State Waivers
From 2017, states can apply for a “state innovation waiver” that allows them to conduct experiments that meet certain criteria. [112] To obtain a waiver, a state must pass legislation establishing an alternative health care system that provides insurance at least as comprehensive and as affordable as the ACA, covers at least as many residents, and does not increase the federal deficit. [113] These states may escape some of the central requirements of the ACA, including individual and employer mandates and the provision of an insurance exchange. [114]The state would receive compensation equal to the full amount of federal grants and tax credits its residents and employers would have been eligible for under the ACA, if they cannot be paid under the state’s plan. State. [112]
Other insurance arrangements
The Community Living Assistance Services and Supports Act (or CLASS Act) established a voluntary, public long-term care insurance option for employees, [115][116][117] The program was terminated as impractical without never take effect. [118]
Consumer-Operated and Oriented Plans (CO-OPs), not-for-profit insurers governed by their members, could begin providing health care coverage, based on a 5-year federal loan. [119] In 2017, only four of the original 23 cooperatives were still in operation. [120]
Nutrition labeling requirements
Nutrition labeling requirements officially came into effect in 2010, but their implementation has been delayed and they actually came into effect on May 7, 2018. [121]
Legislative history
President Obama signs the Patient Protection and Affordable Care Act on March 23, 2010.
The ACA followed a long series of failed attempts by either party to push through major insurance reforms. Innovations were limited to Health Savings Accounts (2003), Medical Savings Accounts (1996), or Flexible Spending Accounts, which increased insurance options, but did not substantially expand coverage. Health care has been a major factor in several elections, but until 2009 neither party had the votes to defeat the other’s opposition.
Individual mandate
The concept of individual mandate dates back to at least 1989, when The Heritage Foundation, a conservative think tank, proposed individual mandate as an alternative to single-payer health care. [122] [123]It was championed for some time by conservative economists and Republican senators as a market-based approach to health care reform based on individual responsibility and avoidance of free rider problems. Specifically, because the Emergency Medical Treatment and Active Labor Act of 1986 (EMTALA) requires any Medicare-participating hospital (almost all do) to provide emergency care to anyone who needs it, the government often indirectly bearing the cost of those without the ability to pay. [124] [125] [126]
President Bill Clinton proposed a major health care reform bill in 1993 [127] which ultimately failed. [ 128] Clinton brokered a compromise with the 105th Congress to instead enact the state’s Children’s Health Insurance Program (SCHIP) in 1997. health care organizations. Republican senators offered an alternative that would have required individuals, but not employers, to purchase insurance.
John Chafee
The Republican Health Equity and Access Reform Today (HEART) Act of 1993, contained a requirement for “universal coverage” with a penalty for non-compliance – an individual mandate – as well as grants to be used in “purchasing groups state-based. [129] Supporters included prominent Republican senators such as John Chafee, Orrin Hatch, Chuck Grassley, Bob Bennett, and Kit Bond. [130] [131] The Republican Consumer Choice Health Safety Act of 1994, initially contained an individual mandate with a penalty provision; [132] however, author Don Nickles later deleted the mandate, stating that “the government shouldn’t be forcing people to buy health insurance.”[133] At the time of these proposals, the Republicans did not raise any constitutional issues; Mark Pauly, who helped craft a proposal that included an individual mandate for George H.W. Bush, remarked, “I don’t recall this coming up at all. The way it was viewed by the Congressional Budget Office in 1994 was, in effect, tax.” [122]
Mitt Romney’s Massachusetts went from having 90% of its residents insured to 98%, the highest rate in the country. [134]
In 2006, an insurance expansion bill was signed into law at the state level of Massachusetts. The bill contained both an individual mandate and an insurance exchange. Republican Gov. Mitt Romney vetoed the mandate, but after Democrats overruled his veto, he signed it into law. [135]Romney’s implementation of the “Health Connector” exchange and individual mandate in Massachusetts was initially hailed by Republicans. During Romney’s 2008 presidential campaign, Senator Jim DeMinta praised Romney’s ability to “take some good conservative ideas, like private health insurance, and apply them to the need to insure everyone.” Romney said of the individual mandate, “I’m proud of what we’ve done. If Massachusetts succeeds in implementing it, then it will be the model for the nation. [136]
In 2007, Republican Senator Bob Bennett and Democratic Senator Ron Wyden introduced the Healthy Americans Act, which included individual mandate and state-based regulated insurance markets called “Health Assistance Agencies of the State”. [126] [136] The bill attracted bipartisan support, but died in committee. Many of its sponsors and co-sponsors remained in Congress during the 2008 health care debate. [137]
In 2008, many Democrats saw this approach as the basis for health care reform. Experts have said that the legislation that eventually emerged from Congress in 2009 and 2010 bore similarities to the 2007 bill, [129] and picked up ideas from the Massachusetts reforms. [138]
Academic foundation
One of the driving forces behind Obama’s health care reform was Peter Orszag, director of the Office of Management and Budget. [139] Obama called Orszag his “health care czar” because of his knowledge of health care reform. [140] Orszag had previously served as director of the Congressional Budget Office, and under his leadership the agency had focused on using cost analysis to create an affordable and effective approach to health care reform. health. Orszag claimed that health care reform became Obama’s top agenda item because he wanted it to be his legacy. [141] According to an article by Ryan Lizza in The New Yorker, the core of the “Obama budget is Orszag’s belief [in] … a government empowered to seek out the most effective medical treatments.” Obama bet “his presidency on Orszag’s thesis on comparative efficiency”. [142] Orszag’s policies were influenced by an article in The Annals of Internal Medicine [143]co-authored by Elliott S. Fisher, David Wennberg and others. The article presented strong evidence based on the co-authors’ research that many procedures, therapies, and tests were delivered with little evidence of their medical value. If these procedures and tests could be eliminated, this evidence suggests that medical costs could provide the savings needed to provide health care to the uninsured population. [144] After reading a New Yorker article that used the “Dartmouth results” [145] to compare two Texas counties with huge variations in Medicare costs using hard data, Obama ordered that all his staff read it. [146]More than anything else, the Dartmouth data intrigued Obama [147] because it gave him academic justification to reshape medicine. [148]
The concept of comparing the effectiveness of health care options based on hard evidence (“comparative effectiveness” and “evidence-based medicine”) was pioneered by John E. Wennberg, founder of the Dartmouth Institute, co- founder of the Foundation for Informed Medical Decision. Making and senior advisor to Health Dialog Inc., a company he and his researchers created to help insurers implement Dartmouth’s findings.
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