The Patient Protection and Affordable Care Act (PPACA) of 2010 was an ambitious piece of public policy designed to lower costs, replace antiquated practices and expand coverage to all citizens. The law was not passed in bipartisan manner, however, which set off a national debate over whether it would truly effect a change in the country's faltering health care system. This paper will review the PPACA, provide a brief history of the legislation, outline its components, and survey its reception.
Keywords: Cadillac Plan; Employer Mandate; Health Care and Education Reconciliation Act of 2010; Health Care Reform; Insurance; Medicaid; Medicare; Patient Protection and Affordable Care Act (PPACA)
One of the goals of any strong modern nation is to ensure that its people have access to a doctor and a health care system that is trustworthy and protects this relationship. Many modern nations have made health care part of the government infrastructure, annually appropriating state funds for health insurance. For other countries, like the United States, the chosen course of action has been to allow private insurers to provide that coverage at market rates, although the government provides coverage for those who are age sixty-five or older, live below the poverty line, or are disabled.
In the United States, the cost of private health insurance has increased steadily over the last several decades, causing political leaders, medical professionals and interest groups to call for nationalized systems akin to those of Europe and Canada. A number of major attempts at health care reform have been offered since the Great Depression, but few have succeeded in making sweeping changes.
In 2010, however, a major piece of legislation, introduced by Congress but strongly advocated by President Barack Obama, succeeded where previous initiatives fell short. The Patient Protection and Affordable Care Act of 2010, also called the Affordable Care Act (ACA) or Obamacare, was an enormous piece of public policy designed to lower costs, replace antiquated practices, and expand coverage to all citizens. The law is controversial, however, and has set off a national debate over whether it can truly effect a change in the country's faltering health care system. This paper will review the PPACA, provide a brief history of the legislation, outline its components, and survey its reception.
A Brief History of Health Care Reform Proposals
The idea of ensuring that every American has access to affordable health care is one that has circulated throughout the twentieth and twenty-first centuries. In 1912, President Theodore Roosevelt and his Bull Moose Party proposed providing health care coverage for industry. In 1915, eight states pushed for mandatory health care, and shortly thereafter, the first proposals for "socialized medicine" (which entailed group medicine and voluntary insurance) began to surface (Hoffman, 2009).
While the World War I effectively shelved Teddy Roosevelt's and other proposals, the use of the term “socialized medicine” was the primary element causing the demise of health care reform proposals by the administration of Franklin Delano Roosevelt. During the New Deal era of the 1930s, the term socialized appeared more than 700 times in just one newspaper, the New York Times, in reference to such reform efforts. Meanwhile, "socialized medicine" appeared 234 times when describing health care proposals (Greenberg, 2007). In light of the growing concern in the United States over communism, applying the word "socialized" to any proposal would in effect guarantee the bill's quick demise.
FDR's defeat on health care reform efforts in the 1930s was hardly the only one for supporters during the twentieth century. His successor, Harry Truman, offered a postwar proposal that was reviled by the American Medical Association and was called a "Communist plot" by a House subcommittee ("Healthcare crisis," 2010). As health care costs increased over the following decades, proposals to nationalize health care failed.
By 1992, the specter of communism had dissipated with the collapse of the Soviet Union. The faltering economy and other domestic matters were the most important issues on the minds of American voters. Soon after taking office in 1993, President Bill Clinton, an advocate of comprehensive health care reform, appointed First Lady Hillary Rodham Clinton to chair his Task Force on National Health Reform. At the time, 36 million Americans did not have health insurance (Friedman, 1993). Along with congressional Democrats, the task force offered bills to address the rising cost of health care. None of the bills succeeded, but Clinton's bill in particular suffered a dramatic defeat.
There were a wide range of factors that played a role in the failure of the Clinton proposal. In addition to the latent rhetorical designation of national health insurance (the centerpiece of the bill) as socialized medicine, congressional Republicans railed against it, while many business and medical organizations shied away from many of its key components. The measure was so modified during the legislative process (the result of compromises in order to gain support of moderates) that critics on both sides of the aisle saw the resulting bill as overly complex, costly, and muddled to the point of near incoherence (Starr, 1995).
The Road to Reform
Following the Clinton administration, the two terms of President George W. Bush saw little movement on the issue, as President Bush focused more on issues such as homeland security and economic recovery. In 2008, however, Senator Barack Obama was elected president, with comprehensive health care reform comprising a key part of his campaign platform.
The platform was based on figures that were generally accepted on a bipartisan level. In 2007, according to the US Census, 45.7 million Americans did not have health care insurance — a number that was down from the previous year but almost certainly rose again when the financial crisis of 2008 began to spread ("The uninsured," 2009). The figure included mostly individuals and families who lived below the poverty line, but also people from a wide range of socioeconomic backgrounds. The dearth of health care for these groups meant that a large percentage of them, instead of visiting a primary care physician, went to a hospital emergency room for non-emergency care. In a nation that spends only four percent of its economic output on Medicaid and Medicare and 16 percent overall on the health care system, such practices have added significantly to the growing issue ("Heading for," 2009).
In February of 2009, President Obama, citing the "crushing cost of health care" suffered by Americans, used his State of the Union address to call upon Congress to pass health care reform (Martin, 2009). Over the course of 2009, scores of proposals of varying size and focus were introduced in the Legislature. By the fall of 2009, three major proposals were under consideration, adopting many of the principles for reform bills the President had proffered in his February speech. These principles were:
- Reducing long-term growth of health care costs
- Protecting families from bankruptcy due to health care costs
- Guaranteeing a choice of doctors and health plans for patients
- Investing in prevention practices
- Improving patient safety and care
- Securing affordable coverage for all Americans
- Maintaining coverage after job loss
- Ending barriers to coverage for people with pre-existing conditions ("Side-by-side Comparison," 2009)
The fall of 2009 was extremely challenging for Democrats. It was preceded by a summer of "town hall"–style forums led by Democratic Congressmen; many of these events were given national media exposure and were marked by strong and often confrontational situations between the legislators and their constituents. Additionally, the frequent Republican criticisms of many of the tenets of reform legislation made it clear that the final version of the health care reform bill would not be the result of...
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