Over the course of the nation’s history, major changes have been made to the health care programs and laws in the United States. The Randolph (n.d.) social policy statement, which will serve as the foundation of this essay, claims that the U.S. health care system evolved from a modest system of home remedies and traveling physicians with limited training to a rather complex system known as the “medical industrial complex.” (Randolph, unknown) In the article, Randolph exhaustively delves into the history and evolution of the United States healthcare policies and programs covering the period 1750 to 2000s. The provision of health care services has seen the sector transform from the government-owned health care centers to the private hospitals and health facilities that offer services to the American population in the present century. Right from Truman to Obama administration, paramount and significant legislations have been witnessed in the health care sector. The health care reform proposals have encountered a series of controversial nationwide debates. Attempts to secure a reformed health care for the Americans have suffered a great deal of partisan political divisiveness, grassroots campaigns against the policies, bitter congressional fights, and considerable political conspiracy. The political conspiracies surrounding health care legislation include groups of politicians who at a particular time get united against given health care legislations and try to convince others not to pass them. The enactment of the Patient Protection and Affordable Care Act (PPACA) and the Health Insurance Portability and Accountability Act (HIPAA) of 1996 were, nevertheless some of the turning points of all these struggles (ASPE, 1996; Byrd and Clayton, 2015). The paper will examine the evolution of the U.S. health care system with particular reference to the above stated social policy, and discuss how policies and programs in this area have evolved over certain periods in history. For clarity purposes, the policies and programs witnessed in the U.S. health sector will get categorized into three historical periods, and the discussion will be limited to the period under review.
Health Care Policies and Programs in the Post-war Era
The first post-war attempt to initiate health care reforms started with President Harry S. Truman’s administration in 1945 barely seven months after assuming office (Markel, 2014). In his message to the Congress, the president proposed a ‘universal’ general health insurance policy which he believed would give a majority of Americans an excellent opportunity to enjoy and attain good and affordable health. The insurance could get financed by the National Health Insurance Board, and according to Truman, it could serve five primary functions which he outlined in his proposition to the Congress. However, after a substantive discussion of the bill in the Congress, the American Medical Association (AMA) painted it as a Communist policy and went ahead to capitalize on American’s paranoia of communism to shoot down the bill (Markel, 2014). Truman’s successor Franklin Roosevelt never did much to advance health care policies and programs in the country. As such, accessing health care remained one of the societal challenges that faced the Americans during the post-war era. Roosevelt’s efforts to reform the health care sector came to a halt following his untimely death in April 1945. Before his death, Roosevelt was aware of the difficulties of getting the national health insurance bill through the Congress and had asked his advisers to prepare an elaborate health care policy that could revolutionize health care in the country. He, however, died before realizing it (Morone, 2010).
The second attempt to have the national health insurance bill passed by the Congress suffered a major blow after the Korean War emerged (Stueck, 2002). Truman, however, managed to modernize and improve the state of hospital facilities across the United States. In 1946, the Congress approved the Hospital Survey and Construction Act (HSCA), that secured federal bequests and loans that facilitated the construction, expansion, and modernization of hospitals in the U.S. (Hoge, 1946).
In 1956, the U.S. government enacted the Military Medicare program which financed the health care service provided to dependents of military workers (Burstin et al., 2016). Additionally, in 1958 the Dwight Eisenhower administration introduced the Forand Bill that sought to extend health insurance to social security beneficiaries and the aging Americans (Cohen, 1958). Nonetheless, it never sailed through the 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. Advanced technology and highly sophisticated therapies and treatments caused the increasing of the cost of health care at the same period. The U.S. policies and institutions of research and health care including the National Institute of Health and the Centers for Disease Control got established (Byrd and Clayton, 2015).
The 1960s witnessed the launch of social plans to aid in providing medical care for the aged (Medicare) and the less advantaged (Medicaid) (Centers for Medicare and Medicaid Services, n.d.). After 1960, there arose a need to pursue a more modest health care coverage for the citizens of the U.S. The government consequently supported the King-Anderson Bill that provided coverage for residents aged 65 years and above, and their benefits could then get integrated into Social Security. It, therefore, laid grounds for the present Medicare and Medicaid programs. Cognizant of the fact that his desire for a re-election would catapult his push for the passage of the bill, President Kennedy decided to hold massive public rallies across the country. In these rallies, he sought to solicit public support for the bill (Dickerson, 2013). President Kennedy could make personal appearances to address masses at New York’s Madison Square Garden to drum up enough support for the bill from the public. It was, however, embarrassing for Kennedy when the Congress did not pass the bill and consequently, it never became law under his reign. 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 the Congress. In March 1965, the bill got introduced in the House Ways and Means Committee, approved by Senate on July 28th, and finally signed into law on July 30th the same year by President Lyndon Johnson (Centers for Medicare and Medicaid Services n.d).
The road to the realization of the Medicare and Medicaid programs began in 1964 with the election of Lyndon B. Johnson as the 36th president of the U.S. (Peters, 2010). With a Congressional Democratic majority, President Johnson had the mandate to oversee extensive social reforms dubbed the “Great Society.” These were social reform programs initiated by President Johnson to eradicate social injustice and paucity (Byrd and Clayton, 2015). Going by his political mileage, public approval, a congressional majority, and guaranteed support from critical industries, hospital, and insurance firms, significant health reforms got passed under his rule. The absence of administrative cost controls and physician fee schedules increased chances of the Senate and Congress passing the reform. Medicare Part A helped to settle bills of hospital care, in addition to home health care and skilled nursing. Medicare Part B contributed to pay physical care bills. Medicaid enabled states to cover the primary care for the poor and extend health insurance coverage not only for the poor but also the disabled as well (Centers for Medicare and Medicaid Services n.d.).
In 1965, Federally Qualified Health Centers (FQHCs) precursors comprising of the neighborhood health centers got established (Burstin et al., 2016). These centers had been initiated by the Office of Economic Opportunity to allow the medically underserved communities and the poor to access health and social services. In 1967, the Social Security amendments got approved (Cohen and Ball, 1968), which increased optional Medicaid categories to incorporate many who could not obtain any cash assistance. During this time, the benefits associated with early and Periodic Screening and Diagnostic Testing EPSDT) got integrated into Medicaid.
At the onset of 1971, the U.S. experienced general inflation and the escalating health care costs significantly led to a worrying trend (Byrd and Clayton, 2015). The then president Richard Nixon popularized his idea of a Comprehensive Health Insurance Plan (CHIP). His administration had to also propose the National Health Insurance Standard Act (NHISA). Through the scheme, the government could prescribe the minimum levels of insurance coverage, which employers were mandated to provide, and the managers and staffs had to meet the financing by 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 the president failed to oversee the passing of NHISA, he succeeded in lobbying for the passing into law of the Health Maintenance Organization Act of 1973, which paved the way for managed care reforms (Todd, 2011).
In 1974, Gerald Ford took over after the resignation of Nixon. His presidency, on the other hand, was meant to facilitate the healing process of the country from the adverse effects of Watergate (Patel and Rushefsky, 2014). The health care facilities not only got restrained but also experienced federally-incentivized growth. The cause of this was the excessive federal funding of the health care system, which ultimately resulted in medical inflation. President Ford’s tenure in office also saw the enactment of the National Health Planning and Resource Development Act (HPRDA) as a remedy to deal with the rising health care costs. HPRDA increased efficiency by reducing the chances of replicating facilities and services in health care provision. The Act also obligated states to obtain instructing certificates before proposing or undertaking any health program (Patel and Rushefsky, 2014).
Health care Programs and Policies in the Economic Recession Period
Whorton (2014) argues that by 1980, the U.S. had already started experiencing the adverse effects of stagflation and health care costs had significantly risen. One of the priorities of President Jimmy Carter, containing the medical expenses of the expanding coverage ranked top. In his address to the U.S. Congress on April 25th, 1977, Carter noted with a lot of concern that the country was spending much on health care than any other state. For instance, in that year the expenditure on health care had reached $160 billion which was around nine percent of the GNP of the U.S. and the trend was up surging every year. As a response to this crisis, Carter sent to the Senate two bills: The Hospital Cost Containment Act of 1977 meant to contain the escalating costs of health care, and the Child Health Assessment Program (CHAP) drafted to develop health services for kids 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 his appointment of 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 (U.S. Department of Labor n.d.).
Administrative health care programs could not be witnessed at the start of President Ronald Reagan’s first term in office (1981-1985). Instead, he embarked on cutting down the health care federal expenditure and improving efficiency (Patel and Rushefsky, 2014). It was mandatory for the administration to adjust Medicare reimbursement methodologies which included slicing payments meant for hospitals, and physicians besides putting in place anti-fraud measures to eliminate any loss of public funds. 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 and Rushefsky, 2014).
As a response to the increasing costs of Medicare and up surging expenditure on health care, the Reagan administration increased the Medicare benefits by enacting the Medicare Catastrophic Coverage Act (MCCA) of 1988 (Whorton, 2014). The act provided for extending Medicare coverage to include outpatient drugs and capped out-of-pocket payments for health services, including hospitals and physicians. It also increased long- term care payments. The funding of this program was to be met by increasing 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 from Ronald Reagan and went on to serve for one term. Not much can be said of H.W. Bush’s health care policies, but he is well remembered for overseeing the repealing of most sections of the MCCA of 1988 (Taylor et al., 2014). His proposal for health care regulation comprised of extra measures to shrink the growth of administrative health care expenditure and reduce misuse and fraud in the Medicaid and Medicare plans. Remarkable among the Bush’s health care jurisdictive reform was a proscription on physician “self-referrals” for clinical laboratory services. However, his greatest undoing was when he fell for the bait of raising taxes against his campaign promises. Speaking after his defeat by Bill Clinton in 1992, Bush regretted raising taxes and explained that his assumption was that by doing so, he would gain total control over the domestic discretionary spending on health care. However, this was not the case as the rise in taxes led to an opposite reaction since expenditure rose by 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 the 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 got enacted in the Clinton regime (Byrd and Clayton, 2015).
Health Care Reforms in the 2000s
George Walker Bush started his reign as the 43rd president by pushing for the enactment of a series of health care programs (Lind and Tamas, 2006). For instance, his administration saw massive expansions in the Medicare program. The passage of the Medicare Drug Improvement and Modernization Act (MMA) in 2003 imparted numerous Medicare changes in the U.S. (Patel and 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 (2009-2016)
Currently, health 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 health care 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 or an individualized mandate. Third, the reforms aimed at initiating measures of making private health insurance readily available and cost effective to the uninsured majority.
Reforming health care was remarkably among the priority areas for President Obama after assuming office (Obama, 2016). His campaign trail featured the promise of an entirely changed health care system that would enhance the reduction of medical costs and expand coverage to most Americans. The key outstanding health care reforms in the U.S. under Obama is the Obamacare. Amid bitter partisan divisiveness, 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 several people and got perceived by many as landmark legislation. By seeking to expand Medicaid coverage to the poorest, PPACA proved favorable to low and middle-income earners. Because their jobs could rarely afford them coverage, this piece of legislation made it easier to purchase 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. is one of its kind and deviates from those of the heavily industrialized countries when it comes to relying on the private sector to finance, purchase and deliver health care services (Whorton, 2014). A considerable portion of the U.S. population has access to the benefits of health insurance through their employers besides accessing services extended to them by the private sector. As such, the employers are subject to a tax subsidy for providing insurance cover to their employees along with their families. The cost of providing the benefits can get proportionately shared among the employees.
Studies have confirmed that close to 44 million Americans do not have access to any insurance scheme whether public or private (Obama, 2016). These residents receive health care services from public clinics and hospitals or rely on private providers for services by paying out of their pockets. It is worth noting that the U.S. finances its health care system by devoting a significant percentage (13.5 percent) of its Gross Domestic Product (GDP) unlike any other nation to health care-related expenditures (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 over two decades.
Conclusion
The evolution of the healthcare policies in the U.S has witnessed significant changes throughout the history of the country. Right from the times of Truman to Obama and now Trump, various policies and programs have been initiated to improve the delivery and quality of services offered to the American people. The U.S. Congress has played a significant role in enacting health care reform proposals to expand the provision, as well as the coverage to millions of Americans. It has also played a critical role in pushing out or repealing those proposals considered not to take into consideration the interests of the Americans. From the discussion, however, it is accurate to note that each president had his own unique approach to health care and this is evident in form of legislations proposed and passed over time. Additionally, insurance firms, hospitals, physicians, medical associations like AMA and other stakeholders in the health sector have also had their say on various legislations throughout the reformation process. The best health care reforms in the history of the U.S. is, however, Obamacare given its elaborate and in-depth consideration of all classes of Americans. This program nevertheless faces challenges under President Trump who wants it repealed and replaced with his administration’s version.
References
Anderson, S. (2016). A brief history of Medicare in America. Medical Resources.org. Retrieved on August 17, 2017 from https://www.medicareresources.org/basic-medicare-information/brief-history-of-medicare/
Byrd, W. M. and Clayton, L.A. (2015). An American health dilemma: Race, medicine, and health care in the United States 1900-2000, 2. New York: Routledge.
Burstin, H., Leatherman, S. and Goldmann, D. (2016). The evolution of health care quality measurement in the United States. Journal of Internal Medicine 279(2), 154-159.
Carter, J. (April 25, 1977). Health care legislation message to the Congress. Online by Peters, G. and Woolley, J.T. The American Presidency Project. Retrieved on August 17, 2017 from http://www.presidency.ucsb.edu/ws/?pid=7401.
Centers for Medicare and Medicaid Services (n.d). CMS’ program history: Medicare and Medicaid. USA: CMS.
Cohen, W. J. (1958). The Forand Bill: Hospital Insurance for the Aged.” The American Journal of Nursing, 58(5), 698-702.
Cohen, W. J. and Ball, R. M. (1968 February). Social Security Amendments of 1967: summary and legislative history. The Bulletin, 3-19.
Dickerson, J. (2013). Kennedycare: Fifty years before Obamacare, JFK had his own health care debacle. Slate. Retrieved on August 17, 2017 from http://www.slate.com/articles/news_and_politics/history/2013/11/john_f_kennedy_s_health_care_failure_jfk_and_barack_obama_s_tough_fights.html
Hoge, V. M. (1946). The Hospital Survey and Construction Act. The Bulletin. Retrieved on August 17, 2017 from https://pdfs.semanticscholar.org/ea63/365aabeeddc6f814e101481da1375752f9a4.pdf
Lind, N. S. and Tamas, B. I. (2006). Controversies of the George W. Bush presidency: pro and con documents. Westport, Conn, Greenwood Press.
Markel, H. (November 19, 2014). 69 years ago, a president pitches his idea for national health care.” PBS. Retrieved on August 17, 2017 from http://www.pbs.org/newshour/updates/november-19-1945-harry-truman-calls-national-health-insurance-program/
Morone, J. A. (2010). Presidents and health Reform: From Franklin D. Roosevelt to Barack Obama.” Health Affairs, 29(6), 1096-1100
Obama, B. (2016). The United States health care reform: progress to date and next steps. Jama 316(5), 525-532. doi:10.1001/jama.2016.9797
Office of the Assistant Secretary for Planning and Evaluation (ASPE). (August 21, 1996). Health Insurance Portability and Accountability Act of 1996. Retrieved on August 17, 2017 from https://aspe.hhs.gov/report/health-insurance-portability-and-accountability-act-1996
Patel, K. and Rushefsky, M.E. (2014). Healthcare politics and policy in America. USA: M.E. Sharpe.
Peters, C. (2010). Lyndon B. Johnson: The American Presidents Series: The 36th President, 1963-1969. USA: Henry Holt and Company.
Shepard, C. M. (2010). The Civil War income tax and the Republican Party, 1861-1872. New York, Algora Pub.
Stueck, W. (2002). Revisionism and the Korean War. The Journal of Conflict Studies, 22(1), 1-13. https://journals.lib.unb.ca/index.php/jcs/article/view/365/576
Taylor, W.J., Burr, J. D., and Forman, L. L. (2014). A brief history on the road to healthcare reform: from Truman to Obama: A brief history of healthcare reform in the U.S., through the years. Hospital Review. ASC communications.
Todd, M. K. (2011). Handbook of medical tourism program development: developing globally integrated health systems. Florida, USA: CRC Press.
U.S. Department of Labor (n.d.). Eula Bingham Administration, 1977-1981: Of minnows, whales and “common sense. Retrieved on August 17, 2017 from https://www.dol.gov/oasam/programs/history/osha13bingham.htm
Waldman, D. (2016). Restoring care to American healthcare. Is Obamacare the answer? USA: Gatekeeper Press.
Whorton, J.C. (2014). Crusaders for fitness: The history of American health reformers. USA: Princeton University Press.
