. Later on, multiple institutions which offered medical training as well as medical insurance agencies were created. In this very period the government became proactive by starting and empowering institutions that provide healthcare, regulation of the drug industry and the evolution of medical insurance programs.

Before 1800, the people in the United States handled medical matters as a family affair. It is the women who were entrusted with the responsibility of treating illnesses except for the ailments which were beyond their capacity to handle. The practice entailed a combination of a few skills that the doctors could practice, in conjunction with the remedies that women provided. The healthcare proposals have encountered a series of controversial nationwide debates. Attempts to secure a better healthcare for the Americans have suffered a great deal of partisan political divisions, grassroots campaigns against the policies, bitter congressional fights, and a considerable amount of fictitious and personal political campaign narratives that were intended to stall the reforms in the healthcare programs. Patient Protection and Affordable Care Act (PPACA) and the Health Insurance Portability and Accountability Act (HIPAA) of 1996 were, nevertheless, the turning points for all the following struggles (ASPE, 1996; Byrd and Clayton, 2015). The paper will examine the evolution of the U.S. health system with particular reference to the above stated social policy, and discuss how policies and programs in this area have evolved during certain periods in the history. For clarity purposes, the policies and programs witnessed in the U.S. health sector will be categorized into three historical periods, and the discussion will be limited to the period under review.

President Franklin Roosevelt, never did much to advance healthcare policies and programs in the country despite the desire and intent he showed when he came into office. As such, accessing healthcare remained one of the societal challenges Americans encountered during the post-war era. Although President Roosevelt wanted to improve social security and national health care policies, his efforts hit a snag following his untimely death in April 1945. Before his death, Roosevelt became aware of the difficulties of promoting the national health insurance bill in the Congress and had asked his advisors to prepare and elaborate health care plan that could revolutionize healthcare system in the country, but he passed on before he managed to realize it (Morone, 2010).

Healthcare Programs and Policies in the Post War Era

The first post-war attempt to initiate health care reform started with the President Harry S. Truman's administration in 1945 barely seven months after him assuming office (Markel, 2014). In his message to Congress, President proposed a ‘universal’ general health insurance policy which as he believed would give a majority of Americans an excellent opportunity to enjoy and attain good health. The insurance could get financed by the National Health Insurance Board, and according to Truman, it would perform five primary functions which were outlined in his proposition to Congress. However, after a substantive discussion of the bill in Congress, the American Medical Association (AMA) painted it as a Communist policy act and went ahead to use current American’s paranoia of the communism to reject the bill (Markel, 2014).

However, Truman managed to modernize and improve the state of hospital facilities across the United States. In 1946, Congress passed the Hospital Survey and Construction Act (HSCA), which secured federal grants and loans that facilitated the construction, expansion, and modernization of hospitals in the U.S. (Hoge, 1946). The healthcare facilities increased dramatically and evoked the need for legislation to bring the situation under control. After President Truman secured a re-election victory in 1948, he again began to lay plans underway to expand the social security. Unfortunately, the bill suffered another setback when the five-year Korean War was intiated and put everything on hold (Stueck, 2002).

Subsequently, the administration of Dwight Eisenhowe enacted the Military Medicare program which financed the healthcare service provided to military workers (Burstin et al., 2016). Additionally, the Dwight regime in 1958, introduced a progressive Forand Bill that intended to extend health insurance to the beneficiaries of social security as well as the aging population (Cohen, 1958). Nonetheless, it never sailed through Congress despite the adequate support it received from the American Federation of Labor and Congress of Industrial Organizations (AFL-CIO). The technological advances after World War II professionalized most roles assumed by non-physician technicians and psychotherapists, including physical, respiratory psychoanalysts, laboratory, and X-ray technicians. The U.S. policies and institutions of research and healthcare including the National Institute of Health and the Centers for Disease Control were launched in this time. (Byrd and Clayton, 2015).

The 1960s saw the initiation of social programs to aid in providing medical care for the aged (Medicare) and the less advantaged (Medicaid). First intentions to enact Medicare and Medicaid programs began in 1964 with the election of Lyndon B. Johnson as the 36th president of the United States (Peters, 2010). President Lyndon Johnson on the 30th of July 1965 signed the King-Anderson Bill that ushered both Medicare and Medicaid (Berkowitz, 2005). After 1960, a need for a cheaper healthcare coverage for the citizens of the U.S arose. The government consequently supported the King-Anderson Bill that provided coverage for residents aged 65 and above, and their benefits could then get integrated into Social Security.

Cognizant of the fact that the desire for a re-election would forward the passage of the bill, President Kennedy decided to hold huge public meetings across the country. In these massive campaigns, he sought to solicit public support of the bill (Dickerson, 2013). President Kennedy could make personal appearances to address masses at New York's Madison Square Garden to gain enough public support for the bill. However, the intention failed when Congress refused to pass the bill, and consequently, it never came into effect during Kennedy’s presidency. Despite the growing opposition from some conservative Republicans and the AMA, the legislation seeking to establish Medicare and Medicaid programs finally gained the approval of Congress. In March 1965, the bill got introduced in the House Ways and Means Committee, was approved by Senate on July 28, and finally came into effect on July 30 of the same year under President Lyndon Johnson’s command (Berkowitz, 2005).

With a congressional democratic majority, President Johnson received the mandate to oversee extensive social reforms proposed in the “Great Society." These were social reform programs initiated by President Johnson to eradicate social injustice and paucity (Byrd & Clayton, 2015). Going by his political mileage, public approval, a congressional majority, and guaranteed support from critical industries, hospital, and insurance, President Johnson managed to establish crucial reforms in the health sector. Medicare Part A helped to settle bills of hospital care, in addition to home healthcare and skilled nursing. Medicare Part B contributed to pay physical care bills. Medicaid enabled states to cover the primary care for those families that struggled with respective bills and extend health insurance coverage not only for the underprivileged but also the disabled as well (Berkowitz, 2005).

In 1965, Federally Qualified Health Centers (FQHCs) precursors, comprising of the neighborhood health centers were established (Burstin et al., 2016). The Office of Economic Opportunity initiated the centers which allowed the medically underserved communities and the poor to access health and social services. The year 1967 saw the approval of Social Security amendments (Cohen & Ball, 1968), which increased optional Medicaid categories to tend those who could not obtain any cash assistance. During this time, the benefits resulting from early and Periodic Screening and Diagnostic Testing EPSDT) were also integrated into Medicaid.

At the onset of 1971, the U.S. experienced general inflation and the escalating healthcare costs significantly led to a worrying trend of healthcare service provision of the country (Byrd & Clayton, 2015). The President Richard Nixon who was in office at that time popularized the idea of a Comprehensive Health Insurance Plan (CHIP). His administration finally proposed the National Health Insurance Standard Act (NHISA). It presumed that the government could prescribe the minimum levels of insurance coverage, which should be provided by all employers, managers and staffs in order to meet the financing and paying premiums. The plan would achieve healthy competition between expanded coverage and private insurers (Anderson, 2016). Additionally, NHISA provided a way to subsidize the premiums paid by individual workers.

The move to have a national health insurance did not materialize following the Watergate hearings and subsequent resignation of Nixon (Burstin et al., 2016). Although President Nixon failed to oversee the passing of NHISA, he succeeded in lobbying the approval of the Health Maintenance Organization Act of 1973 that facilitated managed care reforms (Todd, 2011). Massachusetts Senator, Edward M. Kennedy advanced a competing proposal (HealthCare Security Act) whose intent was to find a single federal payer and make the majority of Americans obtain a comprehensive health coverage (Patel & Rushefsky, 2014).

In 1974, subsequently to Nixon’s resignation, Gerald Ford assumed office. His presidency, on the other hand, was aimed to facilitate the healing process of the country from the adverse effects of Watergate (Patel and Rushefsky, 2014). Consequently, the healthcare facilities experienced federally-incentivized growth. The cause of such an effect was the excessive federal funding of the healthcare system, which ultimately resulted in medical inflation. During President Ford's tenure in office the enactment of the National Health Planning and Resource Development Act (HPRDA) was also undertaken as a remedy to deal with the rising health care costs. HPRD increased efficiency by reducing the chances of replicating facilities and services in healthcare provision. The Act also obligated states to obtain instructing certificates before proposing or promoting any health program. In spite of the fact that HPRDA's CON mandate got repealed in 1986, some states including the District of Columbia still run CON programs up to date (Patel & Rushefsky, 2014).

USA Healthcare Programs and Policies in the Economic Recession Era

As noted by Whorton (2014), by the year 1980 stagflation was already experienced in the U.S. and health costs had significantly risen. Of all the priorities of President Jimmy Carter, containing the medical expenses due to expanding coverage were the most costly ones. In his address to Congress on April 25th, 1977, Carter noted with a lot of concern that the country was spending more on health care than any other state in the world. For instance, in that year the expenditures on healthcare had reached $160 billion which was around 9% of the GDP of the U.S. and the trend was up surging every year. As a response to this crisis, Carter sent two bills to the Senate: The Hospital Cost Containment Act of 1977 presumed to contain the escalating costs of healthcare, and the Child Health Assessment Program (CHAP) drafted to develop health services for children of low-class households (Carter, 1977). He later proposed the mandatory hospital cost regulation which got defeated in the House after passing in the Senate. The health sector, however, witnessed some improvements under Carter after he appointed Dr. Eula Bingham as the director of OSHA. Bingham enacted some of Carter’s propositions amid opposition from both sides of the House which later on rescinded her directions.

Fierce critics of Carter’s health care policies argue that during his rule, the United States experienced severe consequences not only from excessive government borrowing but also as a result of deficit spending (Patel & Rushefsky, 2014). These times proved tough for the recently inaugurated President Reagan who declared the whole situation a crisis and blamed the previous regime for the woes. Administrative healthcare programs could not be witnessed at the start of Reagan’s first term in office (1981-1985). Instead, he embarked on cutting down the federal expenditure on health care and improving efficiency (Patel & Rushefsky, 2014). It was mandatory for the administration to adjust Medicare reimbursement methodologies which included slicing payments meant for hospitals, and physicians. Another measure which dealt with anti-fraud was put in place to eliminate any loss of public funds through illegal means. Patel and Rushefsky (2014) note that in 1981 the federal budget got reconciled which forced states to incur more Medicaid payments against hospitals catering for low-income patients and serving disproportionate Medicaid share. Through OBRA 81, states acquired the obligation to influence managed care for certain Medicaid groups and expand coverage to cater for those vulnerable to institutionalization (Patel & Rushefsky, 2014).

As a response to the increasing costs of Medicare and up surging expenditure on healthcare, the Reagan administration increased the Medicare benefits by enacting the Medicare Catastrophic Act of 1988 (Whorton, 2014). The act promoted extending Medicare coverage in order to include outpatient drugs and capped out-of-pocket payments for health services, including hospitals and physicians. It also led to increase in long- term care payments. The funding of the program was to be met by raising premiums paid by Medicare beneficiaries and taxing wealthier beneficiaries in line with the level of their incomes.

In 1989, President George H.W. Bush assumed office after Ronald Reagan, and though not much can be said of H.W. Bush’s health care policies, he still is well remembered for overseeing the repealing of most sections of the Medicare Catastrophic Coverage Act (MCCA) of 1988 (Taylor et al., 2014). His program for healthcare regulation comprised of extra measures to shrink the growth of administrative healthcare expenditure and reduce misuse and fraud in the Medicaid and Medicare plans. The most remarkable example of the Bush’s healthcare jurisdictive reforms was a proscription on physician "self-referrals" for clinical laboratory services. However, the greatest undoing was raising taxes against his campaign promises. Speaking after his defeat by Bill Clinton in 1992, Bush regretted this decision and explained that his assumption was that by doing so, he would gain total control over the domestic discretionary spending on healthcare. However, this was not the case as the raising of taxes led to an opposite reaction since expenditure rose to 22 billion dollars in 1990 and 1991 (Shepard, 2010).

In 1993, President Bill Clinton proposed the Health Security Act (HSA) which gained significant support in the Congress (Whorton, 2014). The Medicaid waivers got approved which fueled massive nationwide demonstrations. Many states opted for managed care to deliver services and utilized their savings to accommodate uninsured groups. Health Insurance Association of America aired television adverts dubbed "Harry and Louise" to portray the discontent of middle-class couples with Clinton's health care plans. Clinton's proposal advocated for the provision of health insurance coverage by the private entities. It also sought to have each state implement the plan and establish regional health alliances. Employers were obligated to provide insurance coverage for their workers by paying 80 percent of the premiums. State CHIP, HIPAA, and Stark II are some of the remarkable reforms that Clinton regime enacted (Byrd & Clayton, 2015). HIPPA achieved stable pre-existing conditions in determining the requirements for health insurance coverage. Moreover, the act set down the standards for upholding the confidentiality of medical records and boosted the adequate financing of long-term health insurance through taxes.

Healthcare Reforms from 2000 to the Present

George Walker Bush was elected to White House in the year 2001 and served as the 43rd president of the U.S. till 2008. He began his reform agenda by pushing for the enactment of a series of healthcare programs (Lind & Tamas, 2006). The passage of the Medicare Drug Improvement and Modernization Act (MMA) in 2003 initiated numerous Medicare changes in the U.S. (Patel & Rushefsky, 2014). The act enhanced the subsidization of the prescription drug for the benefit of the general public. Furthermore, it ensured the program gets administered via private plans involving prescription-drug plans and Medicare Advantage plans.

Healthcare Reforms under Obama’s Presidency (2009-2016)

Currently, healthcare reform debates seek to address two major issues: cost and coverage (Obama, 2016). At varying degrees and priorities, the reformists are devoted to providing the uninsured millions of Americans with an affordable health insurance. The rationale is to finance the coverage by combining new tax revenues and measures to contain sufficient cost, besides curbing the rising healthcare bill in the country. The proposals for expanding the coverage could be addressed using three broad categories. At first, the proposal seeks to provide the expansion of insurance coverage which is funded by the public coffers, from incremental to a more ambitious one. Secondly, it has to look for the directive to expand coverage by contacting the regulatory authority of the federal administration. In this case, an employer directive may end up proving vital, in case the employer is expected to meet the entire cost of covering the workers or make remittances towards a publicly funded health insurance. Thirdly, the reforms aimed to initiating measures of making private health insurance readily available and effective to the uninsured majority.

Reforming healthcare was remarkable among the priority areas for President Obama after him assuming office (Obama, 2016). His campaign trail featured the promise of an entirely changed healthcare system that would enhance the reduction of medical costs and expand coverage to the majority of Americans. The key outstanding healthcare reforms in the U.S. under Obama’s presidency was the Obamacare program. Amid bitter partisan politics, public misinformation, critical debates in both houses and "socialized medicine" charges, President Obama appended his signature to a very crucial legislation, the Patient Protection and Affordable Care Act (PPACA) on March 23, 2010 (Waldman, 2016). The PPACA gained the support of people and was perceived by many as landmark legislation. By seeking to expand Medicaid coverage to the poorest, PPACA came to the aid of the low and middle-income earners. Due to the fact that their jobs could rarely afford them coverage, this piece of legislation made it easier to purchase the said coverage using the federal subsidies from “American Health Benefit Exchanges." The Act spares the employer the obligation of providing health benefits to employees. However, it established trades in which workers received significant insurance subsidies that could pay their premiums. On the other hand, small businesses got granted access to additional plans through a separate exchange program (Waldman, 2016).

Present Status of the U.S. Health Care System

The current healthcare system in the U.S. deviates from the similar systems of the heavily industrialized countries when it comes to relying on the private sector to finance, purchase and delivery of healthcare services (Whorton, 2014). Although some people still rely on their privately sponsored health insurance, a considerable portion of the U.S. population has access to the benefits of health insurance through their employers. As such, the employers are subjected to a tax subsidy as a result of the provision of insurance cover to their staff members along with their families.

Various studies confirm that around 44 millions of Americans do not have access to any insurance scheme whether it is public or private (Obama, 2016). These residents receive healthcare services from public clinics and hospitals or rely on private providers for services by paying from their own pockets. It is worth noting that the U.S. finances its healthcare system by devoting a significant percentage (13.5 percent) of its Gross Domestic Product (GDP) unlike any other nation (Obama, 2016). The country’s strong economy coupled with the dramatic shift from indemnity insurance to managed care plans have maintained the percentage constant for more than two decades.

According to Patel and Rushefsky (2014), purchasers, funders, and healthcare providers are distinct entities which operate separately. Healthcare service provision is majorly offered by private providers, physicians, and integrated organizations. About 70% of hospitals operating in the 50 States of the U.S. are community-based not-profit organizations. Most U.S.-based physicians, both specialists and primary care practitioners, are engaged in private practice, 39% operate as individual units while 61 percent function in groups comprising of at least two doctors. Compared to OECD countries, the U.S. has a considerably higher ratio of medical experts to patients. The faster spread of managed care has boosted the need of having more primary care providers. Today, the U.S. is estimated to produce around 40% of the most competent physicians in the world.

Conclusion

In conclusion, the way towards reforming the U.S. health care system has been long and difficult. Apart from the American Medical Association (AMA), the legislature and the executive arm of the government of the U.S.A have also played huge roles in reforming the healthcare policies and programs that are geared towards improving the lives of the American citizens. Many reforms programs have been instituted over time such as the Affordable Care Act, and though causing many challenges, they finally managed to improve healthcare and save lives of millions of Americans.







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