During the 2016 election, both candidates included in their platforms the need for continued healthcare reform. While the focus and lens from which the candidates viewed changes to the healthcare system were on opposite spectrums, their voices echoed that of the public—there must be a closer examination of existing law that accelerates towards a model that increases access, deceases costs, and improves quality. President Donald Trump campaigned to address concerns over provisions enacted through the Affordable Care Act, and changing the law was at the forefront of his policy agenda. Approximately two months after President Trump’s inauguration, Congressional leadership in the House of Representatives and the committees of jurisdiction released the American Health Care Act. The bill was placed on the fast-track and was ultimately pulled back from a floor vote. After additional reviews to the bill, it was passed in the House on May 4, 2017. Now, many in the healthcare community speculate, what is the state of play and will there be a bipartisan path to move forward? This article provides a brief overview of healthcare reform that considers both the past and the present status of important aspects such as coverage and access, and offers considerations to think about for the future.
Key Words: Health reform, American Healthcare Act, Affordable Care Act, Medicare, Medicaid
Meaningful healthcare reform has challenged decades of political leaders, economists, experts, healthcare professionals, and the public at large. Meaningful healthcare reform has challenged decades of political leaders, economists, experts, healthcare professionals, and the public at large. The lives and wellness of individuals is not a matter taken lightly. It is imperative that the utmost attention be given to a thoughtful bipartisan discourse where all stakeholder perspectives and relevant evidence is considered in a matter that yields a common denominator— do no harm and champion health. This statement describes the ideal for policy development. Yet, policy and politics can never be separated. This article will attempt to place politics aside, for a moment, and discuss the issue at hand. How has health reform evolved and what is the current state of play? Regardless of individual political affiliation, the interest in ensuring timely access to affordable high-quality care is on the minds of everyone— the path to get there simply differs.
Healthcare Reform: The Past
What do We Mean by Health Reform?
It is important to note that the Patient Protection Affordable Care Act ([ACA], 2010) enacted numerous provisions. Many have commented on the length of the actual law, at nearly 1,000 pages. Some of these provisions were direct changes to statute. Others were new programs, while others had large financial implications. A number of provisions—which were linked to discretionary spending (annual appropriations) — were never funded. For example, a new program to support Nurse Managed Health Clinics (§5208, Public Law No: 111-148) never received an annual appropriation, and its authorization has since expired (ACA, 2010). Discretionary funding for any new programs created under the ACA received little attention at the start of the 112th Congress when the Republican Party took control of the House of Representatives in 2011, and a national focus was placed on cutting the deficit (of note to this focus, President Obama signed the Budget Control Act of 2011 into law on August 2, 2011).
The cost of coverage – who has it and who does not – are topics that individuals and families feel most acutely. When most people think of the ACA, what comes to mind are the individual and employer mandates, Medicaid expansion, and other key provisions related to coverage (e.g., covering pre-existing conditions, allowing coverage on parents’ insurance until the age of 26). While most in the healthcare policy world equate reform to all aspects of care and the system writ large, it is the coverage aspect that gains national attention. And rightfully so, as coverage and access are inextricably linked. The cost of coverage – who has it and who does not – are topics that individuals and families feel most acutely. The minutia of the Social Security Act, Public Health Service Act, and funding mechanisms are vital to health reform, but the average American does not dig that far down in the weeds. It is coverage and its appendages (cost and quality) that have dominated policy change for eight decades.
Taking a Brief Step Back
Setting healthcare policy has been a vigorously debated Congressional and Presidential agenda item for more than 100 years in the United States. Setting healthcare policy has been a vigorously debated Congressional and Presidential agenda item for more than 100 years in the United States (U.S.). A social insurance program was floated by President Theodore Roosevelt in 1912 (Centers for Medicare and Medicaid Services [CMS], n.d.). Later, President Franklin Roosevelt continued to advocate for such a program, and during his term in office, Congress passed the Social Security Act of 1935 (Public Law No. 74-271; 1935), which paved the way for the establishment of Medicare and Medicaid (CMS, n.d.).
In 1937, U.S. Surgeon General Thomas Parran proposed that Social Security beneficiaries be covered by a national health insurance plan (CMS, 2015). President Harry Truman announced his support for such a structure, and it was in 1965 that President Lyndon Jonson signed into law Title XVIII and Title XIX of the Social Security Act (SSA)— the enactment of Medicare and Medicaid (CMS, 2015).
In the past decade and a half, three significant laws have changed the face of the Medicare and Medicaid programs. Over the next few decades, responses to patient and population health demands influenced continued changes to the SSA. For example, in 1972 the Social Security Act was amended to expand coverage to disabled individuals and those with end-stage renal disease (CMS, 2015). In 1986, Congress passed, and President Ronald Reagan signed into law, the Emergency Medical Treatment and Labor Act (EMTALA), passed in the Consolidated Omnibus Reconciliation Act (COBRA) of 1985 (1986) that required any hospital receiving Medicare payments to provide emergency services and stabilizing treatments (CMS, 2015). The 1990s ushered in a number of changes to Medicare and Medicare, most notably in 1996 through the Health Insurance Portability and Accountability Act (HIPAA) (Public Law No. 104-191) and the Balanced Budget Act (BBA) of 1997 (Public Law No. 105-33) (CMS, 2015). HIPAA is best known for changes to health information privacy while the BBA created the Children’s Health Insurance Program (CHIP) and increased the Medicare reimbursement rate for nurse practitioners (CMS, 2015).
...the need to amend the SSA to advance the nation’s Medicare and Medicaid programs is one endeavor that has hit nearly every decade since its inception. In the past decade and a half, three significant laws have changed the face of the Medicare and Medicaid programs. In 2003, President George W. Bush signed into law the Medicare Prescription Drug, Improvement and Modernization Act ([MMA], 2003). This law enacted a new Medicare entitlement program, providing coverage of outpatient prescription drugs (Oliver, Lee, Lipton, 2004). Medicare Prescription Drug coverage (Part D) began enrollment in 2005 (CMS, 2015). On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (ACA, 2010). Mentioned above are a number of the coverage related provisions in the ACA, but that is not where Congress and the Obama Administration stopped. During the 114th Congress, the Medicare Access and CHIP Reauthorization Act (MACRA) of 2015 (2015) was passed and signed into law by President Obama. The law ended the way Medicare Part B prescribers were reimbursed, formerly known as the Sustainable Growth Rate or SGR, and introduced a new methodology focused on alternative payment models that emphasize value over volume (CMS, 2015).
Change is Inevitable
What does this history tell us? Change is inevitable and necessary. In divided governments, and in both Republican and Democratic Administrations, the need to amend the SSA to advance the nation’s Medicare and Medicaid programs is one endeavor that has hit nearly every decade since its inception. It may be a political party change that ushers in a new solution or the demand rising from the public that propels Congressional action. Either way, it is a mainstay of the national discourse that is almost inevitably met by opposition from some segment of the political spectrum.
All political parties, members in both Chambers, and the Administration know that health is core to the vitality of the country, yet how to achieve this state will always be up for debate.One must remember that the healthcare system is not static. Its evolution is driven by innovation, changes to healthcare status, and economic shifts, to name a few. Can policy ever keep pace? No, it cannot. Maintaining a status quo is not possible for health and healthcare. All political parties, members in both Chambers, and the Administration know that health is core to the vitality of the country, yet how to achieve this state will always be up for debate.
Healthcare Reform: The Present
Fast Forward to 2017
The 115th Congress hit the ground running to repeal portions of the ACA through the budget reconciliation process... The 115th Congress hit the ground running to repeal portions of the ACA through the budget reconciliation process, even before President Trump was sworn into office. On January 12 and 13, 2017, the S.ConRes.3 or Concurrent Resolution on the Budget for Fiscal Year 2017 (115th Congress, 2017-2018) was passed in the Senate and the House, respectively. Among other provisions, this action created two reserve funds— one that could be used to repeal portions of the ACA and one to fund new healthcare legislation (Committee for a Responsible Federal Budget, 2017).
One critical action to come after President Trump’s inauguration was the confirmation of former Representative Tom Price (R-GA), a physician, as Secretary of the U.S. Department of Health and Human Services (HHS) on February 10, 2017. Appointing a head of HHS was a crucial landmark to support Congressional and Administrative efforts for health reform. Secretary Price has and will continue to play a pivotal role in major reform in 2017, having offered his own reform proposals while in Congress. Just under a month later, on March 6, 2017, the House Ways and Means Committee (2017) and the House Energy and Commerce Committee (2017) released their sections of the American Health Care Act (AHCA).
The original bill directly addressed many issues discussed on the 2016 campaign trail. It created a patient and state stability fund to allow states to design programs that would meet their own needs; it would halt Medicaid expansion (freezing new enrollment and grandfathering in new enrollees); and create a per capita allotment formula for states (House Energy and Commerce Committee, 2017). The bill removed the individual and employer mandate; expanded health savings accounts for families to spend as needed; and created a monthly tax credit for those who do not receive insurance through work or a government program (House Ways and Means Committee, 2017).
The Congressional Budget Office (CBO) then released their score of the legislation on March 13, 2017. This document projected that the AHCA would “reduce federal deficits by $337 billion over the coming decade and increase the number of people who are uninsured by 24 million in 2026 relative to current law” (CBO, 2017a, para. 1). On March 20, 2017, Representative Diane Black (R-TN), a registered nurse who serves as Chair of the House Budget Committee, formally introduced the American Health Care Act as the legislation was tied to the budget reconciliation process.
Changes were then proposed due to concerns from various segments of the Republican Party and external stakeholder groups. Some of the most notable changes were allowing states to enact a work requirement for Medicaid beneficiaries who were not disabled, elderly, or pregnant and allowing states to move Medicaid from the per capita proposal to block grants (Jost, 2017). The new CBO score, based on these and other amendments, projected that the legislation slated to reduce the federal deficit by $150 billion over a decade and in 2018, 14 million more people would be uninsured compared to the current law (CBO, 2017b).
On March 24, 2017, a vote was anticipated in the House of Representatives on this bill, yet it did not occur. Through a process known as “whipping the votes,” it was clear that the AHCA had not garnered enough support from moderate or conservative Republicans to ensure passage. From the release of the AHCA to the date of the anticipated vote, the work spanned a total of 12 business days.
What is the Current State of Play?
The current state of play remains to be seen. Given the speed of the actions taken by the leadership in the 115th Congress—mid-January to the end of March— one could speculate a swift process may occur again (and since the writing of this article, it has). However, a number of factors must be thoughtfully considered. Healthcare reform in 2017 has been discussed by the Administration and Congress as having three phases. In days following the bill’s withdrawal, Speaker Paul Ryan (R-WI) noted in his press release a commitment to moving forward on health reform and stated, “There remains so much that we can do to help improve people’s lives. And we will.” (Ryan, 2017, para. 5). The President commented on March 24, 2017, the day the AHCA was pulled from a floor vote, that
“I think this is something -- it certainly was an interesting period of time. We all learned a lot. We learned a lot about loyalty. We learned a lot about the vote-getting process. We learned a lot about some very arcane rules in, obviously, both the Senate and in the House. So it's been -- certainly for me, it's been a very interesting experience. But in the end, I think it's going to be an experience that leads to an even better healthcare plan.” (White House, Office of Press Secretary, 2017a, para. 9).
Democrats and Republicans, including each end of the parties’ continuums, will need to find a way forward. This will also take support from external stakeholders. The President also stated in his remarks that the vote of AHCA not coming to the floor was perhaps the best thing that could have happened (White House, Office of Press Secretary, 2017a). In the weeks following the attempt to move the AHCA, national attention was drawn to the work ahead. On May 4, 2017, an amended version of the AHCA was passed by the House of Representatives with a vote of 217-213 (AHCA, 2017). The President and key members of the Republican party held a press conference in the Rose Garden in which the President stated,
But we have an amazing group of people standing behind me. They worked so hard and they worked so long. And when I said, let’s do this, let’s go out, just short little shots for each one of us and let’s say how good this plan is -- we don’t have to talk about this unbelievable victory -- wasn’t it unbelievable? So we don’t have to say it again. But it’s going to be an unbelievable victory, actually, when we get it through the Senate. (White House, Office of the Press Secretary, 2017b, para 10)
The Senate must now take up the bill. On May 24, 2017, the CBO released another score of the House-passed AHCA, noting it would “reduce federal deficits by $119 billion over the coming decade and increase the number of people who are uninsured by 23 million in 2026 relative to current law” (CBO, 2017c). The Senate is underway in their process. Now, it will be a work of both policy and politics to guide the process forward. Now, it will be a work of both policy and politics to guide the process forward. Democrats and Republicans, including each end of the parties’ continuums, will need to find a way forward. This will also take support from external stakeholders.
During the ACA and AHCA conversations, groups like the American Nurses Association, American Hospital Association, American Medical Association, and AARP were vocal in their stance on the entirety of the proposals. Large constituency groups move forward the message of their members when they cannot bring their individual voices to the halls of Congress. Members belong to these advocacy organizations to ensure that their interests are well represented. During the ACA and AHCA conversations, groups like the American Nurses Association, American Hospital Association, American Medical Association, and AARP were vocal in their stance on the entirety of the proposals. These are political and policy shops whose expertise is valued to support or oppose legislative proposals.
They are not the only organizations involved, however. Within the healthcare sector, there are countless specialty organizations that offer great insight to portions of legislative proposals or their entirety. They may not be as visible, but they are ever present and formidable, offering tailored and specific expertise. Coalitions are also hugely effective and respected for the ability to bring forth a united perspective. Within the nursing profession, for example, the Nursing Community coalition unites the individual force of 63 national nursing organizations when weighing in on policy (Nursing Community, n.d.).
Take Home Considerations
...it is important to remember that differing political perspectives are vital to moving a strong agenda forward. First, it is important to remember that differing political perspectives are vital to moving a strong agenda forward. Sound policy construction comes from a foundation of negotiation, compromise, and commitment to a common goal, which in this case, is improving health and health care. Second, controversy and criticism are inevitable. No plan is ever so perfect that it would be embraced by all constituency groups and political parties. The ability to have a national discourse is a cornerstone of our democracy. Third, change is constant. No sustainable future is realized by keeping the baseline the same. Without amendments to public law and the policy considerations necessary to enact change, the healthcare system would not be able to meet the challenges today or those of tomorrow. Fourth, consider education. Understanding how policy is made (along with the intersection of politics and power) is not necessarily an area of expertise for healthcare professionals. To be truly informed, one cannot rely solely on news, political affiliation, or a national organization. Understanding both sides of the issue is foundational to a true education. Finally, never lose sight of the ultimate impact. Lobbyists and policy makers are not “on the ground” like their constituency groups. They rely on hearing from their membership to carry a strong voice forward that shares the possible implications of a proposed bill. Silence can be just as devastating to the outcome as vocal opposition or support.
Conclusion: Thoughts for the Future
The ability to have a national discourse is a cornerstone of our democracy. By the time this article is published, there may have been a swell of action on healthcare reform or little at all. That is the nature of the political process. However, the purpose of this piece was to allow the reader to pause and consider the past, the present, and offer a framework to think about the future. What the nation is currently experiencing is not unlike the past and should continue in the future— open dialogue and debate.
Coming to the discussion with a balanced view accelerates the path forward by finding common ground and a change that would be feasible for both sides. The necessity at hand is to remember the goal of bipartisan work. Individuals are not required to change their political views on a particular policy, but are required to hear and attempt to understand the other perspective. Coming to the discussion with a balanced view accelerates the path forward by finding common ground and a change that would be feasible for both sides. In the end, as initially stated, the work to reform the nation’s healthcare system is not a process to be taken lightly. Such reform can only happen with thoughtful consideration and intentional participation by all.
Suzanne Miyamoto, PhD, RN, FAAN
Suzanne Miyamoto, PhD, RN, FAAN is the Chief Policy Officer at the American Association of Colleges of Nursing. She also is the Convener for the Nursing Community, a coalition of 63 national nursing organizations that collaborate on a wide spectrum of health policy issues. Dr. Miyamoto is a 2014 Robert Wood Johnson Foundation Executive Nurse Fellow and adjunct assistant professor at Georgetown University, School of Nursing and Health Studies. Additionally, she is a Senior Associate Editor and Member of the Editorial Board for the journal Policy, Politics & Nursing Practice.
American Health Care Act of 2017. (2017). Actions overview. Retrieved from https://www.congress.gov/bill/115th-congress/house-bill/1628/actions
Consolidated Omnibus Budget Reconciliation Act of 1985, Pub L. No. 99-272, 100 Stat. 82 (1986). Retrieved from https://www.congress.gov/bill/99th-congress/house-bill/3128
A concurrent resolution setting forth the congressional budget for the United States Government for fiscal year 2017 and setting forth the appropriate budgetary levels for fiscal years 2018 through 2026, S.Con.Res.3. (2017) Retrieved from https://www.congress.gov/bill/115th-congress/senate-concurrent-resolution/3/text?q=%7B%22search%22%3A%5B%22budget+resolution%22%5D%7D&r=9
Budget Control Act of 2011, Pub L. No. 112-025, 125 STAT. 240. (2011). Retrieved from: https://www.congress.gov/112/plaws/publ25/PLAW-112publ25.pdf
Centers for Medicare and Medicaid Services. (n.d.). Tracing the history of CMS programs: From President Theodore Roosevelt to President George W. Bush. Retrieved from https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/PresidentCMSMilestones.pdf
Centers for Medicare and Medicaid Services (2015). Medicare and Medicaid. Milestones 1937-2015. Retrieved from https://www.cms.gov/About-CMS/Agency-Information/History/Downloads/Medicare-and-Medicaid-Milestones-1937-2015.pdf
Committee for a Responsible Federal Budget. (2017, January 3). Chairman Enzi introduces FY 2017 budget resolution providing for ACA repeal in senate. Retrieved from http://crfb.org/blogs/chairman-enzi-introduces-fy2017-budget-resolution-providing-aca-repeal-senate
Congressional Budget Office. (2017a, March 13). American Health Care Act- Cost estimate. Retrieved from https://www.cbo.gov/publication/52486
Congressional Budget Office. (2017b, March 13). H.R. 1628, the American Health Care Act, incorporating manager’s amendments 4, 5, 24, and 25. Retrieved from https://www.cbo.gov/publication/52516
Congressional Budget Office (2017c, May 24). H.R. 1628, American Health Care Act of 2017. Retrieved from https://www.cbo.gov/publication/52752
House Energy and Commerce Committee. (2017, March 6). Walden & Brady WSJ op-ed on plan to repeal and replace Obamacare. Retrieved from https://energycommerce.house.gov/news-center/news/cymi-walden-brady-wsj-op-ed-plan-repeal-and-replace-obamacare
House Ways and Means Committee (2017, March 6). Ways and Means Republicans release legislation to repeal and replace Obamacare. Retrieved from https://waysandmeans.house.gov/american-health-care-act/
Jost, T. (2017, March 21). What’s in the managers amendment to the AHCA? Health Affairs Blog. Retrieved from http://healthaffairs.org/blog/2017/03/21/whats-in-the-managers-amendment-to-ahca/
Medicare prescription drug, improvement, and modernization act of 2003, Pub L. No. 108-173, 117 STAT. 2066. (2003) Retrieved from https://www.gpo.gov/fdsys/pkg/PLAW-108publ173/html/PLAW-108publ173.htm
Medicare Access and CHIP Reauthorization Act of 2015, Pub L. No. 114-10, 129 STAT. 87 (2015). Retrieved from https://www.congress.gov/114/plaws/publ10/PLAW-114publ10.pdf
Nursing Community. (n.d.). About the Nursing Community. Retrieved from http://www.thenursingcommunity.org/
Oliver, T.R., Lee, P.R., & Lipton, H.L. (2004). A political history of Medicare and Prescription drug coverage. The Milbank Quarterly, 82(2), 283-354 doi: 10.1111/j.0887-378X.2004.00311.x.
Patient Protection and Affordable Care Act (PPACA) Pub. L. No. 111-148, §2702, 124 Stat. 119, 318-319. (2010). Retrieved at www.gpo.gov/fdsys/pkg/PLAW-111publ148/pdf/PLAW-111publ148.pdf
Ryan, P. (2017, March 24). Speaker Ryan's remarks from today's press conference. Retrieved from http://www.speaker.gov/press-release/speaker-ryans-remarks-todays-press-conference
Social Security Act of 1935, Pub. L. No. 74-271, 49 Stat. 620. (1935). Retrieved from http://legcounsel.house.gov/Comps/SSA_CMD.pdf
White House, Office of the Press Secretary (2017a, March 24). Remarks by President Trump on the Health Care Bill. Retrieved from https://www.whitehouse.gov/the-press-office/2017/03/24/remarks-president-trump-health-care-bill
White House, Office of the Press Secretary (2017b, May 4). Remarks by President Trump on the healthcare vote in the House of Representatives. Retrieved from https://www.whitehouse.gov/the-press-office/2017/05/04/remarks-president-trump-healthcare-vote-house-representatives