MACMLA 2014: Leighton Ku

Health Reform: How Did We Get Here, What the Heck is Going On, and What Next?

  • It’s a long history
    • 1930s: New Dealers were for it but AMA was against
    • World War II had wage and price controls (except for health insurance); work-based insurance coverage expanded during this time
    • 1965: Medicare enacted
    • Medicaid created as joint federal-state program and fully adopted in 1982
    • 1973: HMO Act passed
      • Required employers to offer HMO and indemnity plans – sets standard of choice for employees
    • 1980s: Incremental change
      • Expands Medicaid coverage of children and pregnant women
      • Medicare Catastrophic Act 1988 passed, but repealed in 1989
    • 1990s: Clinton plan
    • 2000s:
      • Emphasis on reducing federal spending
      • CHIP reauthorized twice, but Bush vetoed twice – Obama approved early in term
      • PPACA (aka ACA, Affordable Care Act, Obamacare) passed on party lines
        • Key ACA components:
          • Insurance expansions: Medicaid, health insurance exchange+tax credit, individual mandate
          • Insurance reforms: essential health benefits, free preventative care, guaranteed issue, no pre-existing conditions, young adults on family policies
    • Now
      • October 2013: Website rollout issues
        • 2/3 of states using the website
        • +7 million joined exchanged and 8 million enrolled in Medicaid = 15 million (~5% of US population)
      • Public opinion has barely changed over the last 5 years of debate and implementation
      • Legal challenges
        • NFIB v Sebelius
          • Claim: Mandate was unconstitutional
          • SCOTUS: Mandate is constitutional as a tax; Medicaid expansion is optional
        • Hobby Lobby
          • Claim: Contraceptive coverage if against religious connection
          • SCOTUS: Private businesses cannot be required to provide contraceptive coverage but insurers still required to provide coverage
        • Halbig v Burwell: Still in progress
          • Claim: Do federal tax credits apply in states with federally administered exchanges?  Could eliminate tax credits and exchanges in about 2/3 of states
          • SCOTUS: Probably going to review next year
      • Preliminary signs of success
        • reduction in uncompensated care costs
        • increased in employment
        • more states considering exchanges
      • Still waiting on stabilization phase
      • Exchanges are too complicated – simplify policies and consumer education
      • Are premiums too high/subsidies not adequate? 1/5 have bronze plans; 2/3 have silver plans
      • Do we have enough primary care practitioners?

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