History of health care reform in the United States
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The history of health care reform in the United States has spanned many decades with health care reform having been the subject of political debate since the early part of the 20th century. Recent reforms remain an active political issue. Alternative reform proposals were offered by both of the major candidates in the
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presidential elections.


Federal health care proposals


Late 18th century

On July 16, 1798,
President John Adams John Adams (October 30, 1735 – July 4, 1826) was an American statesman, attorney, diplomat, writer, and Founding Father The following list of national founding figures is a record, by country, of people who were credited with establi ...
signed the first Federal public health law, "
An act for the relief of sick and disabled Seamen An Act for the relief of sick and disabled seamen was passed by the 5th Congress. It was signed by President John Adams on July 16, 1798. The Act authorized the deduction of twenty cents per month from the wages of seamen, for the sole purpos ...
." This assessed every seaman at American ports 20 cents a month. This was the first prepaid medical care plan in the United States. The money was used for the care of sick seamen and the building of seamen's hospitals. This act created the
Marine Hospital Service The Marine Hospital Service was an organization of Marine Hospitals dedicated to the care of ill and disabled seamen in the United States Merchant Marine, the U.S. Coast Guard and other federal beneficiaries. The Marine Hospital Service evolved ...
under the Department of the Treasury. In 1802 Marine Hospitals were operating in
Boston Boston (), officially the City of Boston, is the state capital and most populous city of the Commonwealth of Massachusetts, as well as the cultural and financial center of the New England region of the United States. It is the 24th- mo ...
; Newport;
Norfolk Norfolk () is a ceremonial and non-metropolitan county in East Anglia in England. It borders Lincolnshire to the north-west, Cambridgeshire to the west and south-west, and Suffolk to the south. Its northern and eastern boundaries are the No ...
; and Charleston, S.C. and medical services were contracted in other ports.


19th century

Another of the earliest health care proposals at the federal level was the 1854
Bill for the Benefit of the Indigent Insane The Bill for the Benefit of the Indigent Insane (also called the Land-Grant Bill For Indigent Insane Persons, formally the bill "Making a grant of public lands to the several States for the benefit of indigent insane persons") was proposed legisla ...
, which would have established asylums for the indigent insane, as well as the blind and deaf, via federal land grants to the states. This bill was proposed by activist
Dorothea Dix Dorothea Lynde Dix (April 4, 1802July 17, 1887) was an American advocate on behalf of the indigent mentally ill who, through a vigorous and sustained program of lobbying state legislatures and the United States Congress, created the first gene ...
and passed both houses of Congress, but was vetoed by President
Franklin Pierce Franklin Pierce (November 23, 1804October 8, 1869) was the 14th president of the United States, serving from 1853 to 1857. He was a northern Democrat who believed that the abolitionist movement was a fundamental threat to the nation's unity ...
. Pierce argued that the federal government should not commit itself to
social welfare Welfare, or commonly social welfare, is a type of government support intended to ensure that members of a society can meet Basic needs, basic human needs such as food and shelter. Social security may either be synonymous with welfare, or refe ...
, which he stated was the responsibility of the states. After the
American Civil War The American Civil War (April 12, 1861 – May 26, 1865; also known by other names) was a civil war in the United States. It was fought between the Union ("the North") and the Confederacy ("the South"), the latter formed by states th ...
, the federal government established the first system of medical care in the South, known as the
Freedmen's Bureau The Bureau of Refugees, Freedmen, and Abandoned Lands, usually referred to as simply the Freedmen's Bureau, was an agency of early Reconstruction, assisting freedmen in the South. It was established on March 3, 1865, and operated briefly as a ...
. The government constructed 40 hospitals, employed over 120 physicians, and treated well over one million sick and dying former slaves. The hospitals were short-lived, lasting from 1865 to 1870.
Freedmen's Hospital Howard University Hospital, previously known as Freedmen's Hospital, is a major hospital located in Washington, D.C., built on the site of the previous Griffith Stadium. The hospital has served the African-American community in the area for over ...
in Washington, D.C. remained in operation until the late nineteenth century when it became part of
Howard University Howard University (Howard) is a private, federally chartered historically black research university in Washington, D.C. It is classified among "R2: Doctoral Universities – High research activity" and accredited by the Middle States Commissi ...
. The next major initiative came in the
New Deal The New Deal was a series of programs, public work projects, financial reforms, and regulations enacted by President Franklin D. Roosevelt in the United States between 1933 and 1939. Major federal programs agencies included the Civilian Cons ...
legislation of the 1930s, in the context of the
Great Depression The Great Depression (19291939) was an economic shock that impacted most countries across the world. It was a period of economic depression that became evident after a major fall in stock prices in the United States. The economic contagio ...
.


1900s–1920s

In the first 10–15 years of the 20th century
Progressivism Progressivism holds that it is possible to improve human societies through political action. As a political movement, progressivism seeks to advance the human condition through social reform based on purported advancements in science, tec ...
was influencing both Europe and the United States. Many European countries were passing the first social welfare acts and forming the basis for compulsory government-run or voluntary subsidized health care programs. The United Kingdom passed the National Insurance Act of 1911 that provided medical care and replacement of some lost wages if a worker became ill. It did not, however, cover spouses or dependents. As early as the 1912 presidential election, former president
Theodore Roosevelt Theodore Roosevelt Jr. ( ; October 27, 1858 – January 6, 1919), often referred to as Teddy or by his initials, T. R., was an American politician, statesman, soldier, conservationist, naturalist, historian, and writer who served as the 26t ...
vaguely called for the creation of a national health service in the 15th plank of his
Progressive Party Progressive Party may refer to: Active parties * Progressive Party, Brazil * Progressive Party (Chile) * Progressive Party of Working People, Cyprus * Dominica Progressive Party * Progressive Party (Iceland) * Progressive Party (Sardinia), Italy ...
platform. However, neither Roosevelt nor his opponents discussed health care plans in detail, and Roosevelt lost the election to
Woodrow Wilson Thomas Woodrow Wilson (December 28, 1856February 3, 1924) was an American politician and academic who served as the 28th president of the United States from 1913 to 1921. A member of the Democratic Party, Wilson served as the president of ...
. A unique American history of
decentralization Decentralization or decentralisation is the process by which the activities of an organization, particularly those regarding planning and decision making, are distributed or delegated away from a central, authoritative location or group. Conce ...
in government,
limited government In political philosophy, limited government is the concept of a government limited in power. It is a key concept in the history of liberalism.Amy Gutmann, "How Limited Is Liberal Government" in Liberalism Without Illusions: Essays on Liberal Theo ...
, and a tradition of
classical liberalism Classical liberalism is a political tradition Political culture describes how culture impacts politics. Every political system is embedded in a particular political culture. Definition Gabriel Almond defines it as "the particular patt ...
are all possible explanations for the suspicion around the idea of compulsory government-run insurance. The
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's state ...
(AMA) was also deeply and vocally opposed to the idea, which it labeled "
socialized medicine Socialized medicine is a term used in the United States to describe and discuss systems of universal health care—medical and hospital care for all by means of government regulation of health care and subsidies derived from taxation. Because of ...
". In addition, many urban US workers already had access to sickness insurance through employer-based sickness funds. Early industrial sickness insurance purchased through employers was one influential economic origin of the current American health care system. These late-19th-century and early-20th-century sickness insurance schemes were generally inexpensive for workers: their small scale and local administration kept overhead low, and because the people who purchased insurance were all employees of the same company, that prevented people who were already ill from buying in. The presence of employer-based sickness funds may have contributed to why the idea of government-based insurance did not take hold in the United States at the same time that the United Kingdom and the rest of Europe was moving toward socialized schemes like the UK National Insurance Act of 1911. Thus, at the beginning of the 20th century, Americans were used to associating insurance with employers, which paved the way for the beginning of third-party health insurance in the 1930s.


1930s–1950s

With the
Great Depression The Great Depression (19291939) was an economic shock that impacted most countries across the world. It was a period of economic depression that became evident after a major fall in stock prices in the United States. The economic contagio ...
, more and more people could not afford medical services. In 1933,
Franklin D. Roosevelt Franklin Delano Roosevelt (; ; January 30, 1882April 12, 1945), often referred to by his initials FDR, was an American politician and attorney who served as the 32nd president of the United States from 1933 until his death in 1945. As the ...
asked Isidore Falk and Edgar Sydenstricter to help draft provisions to Roosevelt's pending
Social Security Welfare, or commonly social welfare, is a type of government support intended to ensure that members of a society can meet basic human needs such as food and shelter. Social security may either be synonymous with welfare, or refer specificall ...
legislation to include
publicly funded health care Publicly funded healthcare is a form of health care financing designed to meet the cost of all or most healthcare needs from a publicly managed fund. Usually this is under some form of democratic accountability, the right of access to which are se ...
programs. These reforms were attacked by the
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's state ...
as well as state and local affiliates of the AMA as "compulsory health insurance." Roosevelt ended up removing the health care provisions from the bill in 1935. Fear of organized medicine's opposition to
universal health care Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized ar ...
became standard for decades after the 1930s. During this time, individual hospitals began offering their own insurance programs, the first of which became Blue Cross. Groups of hospitals as well as physician groups (i.e. Blue Shield) soon began selling group health insurance policies to employers, who then offered them to their employees and collected premiums. In the 1940s Congress passed legislation that supported the new third-party insurers. During
World War II World War II or the Second World War, often abbreviated as WWII or WW2, was a world war that lasted from 1939 to 1945. It involved the vast majority of the world's countries—including all of the great powers—forming two opposin ...
, industrialist
Henry J. Kaiser Henry John Kaiser (May 9, 1882 – August 24, 1967) was an American industrialist who became known as the father of modern American shipbuilding. Prior to World War II, Kaiser was involved in the construction industry; his company was one of ...
used an arrangement in which doctors bypassed traditional fee-for-care and were contracted to meet all the medical needs for his employees on construction projects up and down the West coast. After the war ended, he opened the plan up to the public as a non-profit organization under the name
Kaiser Permanente Kaiser Permanente (; KP), commonly known simply as Kaiser, is an American integrated managed care consortium, based in Oakland, California, United States, founded in 1945 by industrialist Henry J. Kaiser and physician Sidney Garfield. Kaiser P ...
. During World War II, the federal government introduced wages and price controls. In an effort to continue attracting and retaining employees without violating those controls, employers offered and sponsored health insurance to employees in lieu of gross pay. This was a beginning of the third-party paying system that began to replace direct out-of-pocket payments. Following the world war, President
Harry Truman Harry S. Truman (May 8, 1884December 26, 1972) was the 33rd president of the United States, serving from 1945 to 1953. A leader of the Democratic Party, he previously served as the 34th vice president from January to April 1945 under Franklin ...
called for universal health care as a part of his
Fair Deal The Fair Deal was a set of proposals put forward by U.S. President Harry S. Truman to Congress in 1945 and in his January 1949 State of the Union address. More generally. the term characterizes the entire domestic agenda of the Truman administra ...
in 1949 but strong opposition stopped that part of the Fair Deal. However, in 1946 the
National Mental Health Act The National Mental Health Act (1946) became law on July 3, 1946. It established and provided funds for a National Institute of Mental Health (NIMH). The act made the mental health of the people a federal priority. It was inspired by alarm at ...
was passed, as was the Hospital Survey and Construction Act, or Hill-Burton Act. In 1951 the
IRS The Internal Revenue Service (IRS) is the revenue service for the United States federal government, which is responsible for collecting U.S. federal taxes and administering the Internal Revenue Code, the main body of the federal statutory tax ...
declared group premiums paid by employers as a tax-deductible business expense, which solidified the third-party insurance companies' place as primary providers of access to health care in the United States.


1960s–1980s


1960s

In the
Civil Rights era The civil rights movement was a nonviolent social and political movement and campaign from 1954 to 1968 in the United States to abolish legalized institutional racial segregation, discrimination, and disenfranchisement throughout the United S ...
of the 1960s and early 1970s, public opinion shifted towards the problem of the uninsured, especially the elderly. Since care for the elderly would someday affect everyone, supporters of health care reform were able to avoid the worst fears of "socialized medicine," which was considered a dirty word for its association with communism. After
Lyndon B. Johnson Lyndon Baines Johnson (; August 27, 1908January 22, 1973), often referred to by his initials LBJ, was an American politician who served as the 36th president of the United States from 1963 to 1969. He had previously served as the 37th vice ...
was elected president in 1964, the stage was set for the passage of Medicare and
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and pers ...
in 1965. Johnson's plan was not without opposition, however. "Opponents, especially the AMA and insurance companies, opposed the Johnson administration's proposal on the grounds that it was compulsory, it represented socialized medicine, it would reduce the quality of care, and it was 'un-American.'" These views notwithstanding, the Medicare program was established when the
Social Security Amendments of 1965 The Social Security Amendments of 1965, , was legislation in the United States whose most important provisions resulted in creation of two programs: Medicare and Medicaid. The legislation initially provided federal health insurance for the elder ...
were signed into law on July 30, 1965, by President Lyndon B. Johnson. Medicare is a social insurance program administered by the United States government, providing health insurance coverage to people who are either age 65 and over, or who meet other special criteria.


1970s

In 1970, three proposals for
single-payer Single-payer healthcare is a type of universal healthcare in which the costs of essential healthcare for all residents are covered by a single public system (hence "single-payer"). Single-payer systems may contract for healthcare services from ...
universal Universal is the adjective for universe. Universal may also refer to: Companies * NBCUniversal, a media and entertainment company ** Universal Animation Studios, an American Animation studio, and a subsidiary of NBCUniversal ** Universal TV, a ...
national health insurance National health insurance (NHI), sometimes called statutory health insurance (SHI), is a system of health insurance that insures a national population against the costs of health care. It may be administered by the public sector, the private sector ...
financed by payroll taxes and general federal revenues were introduced in the U.S. Congress. In February 1970, Representative
Martha Griffiths Martha Wright Griffiths (January 29, 1912 – April 22, 2003) was an American lawyer and judge before being elected to the United States House of Representatives in 1954. Griffiths was the first woman to serve on the House Committee on Ways and M ...
( D- MI) introduced a national health insurance bill—without any
cost sharing In health care, cost sharing occurs when patients pay for a portion of health care costs not covered by health insurance. The "out-of-pocket" payment varies among healthcare plans and depends on whether or not the patient chooses to use a healthca ...
—developed with the
AFL–CIO The American Federation of Labor and Congress of Industrial Organizations (AFL–CIO) is the largest federation of unions in the United States. It is made up of 56 national and international unions, together representing more than 12 million ac ...
. In April 1970, Senator
Jacob Javits Jacob Koppel Javits ( ; May 18, 1904 – March 7, 1986) was an American lawyer and politician. During his time in politics, he represented the state of New York in both houses of the United States Congress. A member of the Republican Party, he a ...
( R- NY) introduced a bill to extend Medicare to all—retaining existing Medicare cost sharing and coverage limits—developed after consultation with Governor
Nelson Rockefeller Nelson Aldrich Rockefeller (July 8, 1908 – January 26, 1979), sometimes referred to by his nickname Rocky, was an American businessman and politician who served as the 41st vice president of the United States from 1974 to 1977. A member of t ...
( R- NY) and former Johnson administration HEW Secretary
Wilbur Cohen Wilbur Joseph Cohen (June 10, 1913 – May 17, 1987) was an American social scientist and civil servant. He was one of the key architects in the creation and expansion of the American welfare state and was involved in the creation of both the Ne ...
. In August 1970, Senator
Ted Kennedy Edward Moore Kennedy (February 22, 1932 – August 25, 2009) was an American lawyer and politician who served as a United States senator from Massachusetts for almost 47 years, from 1962 until his death in 2009. A member of the Democratic ...
( D- MA) introduced a bipartisan national health insurance bill—without any cost sharing—developed with the Committee for National Health Insurance founded by
United Auto Workers The International Union, United Automobile, Aerospace, and Agricultural Implement Workers of America, better known as the United Auto Workers (UAW), is an American labor union that represents workers in the United States (including Puerto Rico ...
(UAW) president
Walter Reuther Walter Philip Reuther (; September 1, 1907 – May 9, 1970) was an American leader of Labor unions in the United States, organized labor and Civil rights movements, civil rights activist who built the United Automobile Workers (UAW) into one of ...
, with a corresponding bill introduced in the House the following month by Representative
James Corman James Charles Corman (October 20, 1920 – December 30, 2000) was an American politician who served as a member of the Los Angeles City Council from 1957 to 1961 and as a member of the United States House of Representatives between 1961 and 1981. ...
( D- CA). In September 1970, the Senate Labor and Public Welfare Committee held the first congressional hearings in twenty years on national health insurance. In January 1971, Kennedy began a decade as chairman of the Health subcommittee of the Senate Labor and Public Welfare Committee, and introduced a reconciled bipartisan Kennedy–Griffiths bill proposing universal national health insurance. In February 1971, President
Richard Nixon Richard Milhous Nixon (January 9, 1913April 22, 1994) was the 37th president of the United States, serving from 1969 to 1974. A member of the Republican Party, he previously served as a representative and senator from California and was ...
proposed more limited health insurance reform—an employer mandate to offer private health insurance if employees volunteered to pay 25 percent of premiums, federalization of
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and pers ...
for the poor with dependent minor children, merger of Medicare Parts A and B with elimination of the Medicare Part B $5.30 monthly premium, and support for
health maintenance organization In the United States, a health maintenance organization (HMO) is a medical insurance group that provides health services for a fixed annual fee. It is an organization that provides or arranges managed care for health insurance, self-funded healt ...
s (HMOs). Hearings on national health insurance were held by the
House Ways and Means Committee The Committee on Ways and Means is the chief tax-writing committee of the United States House of Representatives. The committee has jurisdiction over all taxation, tariffs, and other revenue-raising measures, as well as a number of other program ...
and the
Senate Finance Committee The United States Senate Committee on Finance (or, less formally, Senate Finance Committee) is a standing committee of the United States Senate. The Committee concerns itself with matters relating to taxation and other revenue measures generall ...
in 1971, but no bill had the support of committee chairmen Representative
Wilbur Mills Wilbur Daigh Mills (May 24, 1909 – May 2, 1992) was an American Democratic politician who represented in the United States House of Representatives from 1939 until his retirement in 1977. As chairman of the House Ways and Means Committee from ...
( D- AR) or Senator
Russell Long Russell Billiu Long (November 3, 1918 – May 9, 2003) was an American Democratic politician and United States Senator from Louisiana from 1948 until 1987. Because of his seniority, he advanced to chairman of the Senate Finance Committee, servin ...
( D- LA). In October 1972, Nixon signed the Social Security Amendments of 1972 extending Medicare to those under 65 who have been severely disabled for over two years or have
end stage renal disease Kidney failure, also known as end-stage kidney disease, is a medical condition in which the kidneys can no longer adequately filter waste products from the blood, functioning at less than 15% of normal levels. Kidney failure is classified as eit ...
(ESRD), and gradually raising the Medicare Part A payroll tax from 1.1% to 1.45% in 1986. In the 1972 presidential election, Nixon won re-election in a landslide over the only Democratic presidential nominee not endorsed by the
AFL–CIO The American Federation of Labor and Congress of Industrial Organizations (AFL–CIO) is the largest federation of unions in the United States. It is made up of 56 national and international unions, together representing more than 12 million ac ...
in its history, Senator
George McGovern George Stanley McGovern (July 19, 1922 – October 21, 2012) was an American historian and South Dakota politician who was a U.S. representative and three-term U.S. senator, and the Democratic Party presidential nominee in the 1972 pres ...
( D- SD), who was a cosponsor of the Kennedy-Griffiths bill, but did not make national health insurance a major issue in his campaign. In October 1973, Long and Senator
Abraham Ribicoff Abraham Alexander Ribicoff (April 9, 1910 – February 22, 1998) was an American Democratic Party politician from the state of Connecticut. He represented Connecticut in the United States House of Representatives and Senate and was the 80th ...
( D- CT) introduced a bipartisan bill for catastrophic health insurance coverage for workers financed by payroll taxes and for Medicare beneficiaries, and federalization of Medicaid with extension to the poor without dependent minor children. In February 1974, Nixon proposed more comprehensive health insurance reform—an employer mandate to offer private health insurance if employees volunteered to pay 25 percent of premiums, replacement of Medicaid by state-run health insurance plans available to all with income-based premiums and cost sharing, and replacement of Medicare with a new federal program that eliminated the limit on hospital days, added income-based out-of-pocket limits, and added outpatient prescription drug coverage. In April 1974, Kennedy and Mills introduced a bill for near-universal national health insurance with benefits identical to the expanded Nixon plan—but with mandatory participation by employers and employees through payroll taxes and with lower cost sharing—both plans were criticized by labor, consumer, and senior citizens organizations because of their substantial cost sharing. In August 1974, after Nixon's resignation and President
Gerald Ford Gerald Rudolph Ford Jr. ( ; born Leslie Lynch King Jr.; July 14, 1913December 26, 2006) was an American politician who served as the 38th president of the United States from 1974 to 1977. He was the only president never to have been elected ...
's call for health insurance reform, Mills tried to advance a compromise based on Nixon's plan—but with mandatory participation by employers and employees through premiums to private health insurance companies and catastrophic health insurance coverage financed by payroll taxes—but gave up when unable to get more than a 13–12 majority of his committee to support his compromise plan. In December 1974, Mills resigned as chairman of the Ways and Means Committee and was succeeded by Representative
Al Ullman Albert Conrad Ullman (March 9, 1914 – October 11, 1986) was an American politician in the Democratic Party who represented in the United States House of Representatives from 1957 to 1981. One of the most influential Oregonians ever to be ele ...
( D- OR), who opposed payroll tax and general federal revenue financing of national health insurance. In January 1975, in the midst of the worst recession in the four decades since the
Great Depression The Great Depression (19291939) was an economic shock that impacted most countries across the world. It was a period of economic depression that became evident after a major fall in stock prices in the United States. The economic contagio ...
, Ford said he would veto any health insurance reform, and Kennedy returned to sponsoring his original universal national health insurance bill. In April 1975, with one third of its sponsors gone after the November 1974 election, the AMA replaced its "Medicredit" plan with an employer mandate proposal similar to Nixon's 1974 plan. In January 1976, Ford proposed adding catastrophic coverage to Medicare, offset by increased cost sharing. In April 1976, Democratic presidential candidate
Jimmy Carter James Earl Carter Jr. (born October 1, 1924) is an American politician who served as the 39th president of the United States from 1977 to 1981. A member of the Democratic Party (United States), Democratic Party, he previously served as th ...
proposed health care reform that included key features of Kennedy's universal national health insurance bill. In December 1977, President Carter told Kennedy his bill must be changed to preserve a large role for private insurance companies, minimize federal spending (precluding payroll tax financing), and be phased-in so not to interfere with balancing the federal budget. Kennedy and organized labor compromised and made the requested changes, but broke with Carter in July 1978 when he would not commit to pursuing a single bill with a fixed schedule for phasing-in comprehensive coverage. In May 1979, Kennedy proposed a new bipartisan universal national health insurance bill—choice of competing federally-regulated private health insurance plans with no cost sharing financed by income-based premiums via an employer mandate and individual mandate, replacement of Medicaid by government payment of premiums to private insurers, and enhancement of Medicare by adding prescription drug coverage and eliminating premiums and cost sharing. In June 1979, Carter proposed more limited health insurance reform—an employer mandate to provide catastrophic private health insurance plus coverage without cost sharing for pregnant women and infants, federalization of Medicaid with extension to the very poor without dependent minor children, and enhancement of Medicare by adding catastrophic coverage. In November 1979, Long led a bipartisan conservative majority of his
Senate Finance Committee The United States Senate Committee on Finance (or, less formally, Senate Finance Committee) is a standing committee of the United States Senate. The Committee concerns itself with matters relating to taxation and other revenue measures generall ...
to support an employer mandate to provide catastrophic-only private health insurance and enhancement of Medicare by adding catastrophic coverage, but abandoned efforts in May 1980 due to budget constraints in the face of a deteriorating economy.


1980s

The
Consolidated Omnibus Budget Reconciliation Act of 1985 The Consolidated Omnibus Budget Reconciliation Act of 1985 (COBRA) is a law passed by the U.S. Congress on a reconciliation basis and signed by President Ronald Reagan that, among other things, mandates an insurance program which gives some emp ...
(COBRA) amended the
Employee Retirement Income Security Act The Employee Retirement Income Security Act of 1974 (ERISA) (, codified in part at ) is a U.S. federal tax and labor law that establishes minimum standards for pension plans in private industry. It contains rules on the federal income tax eff ...
of 1974 (ERISA) to give some employees the ability to continue
health insurance Health insurance or medical insurance (also known as medical aid in South Africa) is a type of insurance that covers the whole or a part of the risk of a person incurring medical expenses. As with other types of insurance, risk is shared among ma ...
coverage after leaving employment.


Clinton initiative

Health care reform was a major concern of the
Bill Clinton administration Bill(s) may refer to: Common meanings * Banknote, paper cash (especially in the United States) * Bill (law), a proposed law put before a legislature * Invoice, commercial document issued by a seller to a buyer * Bill, a bird or animal's beak Plac ...
headed up by First Lady
Hillary Clinton Hillary Diane Rodham Clinton ( Rodham; born October 26, 1947) is an American politician, diplomat, and former lawyer who served as the 67th United States Secretary of State for President Barack Obama from 2009 to 2013, as a United States sen ...
. The 1993 Clinton health care plan included mandatory enrollment in a health insurance plan, subsidies to guarantee affordability across all income ranges, and the establishment of health alliances in each state. Every citizen or permanent resident would thus be guaranteed medical care. The bill faced withering criticism by Republicans, led by
William Kristol William Kristol (; born December 23, 1952) is an American neoconservative writer. A frequent commentator on several networks including CNN, he was the founder and editor-at-large of the political magazine ''The Weekly Standard''. Kristol is now ...
, who communicated his concern that a Democratic health care bill would "revive the reputation of... Democrats as the generous protector of middle-class interests. And it will at the same time strike a punishing blow against Republican claims to defend the middle class by restraining government." The bill was not enacted into law. The "Health Security Express," a cross-country tour by multiple buses carrying supporters of President Clinton's national health care reform, started at the end of July 1994. During each stop, the bus riders would talk about their personal experiences, health care disasters and why they felt it was important for all Americans to have health insurance.


2000-2008: Bush era debates

In 2000 the
Health Insurance Association of America AHIP (formerly America's Health Insurance Plans) is an American political advocacy and trade association of health insurance companies that offer coverage through the employer-provided, Medicare Advantage, Medicaid managed care, and individual m ...
(HIAA) partnered with
Families USA Families USA is a nonprofit, nonpartisan consumer health advocacy and policy organization. Co-founded founded in 1981 by Ronald Pollack, the first executive director, and Philippe Villers, the organization's current president, Families USA's advo ...
and the American Hospital Association (AHA) on a "strange bedfellows" proposal intended to seek common ground in expanding coverage for the uninsured. In 2001, a
Patients' Bill of Rights A patient's bill of rights is a list of guarantees for those receiving medical care. It may take the form of a law or a non-binding declaration. Typically a patient's bill of rights guarantees patients information, fair treatment, and autonomy o ...
was debated in Congress, which would have provided patients with an explicit list of rights concerning their health care. This initiative was essentially taking some of ideas found in the Consumers' Bill of Rights and applying it to the field of health care. It was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the health care industry. Standardizing the nature of health care institutions in this manner proved rather provocative. In fact, many
interest group Advocacy groups, also known as interest groups, special interest groups, lobbying groups or pressure groups use various forms of advocacy in order to influence public opinion and ultimately policy. They play an important role in the developm ...
s, including the
American Medical Association The American Medical Association (AMA) is a professional association and lobbying group of physicians and medical students. Founded in 1847, it is headquartered in Chicago, Illinois. Membership was approximately 240,000 in 2016. The AMA's state ...
(AMA) and the
pharmaceutical industry The pharmaceutical industry discovers, develops, produces, and markets drugs or pharmaceutical drugs for use as medications to be administered to patients (or self-administered), with the aim to cure them, vaccinate them, or alleviate symptoms. ...
came out vehemently against the congressional bill. Basically, providing emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the biggest stumbling blocks for this bill. As a result of this intense opposition, the
Patients' Bill of Rights A patient's bill of rights is a list of guarantees for those receiving medical care. It may take the form of a law or a non-binding declaration. Typically a patient's bill of rights guarantees patients information, fair treatment, and autonomy o ...
initiative eventually failed to pass
Congress A congress is a formal meeting of the representatives of different countries, constituent states, organizations, trade unions, political parties, or other groups. The term originated in Late Middle English to denote an encounter (meeting of a ...
in 2002. As president,
Bush Bush commonly refers to: * Shrub, a small or medium woody plant Bush, Bushes, or the bush may also refer to: People * Bush (surname), including any of several people with that name **Bush family, a prominent American family that includes: *** ...
signed into law the
Medicare Prescription Drug, Improvement, and Modernization Act The Medicare Prescription Drug, Improvement, and Modernization Act, also called the Medicare Modernization Act or MMA, is a federal law of the United States, enacted in 2003. It produced the largest overhaul of Medicare in the public health progr ...
which included a prescription drug plan for
elderly Old age refers to ages nearing or surpassing the life expectancy of human beings, and is thus the end of the human life cycle. Terms and euphemisms for people at this age include old people, the elderly (worldwide usage), OAPs (British usage ...
and
disabled Disability is the experience of any condition that makes it more difficult for a person to do certain activities or have equitable access within a given society. Disabilities may be cognitive, developmental, intellectual, mental, physical, se ...
Americans. During the 2004 presidential election, both the
George Bush George Bush most commonly refers to: * George H. W. Bush (1924–2018), 41st president of the United States and father of the 43rd president * George W. Bush (born 1946), 43rd president of the United States and son of the 41st president Georg ...
and
John Kerry John Forbes Kerry (born December 11, 1943) is an American attorney, politician and diplomat who currently serves as the first United States special presidential envoy for climate. A member of the Forbes family and the Democratic Party (Unite ...
campaigns offered health care proposals. Bush's proposals for expanding health care coverage were more modest than those advanced by Senator Kerry. Several estimates were made comparing the cost and impact of the Bush and Kerry proposals. While the estimates varied, they all indicated that the increase in coverage and the funding requirements of the Bush plan would both be lower than those of the more comprehensive Kerry plan. In 2006 the HIAA's successor organization,
America's Health Insurance Plans AHIP (formerly America's Health Insurance Plans) is an American political advocacy and trade association of health insurance companies that offer coverage through the employer-provided, Medicare Advantage, Medicaid managed care, and individual ...
(AHIP), issued another set of reform proposals. In January 2007 Rep.
John Conyers John James Conyers Jr. (May 16, 1929October 27, 2019) was an American politician of the Democratic Party who served as a U.S. representative from Michigan from 1965 to 2017. The districts he represented always included part of western Detroit. ...
, Jr. (D-MI) has introduced The United States National Health Care Act (HR 676) in the
House of Representatives House of Representatives is the name of legislative bodies in many countries and sub-national entitles. In many countries, the House of Representatives is the lower house of a bicameral legislature, with the corresponding upper house often c ...
. As of October 2008, HR 676 has 93 co-sponsors. Also in January 2007, Senator
Ron Wyden Ronald Lee Wyden (; born May 3, 1949) is an American politician and retired educator serving as the Seniority in the United States Senate, senior United States Senate, United States senator from Oregon, a seat he has held since 1996 United Stat ...
introduced the
Healthy Americans Act The Healthy Americans Act (HAA), also known as the Wyden-Bennett Act, is a Senate bill that had proposed to improve health care in the United States, with changes that included the establishment of universal health care. It would transition a ...
(S. 334) in the
Senate A senate is a deliberative assembly, often the upper house or chamber of a bicameral legislature. The name comes from the ancient Roman Senate (Latin: ''Senatus''), so-called as an assembly of the senior (Latin: ''senex'' meaning "the el ...
. As of October 2008, S. 334 had 17 cosponsors. Also in 2007, AHIP issued a proposal for guaranteeing access to coverage in the individual health insurance market and a proposal for improving the quality and safety of the U.S. health care system. "Economic Survey of the United States 2008: Health Care Reform" by the
Organisation for Economic Co-operation and Development The Organisation for Economic Co-operation and Development (OECD; french: Organisation de coopération et de développement économiques, ''OCDE'') is an intergovernmental organization, intergovernmental organisation with 38 member countries ...
, published in December 2008, said that: * Tax benefits of employer-based insurances should be abolished. * The resulting tax revenues should be used to subsidize the purchase of insurance by individuals. * These subsidies, "which could take many forms, such as direct subsidies or refundable tax credits, would improve the current situation in at least two ways: they would reach those who do not now receive the benefit of the tax exclusion; and they would encourage more cost-conscious purchase of health insurance plans and health care services as, in contrast to the uncapped tax exclusion, such subsidies would reduce the incentive to purchase health plans with little cost sharing." In December 2008, the Institute for America's Future, together with the chairman of the Ways and Means Health Subcommittee, Pete Stark, launched a proposal from Jacob Hacker, co-director of the U.C. Berkeley School of Law Center on Health, that in essence said that the government should offer a public health insurance plan to compete on a level playing field with private insurance plans. This was said to be the basis of the Obama/Biden plan. The argument is based on three basic points. Firstly, public plans success at managing cost control (Medicare medical spending rose 4.6% p.a. compared 7.3% for private health insurance on a like-for-like basis in the 10 years from 1997 to 2006). Secondly, public insurance has better payment and quality-improvement methods because of its large databases, new payment approaches, and care-coordination strategies. Thirdly, it can set a standard against which private plans must compete, which would help unite the public around the principle of broadly shared risk while building greater confidence in government in the long term. Also in December 2008,
America's Health Insurance Plans AHIP (formerly America's Health Insurance Plans) is an American political advocacy and trade association of health insurance companies that offer coverage through the employer-provided, Medicare Advantage, Medicaid managed care, and individual ...
(AHIP) announced a set of proposals which included setting a national goal to reduce the projected ''growth'' in health care spending by 30%. AHIP said that if this goal were achieved, it would result in cumulative five-year savings of $500 billion. Among the proposals was the establishment of an independent comparative effectiveness entity that compares and evaluates the benefits, risks, and incremental costs of new drugs, devices, and biologics. An earlier "Technical Memo" published by AHIP in June 2008 had estimated that a package of reforms involving comparative effectiveness research, health information technology (HIT), medical liability reform, "pay-for-performance" and disease management and prevention could reduce U.S. national health expenditures "by as much as 9 percent by the year 2025, compared with current baseline trends."


Debate in the 2008 presidential election

Although both candidates had a health care system that revolved around private insurance markets with help from public insurance programs, both had different opinions on how this system should operate when put in place. Senator
John McCain John Sidney McCain III (August 29, 1936 – August 25, 2018) was an American politician and United States Navy officer who served as a United States senator from Arizona from 1987 until his death in 2018. He previously served two terms ...
proposed a plan that focused on making health care more affordable. The senator proposed to replace special tax breaks for persons with employer-based health care coverage with a universal system of tax credits. These credits, $2,500 for an individual and $5,000 for a family would be available to Americans regardless of income, employment or tax liability. In his plan, Senator McCain proposed the Guaranteed Access Plan which would provide federal assistance to the states to secure health insurance coverage through high-risk areas. Senator McCain also proposed the idea of an open-market competition system. This would give families the opportunity to go across state lines and buy health plans, expanding personal options for affordable coverage and force the health insurance companies to compete over the consumers’ money on an unprecedented scale.
Barack Obama Barack Hussein Obama II ( ; born August 4, 1961) is an American politician who served as the 44th president of the United States from 2009 to 2017. A member of the Democratic Party, Obama was the first African-American president of the U ...
called for
universal health care Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized ar ...
. His health care plan called for the creation of a National Health Insurance Exchange that would include both private insurance plans and a Medicare-like government run option. Coverage would be guaranteed regardless of health status, and premiums would not vary based on health status either. It would have required parents to cover their children, but did not require adults to buy insurance. ''
The Philadelphia Inquirer ''The Philadelphia Inquirer'' is a daily newspaper headquartered in Philadelphia, Pennsylvania. The newspaper's circulation is the largest in both the U.S. state of Pennsylvania and the Delaware Valley metropolitan region of Southeastern Pennsy ...
'' reported that the two plans had different philosophical focuses. They described the purpose of the McCain plan as to "make insurance more affordable," while the purpose of the Obama plan was for "more people to have health insurance." ''
The Des Moines Register ''The Des Moines Register'' is the daily morning newspaper of Des Moines, Iowa. History Early period The first newspaper in Des Moines was the ''Iowa Star''. In July 1849, Barlow Granger began the paper in an abandoned log cabin by the junctio ...
'' characterized the plans similarly. A poll released in early November, 2008, found that voters supporting Obama listed health care as their second priority; voters supporting McCain listed it as fourth, tied with the war in Iraq. Affordability was the primary health care priority among both sets of voters. Obama voters were more likely than McCain voters to believe government can do much about health care costs.


2009 reform debate

In March 2009 AHIP proposed a set of reforms intended to address waste and unsustainable growth in the current health care market. These reforms included: * An individual insurance mandate with a financial penalty as a quid pro quo for guaranteed issue * Updates to the Medicare physician fee schedule; * Setting standards and expectations for safety and quality of diagnostics; * Promoting care coordination and patient-centered care by designating a "
medical home The medical home, also known as the patient-centered medical home (PCMH), is a team-based health care delivery model led by a health care provider to provide comprehensive and continuous medical care to patients with a goal to obtain maximal heal ...
" that would replace fragmented care with a coordinated approach to care. Physicians would receive a periodic payment for a set of defined services, such as care coordination that integrates all treatment received by a patient throughout an illness or an acute event. This would promote ongoing comprehensive care management, optimizes patients’ health status and assist patients in navigating the health care system * Linking payment to quality, adherence to guidelines, achieving better clinical outcomes, giving better patient experience and lowering the total cost of care. *
Bundled payment Bundled payment is the reimbursement of health care providers (such as hospitals and physicians) "on the basis of expected costs for defined episodes of care." It has been described as "a middle ground" between fee-for-service reimbursement (in wh ...
s (instead of individual billing) for the management of chronic conditions in which providers would have shared accountability and responsibility for the management of chronic conditions such as coronary artery disease, diabetes, chronic obstructive pulmonary disease and asthma, and similarly * A fixed rate all-inclusive average payment for acute care episodes which tend to follow a pattern (even though some acute care episodes may cost more or less than this). On May 5, 2009,
US Senate Finance Committee The United States Senate Committee on Finance (or, less formally, Senate Finance Committee) is a standing committee of the United States Senate. The Committee concerns itself with matters relating to taxation and other revenue measures generall ...
held hearings on Health care reform. On the panel of the "invited stakeholder", no supporter of the
Single-payer health care Single-payer healthcare is a type of universal healthcare in which the costs of essential healthcare for all residents are covered by a single public system (hence "single-payer"). Single-payer systems may contract for healthcare services from p ...
system was invited. The panel featured Republican senators and industry panelists who argued against any kind of expanded health care coverage. The preclusion of the single payer option from the discussion caused significant protest by doctors in the audience. On June 15, 2009, the
U.S. Congressional Budget Office The Congressional Budget Office (CBO) is a federal agency within the legislative branch of the United States government that provides budget and economic information to Congress. Inspired by California's Legislative Analyst's Office that manages ...
(CBO) issued a preliminary analysis of the major provisions of the Affordable Health Choices Act. The CBO estimated the ten-year cost to the federal government of the major insurance-related provisions of the bill at approximately $1.0 trillion. Over the same ten-year period from 2010 to 2019, the CBO estimated that the bill would reduce the number of uninsured Americans by approximately 16 million. At about the same time, the
Associated Press The Associated Press (AP) is an American non-profit news agency headquartered in New York City. Founded in 1846, it operates as a cooperative, unincorporated association. It produces news reports that are distributed to its members, U.S. newspa ...
reported that the CBO had given Congressional officials an estimate of $1.6 trillion for the cost of a companion measure being developed by the Senate Finance Committee. In response to these estimates, the Senate Finance Committee delayed action on its bill and began work on reducing the cost of the proposal to $1.0 trillion, and the debate over the Affordable Health Choices act became more acrimonious. Congressional Democrats were surprised by the magnitude of the estimates, and the uncertainty created by the estimates has increased the confidence of Republicans who are critical of the Obama Administration's approach to health care. However, in a June
New York Times ''The New York Times'' (''the Times'', ''NYT'', or the Gray Lady) is a daily newspaper based in New York City with a worldwide readership reported in 2020 to comprise a declining 840,000 paid print subscribers, and a growing 6 million paid d ...
editorial, economist
Paul Krugman Paul Robin Krugman ( ; born February 28, 1953) is an American economist, who is Distinguished Professor of Economics at the Graduate Center of the City University of New York, and a columnist for ''The New York Times''. In 2008, Krugman was th ...
argued that despite these estimates universal health coverage is still affordable. "The fundamental fact is that we can afford universal health insurance—even those high estimates were less than the $1.8 trillion cost of the Bush tax cuts." In contrast to earlier advocacy of a
publicly funded health care Publicly funded healthcare is a form of health care financing designed to meet the cost of all or most healthcare needs from a publicly managed fund. Usually this is under some form of democratic accountability, the right of access to which are se ...
program, in August 2009 Obama administration officials announced they would support a
health insurance cooperative A health insurance cooperative is a cooperative entity that has the goal of providing health insurance and is also owned by the people that the organization insures. It is a form of mutual insurance. United States In the debate over healthcare re ...
in response to deep political unrest amongst Congressional Republicans and amongst citizens in town hall meetings held across America. However, in a June 2009
NBC News NBC News is the news division of the American broadcast television network NBC. The division operates under NBCUniversal Television and Streaming, a division of NBCUniversal, which is, in turn, a subsidiary of Comcast. The news division's var ...
/
Wall Street Journal ''The Wall Street Journal'' is an American business-focused, international daily newspaper based in New York City, with international editions also available in Chinese and Japanese. The ''Journal'', along with its Asian editions, is published ...
survey, 76% said it was either "extremely" or "quite" important to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance." During the summer of 2009, members of the "Tea Party" protested against proposed health care reforms. Former insurance PR executive
Wendell Potter Wendell Potter (born July 16, 1951) is an American advocate for health insurance payment reform, ''New York Times'' bestselling author, and former health insurance industry communications director. A critic of HMOs and the tactics used by health ...
of the
Center for Media and Democracy The Center for Media and Democracy (CMD) is a progressive nonprofit watchdog and advocacy organization based in Madison, Wisconsin. CMD publishes ExposedbyCMD.org, SourceWatch.org, and ALECexposed.org. History CMD was founded in 1993 by progr ...
- whose funding comes from groups such as the
Tides Foundation Tides Foundation is an American public charity and fiscal sponsor working to advance progressive causes and policy initiatives in areas such as the environment, health care, labor issues, immigrant rights, LGBTQ+ rights, women's rights and human ...
- argue that the hyperbole generated by this phenomenon is a form of corporate
astroturfing Astroturfing is the practice of masking the sponsors of a message or organization (e.g., political, advertising, religious or public relations) to make it appear as though it originates from and is supported by grassroots participants. It is a p ...
, which he says that he used to write for
CIGNA Cigna is an American multinational managed healthcare and insurance company based in Bloomfield, Connecticut. Its insurance subsidiaries are major providers of medical, dental, disability, life and accident insurance and related products and se ...
. Opponents of more government involvement, such as Phil Kerpen of
Americans for Prosperity Americans for Prosperity (AFP), founded in 2004, is a libertarian conservative political advocacy group in the United States funded by Charles Koch and formerly his brother David. As the Koch brothers' primary political advocacy group, it is one ...
- whose funding comes mainly from the
Koch Industries Koch Industries, Inc. ( ) is an American privately held multinational conglomerate corporation based in Wichita, Kansas and is the second-largest privately held company in the United States, after Cargill. Its subsidiaries are involved in th ...
corporation counter-argue that those corporations oppose a public-plan, but some try to push for government actions that will unfairly benefit them, like employer mandates forcing private companies to buy health insurance. Journalist Ben Smith has referred to mid-2009 as "The Summer of Astroturf" given the organizing and coordinating efforts made by various groups on both pro- and anti-reform sides.


Healthcare debate, 2008–2010

Healthcare reform was a major topic of discussion during the
2008 Democratic presidential primaries From January 3 to June 3, 2008, voters of the Democratic Party chose their nominee for president in the 2008 United States presidential election. Senator Barack Obama of Illinois was selected as the nominee, becoming the first African Amer ...
. As the race narrowed, attention focused on the plans presented by the two leading candidates,
New York New York most commonly refers to: * New York City, the most populous city in the United States, located in the state of New York * New York (state), a state in the northeastern United States New York may also refer to: Film and television * '' ...
Senator
Hillary Clinton Hillary Diane Rodham Clinton ( Rodham; born October 26, 1947) is an American politician, diplomat, and former lawyer who served as the 67th United States Secretary of State for President Barack Obama from 2009 to 2013, as a United States sen ...
and the eventual nominee,
Illinois Illinois ( ) is a U.S. state, state in the Midwestern United States, Midwestern United States. Its largest metropolitan areas include the Chicago metropolitan area, and the Metro East section, of Greater St. Louis. Other smaller metropolita ...
Senator Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to not have health insurance at some point each year. Clinton's plan would have required all Americans obtain coverage (in effect, an individual
health insurance mandate A health insurance mandate is either an employer or individual mandate to obtain private health insurance instead of (or in addition to) a national health insurance plan.D. Andrew Austin, Thomas L. Hungerford (2010). Market Structure of the He ...
), while Obama's provided a
subsidy A subsidy or government incentive is a form of financial aid or support extended to an economic sector (business, or individual) generally with the aim of promoting economic and social policy. Although commonly extended from the government, the ter ...
but did not include a mandate. During the
general election A general election is a political voting election where generally all or most members of a given political body are chosen. These are usually held for a nation, state, or territory's primary legislative body, and are different from by-elections ( ...
, Obama said that fixing healthcare would be one of his top four priorities if he won the presidency. After his inauguration, Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform. By July, a series of bills were approved by committees within the
House of Representatives House of Representatives is the name of legislative bodies in many countries and sub-national entitles. In many countries, the House of Representatives is the lower house of a bicameral legislature, with the corresponding upper house often c ...
. On the Senate side, from June through to September, the
Senate Finance Committee The United States Senate Committee on Finance (or, less formally, Senate Finance Committee) is a standing committee of the United States Senate. The Committee concerns itself with matters relating to taxation and other revenue measures generall ...
held a series of 31 meetings to develop of a healthcare reform bill. This group – in particular, Senators Max Baucus (D-MT), Chuck Grassley (R-IA), Kent Conrad (D-ND), Olympia Snowe (R-ME), Jeff Bingaman (D-NM), and Mike Enzi (R-WY) – met for more than 60 hours, and the principles that they discussed, in conjunction with the other Committees, became the foundation of the Senate's healthcare reform bill. With
universal healthcare Universal health care (also called universal health coverage, universal coverage, or universal care) is a health care system in which all residents of a particular country or region are assured access to health care. It is generally organized ar ...
as one of the stated goals of the Obama Administration, Congressional Democrats and health policy experts like Jonathan Gruber and
David Cutler David Matthew Cutler (born June 22, 1965) is the Otto Eckstein Professor of Applied Economics at Harvard University. He was given a five-year term appointment of Harvard College Professor, which recognizes excellence in undergraduate teaching. He ...
argued that
guaranteed issue Guaranteed issue is a term used in health insurance to describe a situation where a policy is offered to any eligible applicant without regard to health status. Often this is the result of guaranteed issue statutes regarding how health insurance may ...
would require both a
community rating Community rating is a concept usually associated with health insurance, which requires health insurance providers to offer health insurance policies within a given territory at the same price to all persons without medical underwriting, regardless ...
and an
individual mandate An individual mandate is a requirement by law for certain persons to purchase or otherwise obtain a good or service. United States Militia act The Militia Acts of 1792, based on the Constitution's militia clause (in addition to its affirmative ...
to prevent either
adverse selection In economics, insurance, and risk management, adverse selection is a market situation where buyers and sellers have different information. The result is that participants with key information might participate selectively in trades at the expe ...
and/or free riding from creating an insurance death spiral; they convinced Obama that this was necessary, persuading him to accept Congressional proposals that included a mandate. This approach was preferred because the President and Congressional leaders concluded that more liberal plans, such as Medicare-for-all, could not win filibuster-proof support in the Senate. By deliberately drawing on bipartisan ideas – the same basic outline was supported by former Senate Majority Leaders Howard Baker (R-TN), Bob Dole (R-KS), Tom Daschle (D-SD) and George Mitchell (D-ME) – the bill's drafters hoped to increase the chances of getting the necessary votes for passage. However, following the adoption of an individual mandate as a central component of the proposed reforms by Democrats, Republicans began to oppose the mandate and threaten to
filibuster A filibuster is a political procedure in which one or more members of a legislative body prolong debate on proposed legislation so as to delay or entirely prevent decision. It is sometimes referred to as "talking a bill to death" or "talking out ...
any bills that contained it. Senate Minority Leader Mitch McConnell (R-KY), who lead the Republican Congressional strategy in responding to the bill, calculated that Republicans should not support the bill, and worked to keep party discipline and prevent defections: Republican Senators, including those who had supported previous bills with a similar mandate, began to describe the mandate as "unconstitutional". Writing in ''
The New Yorker ''The New Yorker'' is an American weekly magazine featuring journalism, commentary, criticism, essays, fiction, satire, cartoons, and poetry. Founded as a weekly in 1925, the magazine is published 47 times annually, with five of these issues ...
'', Ezra Klein stated that "the end result was... a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition." The ''
New York Times ''The New York Times'' (''the Times'', ''NYT'', or the Gray Lady) is a daily newspaper based in New York City with a worldwide readership reported in 2020 to comprise a declining 840,000 paid print subscribers, and a growing 6 million paid d ...
'' subsequently noted: "It can be difficult to remember now, given the ferocity with which many Republicans assail it as an attack on freedom, but the provision in President Obama's healthcare law requiring all Americans to buy health insurance has its roots in conservative thinking." The reform negotiations also attracted a great deal of attention from
lobbyists In politics, lobbying, persuasion or interest representation is the act of lawfully attempting to influence the actions, policies, or decisions of government officials, most often legislators or members of regulatory agencies. Lobbying, which ...
, including deals among certain lobbies and the advocates of the law to win the support of groups who had opposed past reform efforts, such as in 1993. The
Sunlight Foundation The Sunlight Foundation was an American 501(c)(3) nonpartisan, nonprofit organization that advocated for open government. The organization was founded in April 2006 with the goal of increasing transparency and accountability in the United States ...
documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties. During the August 2009 summer congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. Over the recess, the
Tea Party movement The Tea Party movement was an American fiscally conservative political movement within the Republican Party that began in 2009. Members of the movement called for lower taxes and for a reduction of the national debt and federal budget defic ...
organized protests and many
conservative Conservatism is a cultural, social, and political philosophy that seeks to promote and to preserve traditional institutions, practices, and values. The central tenets of conservatism may vary in relation to the culture and civilization i ...
groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills. There were also many threats made against members of Congress over the course of the Congressional debate, and many were assigned extra protection. To maintain the progress of the legislative process, when Congress returned from recess, in September 2009 President Obama delivered a speech to a joint session of Congress supporting the ongoing Congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals. In it he acknowledged the polarization of the debate, and quoted a letter from the late-Senator Ted Kennedy urging on reform: "what we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country." On November 7, the House of Representatives passed the
Affordable Health Care for America Act The Affordable Health Care for America Act (or HR 3962) was a bill that was crafted by the United States House of Representatives of the 111th United States Congress on October 29, 2009. The bill was sponsored by Representative Charles Rangel. ...
on a 220–215 vote and forwarded it to the Senate for passage.


Senate

The Senate began work on its own proposals while the House was still working on the
Affordable Health Care for America Act The Affordable Health Care for America Act (or HR 3962) was a bill that was crafted by the United States House of Representatives of the 111th United States Congress on October 29, 2009. The bill was sponsored by Representative Charles Rangel. ...
. Instead, the Senate took up H.R. 3590, a bill regarding housing tax breaks for service members. As the
United States Constitution The Constitution of the United States is the Supremacy Clause, supreme law of the United States, United States of America. It superseded the Articles of Confederation, the nation's first constitution, in 1789. Originally comprising seven ar ...
requires all revenue-related bills to originate in the House, U.S. Const. art. I, § 7, cl. 1. the Senate took up this bill since it was first passed by the House as a revenue-related modification to the
Internal Revenue Code The Internal Revenue Code (IRC), formally the Internal Revenue Code of 1986, is the domestic portion of federal statutory tax law in the United States, published in various volumes of the United States Statutes at Large, and separately as Title 26 ...
. The bill was then used as the Senate's vehicle for their healthcare reform proposal, completely revising the content of the bill. The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate
Health Health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World Health Organiza ...
and
Finance Finance is the study and discipline of money, currency and capital assets. It is related to, but not synonymous with economics, the study of production, distribution, and consumption of money, assets, goods and services (the discipline of fina ...
committees. With the Republican minority in the Senate vowing to
filibuster A filibuster is a political procedure in which one or more members of a legislative body prolong debate on proposed legislation so as to delay or entirely prevent decision. It is sometimes referred to as "talking a bill to death" or "talking out ...
any bill that they did not support, requiring a
cloture vote Cloture (, also ), closure or, informally, a guillotine, is a motion or process in parliamentary procedure aimed at bringing debate to a quick end. The cloture procedure originated in the French National Assembly, from which the name is taken. ' ...
to end debate, 60 votes would be necessary to get passage in the Senate. At the start of the
111th Congress The 111th United States Congress was a meeting of the legislative branch of the United States federal government from January 3, 2009, until January 3, 2011. It began during the last weeks of the George W. Bush administration, with th ...
, Democrats had only 58 votes; the Senate seat in Minnesota that would be won by
Al Franken Alan Stuart Franken (born May 21, 1951) is an American comedian, politician, media personality, and author who served as a United States senator from Minnesota from 2009 to 2018. He gained fame as a writer and performer on the television comed ...
was still undergoing a recount, and
Arlen Specter Arlen Specter (February 12, 1930 – October 14, 2012) was an American lawyer, author and politician who served as a United States Senator from Pennsylvania from 1981 to 2011. Specter was a Democrat from 1951 to 1965, then a Republican from ...
was still a Republican. To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring aboard several Republican Senators; particular attention was given to Bob Bennett (R-UT), Chuck Grassley (R-IA), Mike Enzi (R-WY), and Olympia Snowe (R-ME). Negotiations continued even after July 7—when Al Franken was sworn into office, and by which time Arlen Specter had switched parties—because of disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. However, on August 25, before the bill could come up for a vote, Ted Kennedy—a long-time advocate for healthcare reform—died, depriving Democrats of their 60th vote. Before the seat was filled, attention was drawn to
Senator Snowe Olympia Jean Snowe (; born February 21, 1947) is an American businesswoman and politician who was a United States Senate, United States Senator from Maine from 1995 to 2013. Snowe, a member of the Republican Party (United States), Republican Part ...
because of her vote in favor of the draft bill in the Finance Committee on October 15, however she explicitly stated that this did not mean she would support the final bill. Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24. Following the Finance Committee vote, negotiations turned to the demands of moderate Democrats to finalize their support, whose votes would be necessary to break the Republican filibuster. Majority Leader Harry Reid focused on satisfying the centrist members of the Democratic caucus until the hold-outs narrowed down to Connecticut's
Joe Lieberman Joseph Isadore Lieberman (; born February 24, 1942) is an American politician, lobbyist, and attorney who served as a United States Senate, United States senator from Connecticut from 1989 to 2013. A former member of the Democratic Party (Uni ...
, an independent who caucused with Democrats, and Nebraska's
Ben Nelson Earl Benjamin Nelson (born May 17, 1941) is an American attorney, businessman, and politician who served as the 37th governor of Nebraska from 1991 to 1999 and as a United States Senator from Nebraska from 2001 to 2013. He is a member of the Demo ...
. Lieberman, despite intense negotiations in search of a compromise by Reid, refused to support a
public option The public health insurance option, also known as the public insurance option or the public option, is a proposal to create a government-run health insurance agency that would compete with other private health insurance companies within the United ...
; a concession granted only after Lieberman agreed to commit to voting for the bill if the provision was not included, even though it had majority support in Congress. There was debate among supporters of the bill about the importance of the public option, although the vast majority of supporters concluded that it was a minor part of the reform overall, and that Congressional Democrats' fight for it won various concessions; this included conditional waivers allowing states to set up state-based public options, for example Vermont's
Green Mountain Care In 2011, the Vermont state government enacted a law functionally establishing the first state-level single-payer health care system in the United States. Green Mountain Care, established by the passage of H.202, creates a system in the state whe ...
. With every other Democrat now in favor and every other Republican now overtly opposed, the White House and Reid moved on to addressing Senator Nelson's concerns in order to win filibuster-proof support for the bill; they had by this point concluded that "it was a waste of time dealing with nowe because, after her vote for the draft bill in the Finance Committee, Snowe had come under intense pressure from the Republican Senate Leadership who opposed reform. (Snowe retired at the end of her term, citing partisanship and polarization). After a final 13-hour negotiation, Nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges," which would require consumers to pay for the procedure out-of-pocket if the state so decided; and an amendment to offer a higher rate of
Medicaid Medicaid in the United States is a federal and state program that helps with healthcare costs for some people with limited income and resources. Medicaid also offers benefits not normally covered by Medicare, including nursing home care and pers ...
reimbursement for Nebraska. The latter half of the compromise was derisively referred to as the "Cornhusker Kickback" and was later repealed by the subsequent reconciliation amendment bill. On December 23, the Senate voted 60–39 to end debate on the bill: a
cloture vote Cloture (, also ), closure or, informally, a guillotine, is a motion or process in parliamentary procedure aimed at bringing debate to a quick end. The cloture procedure originated in the French National Assembly, from which the name is taken. ' ...
to end the
filibuster A filibuster is a political procedure in which one or more members of a legislative body prolong debate on proposed legislation so as to delay or entirely prevent decision. It is sometimes referred to as "talking a bill to death" or "talking out ...
by opponents. The bill then passed by a vote of 60–39 on December 24, 2009, with all Democrats and two independents voting for, and all Republicans voting against except one ( Jim Bunning (R-KY), not voting). The bill was endorsed by the AMA and
AARP AARP (formerly called the American Association of Retired Persons) is an interest group in the United States focusing on issues affecting those over the age of fifty. The organization said it had more than 38 million members in 2018. The magazin ...
. Several weeks after the vote, on January 19, 2010,
Massachusetts Massachusetts (Massachusett language, Massachusett: ''Muhsachuweesut assachusett writing systems, məhswatʃəwiːsət'' English: , ), officially the Commonwealth of Massachusetts, is the most populous U.S. state, state in the New England ...
Republican
Scott Brown Scott Brown may refer to: Sportsmen *Scott Brown (American football), American college football coach of Kentucky State * Scott Brown (baseball) (born 1956), former Major League Baseball pitcher for the Cincinnati Reds *Scott Brown (footballer, bor ...
was elected to the Senate in a special election to replace the late Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain filibusters, even signing autographs as "Scott 41." The special election had become significant to the reform debate because of its effects on the legislative process. The first was a psychological one: the symbolic importance of losing the traditionally Democratic (‘blue’) Massachusetts seat formerly held by Ted Kennedy, a staunch support of reform, made many Congressional Democrats concerned about the political cost of passing a bill. The second effect was more practical: the loss of the Democrat's
supermajority A supermajority, supra-majority, qualified majority, or special majority is a requirement for a proposal to gain a specified level of support which is greater than the threshold of more than one-half used for a simple majority. Supermajority ru ...
complicated the legislative strategy of reform proponents.


House

The election of Scott Brown meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff
Rahm Emanuel Rahm Israel Emanuel (; born November 29, 1959) is an American politician and diplomat who is the current United States Ambassador to Japan. A member of the Democratic Party, he previously served two terms as the 55th Mayor of Chicago from 2011 ...
argued the Democrats should scale-back for a less ambitious bill; House Speaker
Nancy Pelosi Nancy Patricia Pelosi (; ; born March 26, 1940) is an American politician who has served as Speaker of the United States House of Representatives since 2019 and previously from 2007 to 2011. She has represented in the United States House of ...
pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care." Obama also remained insistent on comprehensive reform, and the news that
Anthem An anthem is a musical composition of celebration, usually used as a symbol for a distinct group, particularly the national anthems of countries. Originally, and in music theory and religious contexts, it also refers more particularly to short ...
in
California California is a U.S. state, state in the Western United States, located along the West Coast of the United States, Pacific Coast. With nearly 39.2million residents across a total area of approximately , it is the List of states and territori ...
intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win. On February 22 Obama laid out a "Senate-leaning" proposal to consolidate the bills. He also held a meeting, on February 25, with leaders of both parties urging passage of a reform bill. The summit proved successful in shifting the political narrative away from the Massachusetts loss back to healthcare policy. With Democrats having lost a filibuster-proof supermajority in the Senate, but having already passed the Senate bill with 60 votes on December 24, the most viable option for the proponents of comprehensive reform was for the House to abandon its own health reform bill, the
Affordable Health Care for America Act The Affordable Health Care for America Act (or HR 3962) was a bill that was crafted by the United States House of Representatives of the 111th United States Congress on October 29, 2009. The bill was sponsored by Representative Charles Rangel. ...
, and pass the Senate's bill, The Patient Protection and Affordable Care Act, instead. Various health policy experts encouraged the House to pass the Senate version of the bill. However, House Democrats were not happy with the content of the Senate bill, and had expected to be able to negotiate changes in a House–Senate Conference before passing a final bill. With that option off the table, as any bill that emerged from Conference that differed from the Senate bill would have to be passed in the Senate over another Republican filibuster; most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill. They drafted the
Health Care and Education Reconciliation Act The Health Care and Education Reconciliation Act of 2010 (, ) is a law that was enacted by the 111th United States Congress, by means of the reconciliation process, in order to amend the Affordable Care Act (ACA) (). The law includes the Stu ...
, which could be passed via the
reconciliation process Budget reconciliation is a special parliamentary procedure of the United States Congress set up to expedite the passage of certain budgetary legislation in the United States Senate. The procedure overrides the filibuster rules in the Senate, w ...
. Unlike rules under regular order, as per the
Congressional Budget Act of 1974 The Congressional Budget and Impoundment Control Act of 1974 (, , ) is a United States federal law that governs the role of the Congress in the United States budget process. The Congressional budget process Titles I through IX of the law are also ...
reconciliation cannot be subject to a
filibuster A filibuster is a political procedure in which one or more members of a legislative body prolong debate on proposed legislation so as to delay or entirely prevent decision. It is sometimes referred to as "talking a bill to death" or "talking out ...
, which requires 60 votes to break, but the process is limited to budget changes; this is why the procedure was never able to be used to pass a comprehensive reform bill in the first place, such as the ACA, due to inherently non-budgetary regulations. Whereas the already passed Senate bill could not have been put through reconciliation, most of House Democrats' demands were budgetary: "these changes – higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal – mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation." The remaining obstacle was a pivotal group of
anti-abortion Anti-abortion movements, also self-styled as pro-life or abolitionist movements, are involved in the abortion debate advocating against the practice of abortion and its legality. Many anti-abortion movements began as countermovements in respons ...
Democrats, initially reluctant to support the bill, led by Congressman
Bart Stupak Bartholomew Thomas Stupak (; born February 29, 1952) is an American politician and lobbyist. A member of the Democratic Party, Stupak served as the U.S. representative from from 1993 to 2011. Stupak chose not to seek re-election in 2010. He dep ...
. The group found the possibility of federal funding for
abortion Abortion is the termination of a pregnancy by removal or expulsion of an embryo or fetus. An abortion that occurs without intervention is known as a miscarriage or "spontaneous abortion"; these occur in approximately 30% to 40% of pregn ...
would be substantive enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as it would be outside the scope of the process with its budgetary limits. Instead, President Obama issued
Executive Order 13535 Executive Order 13535 is an executive order announced by President Barack Obama on March 21, 2010, and signed on March 24, 2010. It reinforces a commitment to preservation of the Hyde Amendment's policy restricting federal funds for abortion within ...
, reaffirming the principles in the
Hyde Amendment In U.S. politics, the Hyde Amendment is a legislative provision barring the use of federal funds to pay for abortion, except to save the life of the woman, or if the pregnancy arises from incest or rape. Before the Hyde Amendment took effect i ...
.
Executive Order 13535 Executive Order 13535 is an executive order announced by President Barack Obama on March 21, 2010, and signed on March 24, 2010. It reinforces a commitment to preservation of the Hyde Amendment's policy restricting federal funds for abortion within ...
of March 24, 2010 – ''Ensuring Enforcement and Implementation of Abortion Restrictions in the Patient Protection and Affordable Care Act'', Vol. 75, No. 59, , March 29, 2010.
This concession won the support of Stupak and members of his group and assured passage of the bill. The House passed the Senate bill with a vote of 219 to 212 on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it. The following day, Republicans introduced legislation to repeal the bill. Obama signed the ACA into law on March 23, 2010. The amendment bill, The Health Care and Education Reconciliation Act, was also passed by the House on March 21, then by the Senate via reconciliation on March 25, and finally signed by President Obama on March 30.


State and city reform efforts

A few states have taken steps toward universal health care coverage, most notably
Minnesota Minnesota () is a state in the upper midwestern region of the United States. It is the 12th largest U.S. state in area and the 22nd most populous, with over 5.75 million residents. Minnesota is home to western prairies, now given over to ...
,
Massachusetts Massachusetts (Massachusett language, Massachusett: ''Muhsachuweesut assachusett writing systems, məhswatʃəwiːsət'' English: , ), officially the Commonwealth of Massachusetts, is the most populous U.S. state, state in the New England ...
and
Connecticut Connecticut () is the southernmost state in the New England region of the Northeastern United States. It is bordered by Rhode Island to the east, Massachusetts to the north, New York to the west, and Long Island Sound to the south. Its cap ...
. Examples include the
Massachusetts 2006 Health Reform Statute The Massachusetts health care reform, commonly referred to as Romneycare, was a healthcare reform law passed in 2006 and signed into law by Governor Mitt Romney with the aim of providing health insurance to nearly all of the residents of the Co ...
and Connecticut's SustiNet plan to provide health care to state residents. The influx of more than a quarter of a million newly insured residents has led to overcrowded waiting rooms and overworked primary-care physicians who were already in short supply in Massachusetts. Other states, while not attempting to insure all of their residents, cover large numbers of people by reimbursing hospitals and other health care providers using what is generally characterized as a
charity care In the United States, charity care is health care provided for free or at reduced prices to low income patients. The percentage of doctors providing charity care dropped from 76% in 1996–97 to 68% in 2004–2005. Potential reasons for the decli ...
scheme;
New Jersey New Jersey is a state in the Mid-Atlantic and Northeastern regions of the United States. It is bordered on the north and east by the state of New York; on the east, southeast, and south by the Atlantic Ocean; on the west by the Delaware ...
is an example of a state that employs the latter strategy. Several single payer referendums have been proposed at the state level, but so far all have failed to pass:
California California is a U.S. state, state in the Western United States, located along the West Coast of the United States, Pacific Coast. With nearly 39.2million residents across a total area of approximately , it is the List of states and territori ...
in 1994,
Massachusetts Massachusetts (Massachusett language, Massachusett: ''Muhsachuweesut assachusett writing systems, məhswatʃəwiːsət'' English: , ), officially the Commonwealth of Massachusetts, is the most populous U.S. state, state in the New England ...
in 2000, and
Oregon Oregon () is a U.S. state, state in the Pacific Northwest region of the Western United States. The Columbia River delineates much of Oregon's northern boundary with Washington (state), Washington, while the Snake River delineates much of it ...
in 2002. The state legislature of California twice passed SB 840, The Health Care for All Californians Act, a single-payer health care system. Both times, Governor
Arnold Schwarzenegger Arnold Alois Schwarzenegger (born July 30, 1947) is an Austrian and American actor, film producer, businessman, retired professional bodybuilder and politician who served as the 38th governor of California between 2003 and 2011. ''Time'' ...
(R) vetoed the bill, once in 2006 and again in 2008. The percentage of residents that are uninsured varies from state to state. In 2008
Texas Texas (, ; Spanish language, Spanish: ''Texas'', ''Tejas'') is a state in the South Central United States, South Central region of the United States. At 268,596 square miles (695,662 km2), and with more than 29.1 million residents in 2 ...
had the highest percentage of residents without health insurance, 24%.
New Mexico ) , population_demonym = New Mexican ( es, Neomexicano, Neomejicano, Nuevo Mexicano) , seat = Santa Fe , LargestCity = Albuquerque , LargestMetro = Tiguex , OfficialLang = None , Languages = English, Spanish ( New Mexican), Navajo, Ker ...
had the second highest percentage of uninsured that year at 22%. States play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans, which give them multiple opportunities to try to improve how it functions. While states are actively working to improve the system in a variety of ways, there remains room for them to do more. One municipality,
San Francisco, California San Francisco (; Spanish for " Saint Francis"), officially the City and County of San Francisco, is the commercial, financial, and cultural center of Northern California. The city proper is the fourth most populous in California and 17th ...
, has established a program to provide health care to all uninsured residents (
Healthy San Francisco Healthy San Francisco is a health access program launched in 2007 to subsidize medical care for uninsured residents of San Francisco, California. The program's stated objective is to bring universal health care to the city.Connecticut Connecticut () is the southernmost state in the New England region of the Northeastern United States. It is bordered by Rhode Island to the east, Massachusetts to the north, New York to the west, and Long Island Sound to the south. Its cap ...
passed into law a plan called SustiNet, with the goal of achieving health care coverage of 98% of its residents by 2014. The SustiNet law establishes a nine-member board to recommend to the legislature, by January 1, 2011, the details of and implementation process for a self-insured health care plan called SustiNet. The recommendations must address (1) the phased-in offering of the SustiNet plan to state employees and retirees, HUSKY A and B beneficiaries, people without employer-sponsored insurance (ESI) or with unaffordable ESI, small and large employers, and others; (2) establishing an entity that can contract with insurers and health care providers, set reimbursement rates, develop medical homes for patients, and encourage the use of health information technology; (3) a model benefits package; and (4) public outreach and ways to identify uninsured citizens. The board must establish committees to make recommendations to it about health information technology, medical homes, clinical care and safety guidelines, and preventive care and improved health outcomes. The act also establishes an independent information clearinghouse to inform employers, consumers, and the public about SustiNet and private health care plans and creates task forces to address obesity, tobacco usage, and health care workforce issues. The effective date of the SustiNet law was July 1, 2009, for most provisions. In May 2011, the state of Vermont became the first state to pass legislation establishing a single-payer health care system. The legislation, known as Act 48, establishes health care in the state as a "human right" and lays the responsibility on the state to provide a health care system which best meets the needs of the citizens of Vermont. In December 2014, the governor of the state of Vermont suspended plans to implement this single-payer system because of its cost.


See also

*
Health care reform in the United States Healthcare reform in the United States has a long history. Reforms have often been proposed but have rarely been accomplished. In 2010, landmark reform was passed through two federal statutes enacted in 2010: the Patient Protection and Affordab ...
*
Health economics Health economics is a branch of economics concerned with issues related to efficiency, effectiveness, value and behavior in the production and consumption of health and healthcare. Health economics is important in determining how to improv ...
*
Health insurance exchange In the United States, health insurance marketplaces, also called health exchanges, are organizations in each state through which people can purchase health insurance. People can purchase health insurance that complies with the Patient Protection ...
*
Health insurance in the United States Health insurance in the United States is any program that helps pay for medical expenses, whether through privately purchased insurance, social insurance, or a social welfare program funded by the government. Synonyms for this usage include ...
*
Health policy analysis Health, according to the World Health Organization, is "a state of complete physical, mental and social well-being and not merely the absence of disease and infirmity".World Health Organization. (2006)''Constitution of the World Health Organiza ...
* Health care politics *
List of healthcare reform advocacy groups in the United States Healthcare reform advocacy groups in the United States are non-profit organizations in the US who have as one of their primary goals healthcare reform in the United States. These notable organizations address issues such as universal healthcare, n ...
*
Medicare for All Act The Medicare for All Act, aka the Expanded and Improved Medicare for All Act or United States National Health Care Act, is a bill first introduced in the United States House of Representatives by Representative John Conyers (D-MI) in 2003, with ...
*
National health insurance National health insurance (NHI), sometimes called statutory health insurance (SHI), is a system of health insurance that insures a national population against the costs of health care. It may be administered by the public sector, the private sector ...


References

{{United States topics
History History (derived ) is the systematic study and the documentation of the human activity. The time period of event before the History of writing#Inventions of writing, invention of writing systems is considered prehistory. "History" is an umbr ...
Political history of the United States History of the United States by topic