A Love/ Hate Relationship: A brief history of the healthcare reform and the ACA
Health Insurance Insights | 03-04-19

A Love/ Hate Relationship: A brief history of the healthcare reform and the ACA

Health Reform in the Last Century

In American politics, one of the longest running debates has been over healthcare reform. An ever contentious debate that has drawn on since just after World War II, the debate as to how to curtail the costs and improve access to healthcare has been ingrained in American politics and has been the source of much partisan fighting.

Fresh out of the war, President Truman recommended to Congress a proposal for universal health insurance coverage, administered and paid for by a National Health Insurance Board. Opponents of the proposal, including the American Medical Association, decried it as "socialized medicine," and the bill died in Congress. Both Presidents Eisenhower and Kennedy continued the push for a robust federal health insurance program, but were as unsuccessful as Truman due to a strong opposition from the American Medical Association.

President Johnson pushed for federally funded health insurance coverage for the elderly and impoverished as part of his “Great Society” campaign. In the Social Security Amendments of 1965 Act, he was able to establish protection for these groups by creating two programs that have become core to the American healthcare landscape known as Medicare and Medicaid.

When President Nixon was elected, he proposed the National Health Insurance Standard Act. The proposal called for government-prescribed minimal levels of insurance coverage, mandated to be provided through employers and financed by payment of premiums by employers and employees. This plan would maintain competition between private insurers and expand coverage. The NHISA would also provide government subsidies for premiums for certain employees much like the Affordable Care Act that passed years later. The bill never passed Congress, and embroiled in controversy of the Watergate scandal, President Nixon would drop his fight for healthcare reform. His successor, President Ford never approached the health insurance coverage fight during his term.

With his election, President Carter brought a universal healthcare proposal that was first broached by President Johnson. This measure was thought at first to have the support needed to pass, but political infighting within the Democratic party left the bill dead on arrival. A new era in American politics began with the election of President Reagan. His election, signalled that many Americans had become tired of what they perceived as out-of-control government spending, and there were no administration proposals for new government-run or administered healthcare programs during his presidency. But the Reagan Administration also advanced through Congress the first major expansion of Medicare benefits: the Medicare Catastrophic Coverage Act of 1988. The law expanded Medicare coverage for outpatient drugs, put a ceiling on out of pocket co-pays for hospital and physician services, and modestly expanded payments for long term care. The program was to be funded entirely by Medicare beneficiaries through increased premiums and a surtax on wealthier beneficiaries based on income. President Bush would see this bill repealed just over a year later after much anger from the elderly over added taxes.

President Clinton was the first Democrat elected president in 12 years, and his administration wasted little time in proposing major health care reforms. After the release of a report by a highly controversial task force headed by First Lady Hillary Clinton, President Clinton sent the American Health Security Act of 1993 to Congress. It proposed to provide affordable health insurance for all through a concept called "managed competition." Under the Clinton proposal, health insurance coverage would be provided through private insurers competing for customers in a highly regulated market, overseen and coordinated by regional health alliances to be established in each state. All health plans would be required to provide a minimum level of benefits. Employers would be required to provide insurance coverage for their employees and pay 80 percent of the premium. The AHSA was opposed by much of the healthcare industry. It was subjected to bitter partisanship in Congress, with even Democratic lawmakers split and some offering alternative or compromise plans. By September 1994, the proposal was declared dead by Senate Majority Leader George Mitchell.

The second President Bush oversaw one of the largest expansions of Medicare in the program's history. The Medicare Drug Improvement and Modernization Act of 2003 made numerous changes to the Medicare program, the most important of which was the prescription drug coverage benefit, created as Medicare Part D.

The Patient Protection and Affordable Care Act

In November of 2008, the junior Senator from Illinois made history. Barack Obama was elected the first African American President of the United States. This along with a Democratic Senate and House set the stage for the newest fight in America’s long fight over healthcare reform.

In October of 2009, Speaker of the House Nancy Pelosi and House Democrats introduced the Affordable Care for America Act (HR 3962). This bill passed the house with a small majority before being sent to the Senate.

With the untimely death of Senator Kennedy from Massachusetts and the subsequent special election of Republican Scott Brown to his senate seat, the 60 seat majority needed by Democrats to ensure that the bill would pass without filibuster was lost. This meant that a previously-passed Senate version would have to be used as the Senate Republicans would now filibuster any bill from the House. As a result, Speaker Pelosi would pass the Senate bill in the House and a second bill, the Health Care and Education Reconciliation Act of 2010, to address any holes in the Senate version was passed by means of reconciliation which meant it could not be filibustered in the Senate

Almost immediately Republicans started their fight to repeal the law. With the enactment of the ACA earlier in the year, the 2010 midterm election drastically changed the dynamics of Congress with Republicans taking the House and making up ground in the Senate.

In 2011, after Republicans gained control of the House of Representatives, one of the first votes held was on a bill titled “Repealing the Job-Killing Health Care Law Act,” which the House passed 245–189. All Republicans and three Democrats voted for repeal. House Democrats proposed an amendment that repeal not take effect until a majority of the Senators and Representatives had opted out of the Federal Employees Health Benefits Program; Republicans voted down the measure. In the Senate, the bill was offered as an amendment to an unrelated bill, but was voted down. President Obama had stated that he would have vetoed the bill even if it had passed both chambers of Congress.

In 2012 the Supreme Court heard arguments over a lawsuit brought by the National Federation of Independent Business that claimed the ACA was unconstitutional. Although the court was split, the ruling deemed the ACA as constitutional with a 5-4 vote. Chief Justice Roberts wrote the opinion upholding the law with the logic that the individual mandate was in fact a tax.

Following the 2012 Supreme Court ruling upholding ACA as constitutional, Republicans held their 33rd attempt to repeal at least a portion of the law on July 11 with no success.

In 2013, Republicans attempted to defund its implementation, and House Republicans refused to fund the federal government unless accompanied with a delay in ACA implementation, after President Obama unilaterally deferred the employer mandate by one year, which critics claimed he had no power to do. The House passed three versions of a bill funding the government while submitting various versions that would repeal or delay ACA, with the last version delaying enforcement of the individual mandate. The Democratic Senate leadership stated the Senate would only pass a "clean" funding bill without any restrictions on ACA. The government was subsequently shutdown from October 1 to October 17.

The House passed the Restoring Americans' Healthcare Freedom Reconciliation Act of 2015 on October 23, 2015. The bill would have partially repealed the provisions of the Affordable Care Act including the individual and employer mandates. The bill was the 61st time that the House had voted to fully or partially repeal the Affordable Care Act. The bill also would have removed federal funding for Planned Parenthood for one year. The bill was expected to be vetoed by President Obama had it passed the Senate.

In early December 2015, the Senate passed an amended version of the healthcare reconciliation bill, sending it back to the House. It was passed by the House on January 6, 2016, and vetoed by President Obama on January 8. The House failed to override the President's veto in February.

With the election of President Trump and the Republicans retaining control of both houses of Congress, a new energy emerged to repeal Obamacare.

On January 12, 2017, the Senate voted 51 to 48 to pass an FY2017 budget resolution, S.Con.Res. 3, that contained language allowing the repeal of many parts of the Affordable Care Act through the budget reconciliation process, which disallows a filibuster in the Senate.

In his first day in office, President Trump signed an executive order, that according to the White House Press Secretary Sean Spicer would "ease the burden of Obamacare as we transition from repeal and replace." Spicer did not elaborate further when asked for more details.

On March 6, 2017, House Republicans announced their replacement for the ACA, the American Health Care Act. Not able to get the votes to pass as a result of infighting in the Republican party, the bill was withdrawn on March 24, 2017.

In May after making changes to gain more votes, the House voted to pass the American Health Care Act and repeal most of the Affordable Care Act. The bill was sent to the Senate for deliberation, but Senate leaders indicated they would write their own version of the bill, instead of voting on the House version. In June, the Better Care Reconciliation Act of 2017 was unveiled.

The Health Care Freedom Act was introduced at the end of July 2017. This bill was also known as the "skinny repeal." This bill was defeated 49–51, with Republican senators Susan Collins, John McCain, and Lisa Murkowski voting against it along with all the Democrats and Independents.

In September 2017, an amendment to the American Health Care Act, commonly known as Graham-Cassidy, was submitted. A spokesman for the Senate Majority Leader Mitch McConnell said that a vote was planned to occur before September 30th, which was the deadline to pass this bill under budget reconciliation. After multiple Republican Senators indicated that they would not vote for the bill, Majority Leader Mitch McConnell announced on September 26th that the Senate would not vote on the bill.

After multiple failed attempts to “repeal and replace” under President Trump, the failure of Graham-Cassidy marked the end of the attempts by Congress to repeal in full the ACA. Instead, Republican Congress members focused on attempts to reduce it in pieces.

With the passage of the Tax Cuts and Jobs Act of 2017,the Individual Shared Responsibility Payment, better known as the Obamacare tax penalty was abolished starting in the 2019 tax year.

Due to this tax penalty removal, in February 2018, 18 Republican state Attorneys General headed by the Texas AG Ken Paxton filed a lawsuit in Texas claiming that without the tax penalty, the ACA was unconstitutional. U.S. District Judge Reed O’Connor ruled in favor of the Republican AGs ruling the bill unconstitutional, but with a stay until higher courts have the ability to rule.

The fate of the Affordable Care Act, and healthcare reform in general remains very much in flux, and we will see what will come in future years. With many members of the Democratic House and 2020 Presidential candidates pushing for Medicare for all, there is no doubt that new changes and fights will be coming.

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