Friday, September 30, 2011
Tuesday, September 27, 2011
Tuesday, July 19, 2011
A Policy Summary of The Defense of Marriage Act (DOMA )
The Defense of Marriage Act, also known as DOMA came into being amid a controversy over federalism and the Full Faith and Credit Clause in Article IV section 1 of the US Constitution. It was the mid-90‘s and at that time a court decision (Baehr v. Miike, originally Baehr v. Lewin) was issued from the Supreme Court of Hawaii suggesting that there was a right to same-sex marriage under the Hawaii state constitution (domawatch). Federal lawmakers became concerned that if Hawaii allowed same-sex couples to marry, how would that affect the other 49 states, federal laws, the institution of marriage, traditional notions of morality, and state sovereignty (domawatch.org, para 1). So instead of tackling the issues of federalism and the full faith and credit clause, Conservative lawmakers hastily reacted marginalizing an entire population of LGBT (Lesbian, Gay, Bi-sexual, Transgendered) Americans. The following summarizes what the Defense of Marriage Act is and how it affects the states and federal government, the actors and interests involved, how the law has affected LGBT Americans, and pending DOMA court cases. In addition, the Obama administration made news recently on DOMA which will also be discussed.
The Defense of Marriage Act was introduced on May 7, 1996 to the 104th Congress of the United States (LOC). The original sponsor of the bill was Rep. Bob Barr of Georgia’s 7th District (LOC). The Defense of Marriage Act is split into two distinct sections, the first provides states with the authority to deny Full Faith and Credit of one states’ “effects” - in this case a marriage certificate given to a same-sex couple - by another state. “No State, territory, or possession of the United States, or Indian tribe, shall be required to give effect to any public act, record, or judicial proceeding of any other State, territory, possession, or tribe respecting a relationship between persons of the same sex that is treated as a marriage under the laws of such other State, territory, possession, or tribe, or a right or claim arising from such relationship (LOC). This language allows the states to decided for themselves wether it wants to grant Full Faith and Credit on the status of marriage; but only to same-sex unions, heterosexual marriages cannot be denied.
According to Lectic Law, the Congress has exercised its power under the “Effect” Clause of Article IV (Full Faith and Credit) before, declaring what “effect” one State’s acts, records, and judicial proceedings shall have in another state (Lectric Law). The Parental Kidnaping Prevention Act of 1980 and the Full Faith and Credit for Child Support Act of 1994, are both instances where Congress has regulated how one State must act in accordance with another States’ action. The Defense of Marriage Act in essence says that the Full Faith and Credit clause found in the Constitution does not apply (unless States’ so choose) to LGBT Americans living in committed, loving, relationships who have a marriage license from another state.
The second portion of the Defense of Marriage Act is very straight forward, no pun intended. It amends the U.S. Code to define marriage for all federal purposes as a legal union of a man and a woman as husband and wife. DOMA also defines what the term spouse is for federal purposes. “In determining the meaning of any Act of Congress, or of any ruling, regulation, or interpretation of the various administrative bureaus and agencies of the United States, the word 'marriage' means only a legal union between one man and one woman as husband and wife, and the word 'spouse' refers only to a person of the opposite sex who is a husband or a wife” (LOC).
The Defense of Marriage Act’s definition of “marriage” can be rooted back to a 1974 Washington State case, where it was cited that over a century ago the US Supreme Court spoke of the “union for life of one man and one woman in the holy estate of matrimony” (Lectric Law). Using similar words and holding similar sentiment the proponents of the language in the Defense of Marriage Act, choose to cast a dark cloud over thousands of federal employees and their partners who happen to be identify as LGBT.
In the mid-90’s the partisan divide was tremendous. We had divided government much like we do today; with a Republican controlled House of Representatives and centrist Democrat as President. With the threat of a progressive interpretation of marriage pushing up against notions of federalism, it was Robert Barr, a libertarian-leaning Republican from Georgia’s 7th District that began to author legislation that would become the Defense of Marriage Act which preemptively deny rights afforded in the US Constitution to gays and lesbians. Barr along with 120 Democrats and 219 Republican passed H.R 3396 - The Defense of Marriage Act in the House on July 12, 1996. There were 342 yea votes, 67 nay votes, and 22 who did not vote on the bill. On September 10, 1996 the Senate passed the bill 85 (yea) to 14 (nay) and President Clinton signed it into law eleven days later September 21, 1996.
Social views of homosexuality were not as tolerant then as they are now. Visceral fears of AIDS still dominated much of how the public viewed gay Americans; especially gay men. About a year before Ellen Degeneres came out of the closet on prime time television, Democrats and Republicans from all eight Maryland Congressional districts voted for the Defense of Marriage Act. However, Govtrack, an online Congressional clearinghouse website, notes there was one Republican, Steven Gunderson of Wisconsin’s 3rd District who voted no. Other notable “nay” votes came from progressives Democrats like both Kennedy’s in Congress, Edward Markey (MA), Charlie Rangel (NY) , John Conyers (MI), Bernie Sanders (VT), Henry Waxman (CA), Maxine Waters (CA), and surprisingly even my representative (at the time) James Moran (VA).
The issue of LGBT rights comes with a host of emotion from both proponents and opponents alike. In support of their cause many different advocacy groups have begun the work to repeal the Defense of Marriage Act or fight to keep it existing law. Pro-gay rights groups come in many sizes, however, the Human Rights Campaign and Lambda Legal are two well organized groups actively lobbying and litigating , respectively, to end the Defense of Marriage Act. Lobbying efforts by HRC and Equality Maryland, a Baltimore-based LGBT rights group, have worked to get repeal legislation through Congress. In September 2009 Rep. Jerrold Nadler of New York introduced H.R 1116 - The Respect for Marriage Act to the 111th Congress. California Senator Diane Feinstein introduced S. 598 to the Senate and Rep Nadler re-introduced The Respect for Marriage Act in the House on March 16, 2011.
Opponents to repeal of the Defense of Marriage Act are familiar and should not come as a surprise. The same conservative, typically religious right wing organizations include; Family Research Counsel, Heritage Foundation, and Concerned Women of America, amongst others. All of these organizations have released statements defending the Defense of Marriage Act, however, I was unable to find direct funding to legislators attempting to kill the Respect for Marriage Act, which would effectively repeal the discriminatory DOMA law. It is noteworthy to mention that the original sponsor and drafter of the so-called Defense of Marriage Act, Robert Barr, now opposes the Defense of Marriage Act, as well as, the Federal Marriage Amendment, and supports the Respect for Marriage Act (Barr Youtube Video).
The affect the Defense of Marriage Act has had on the LGBT community has been hard not to notice. Since the federal government adopted the policy in 1994, and up until the Obama administration, gay federal employees with partners were denied offering health benefits to their spouse because of the language directly associated with the so-called Defense of Marriage Act. Since 1994 five states including the District of Columbia issue marriage licenses to same-sex couples (HRC). Because of this reality federal courts have heard and decided cases brought forth by gay-rights advocacy groups. A recent example is a 2011 case brought forth from Lambda Legal, representing Karen Golinski. Ms. Golinski is a federal court employee who is challenging the constitutionality of the Defense of Marriage Act on the grounds that her wife was denied spousal benefits (Alliance). “As part of an internal HR adjudication process, Chief Judge Alex Kozinski ruled that denying the benefits violated the court’s EEO policy and ordered that they be provided to the employee’s wife. The Office of Personnel Management, which administers federal employee health benefits, refused to comply and the employee filed suit in federal district court in California” (HRC, para 9).
According to the Human Rights Campaign, approximately five more cases are pending across the country challenging the Defense of Marriage Act. Gill v. Office of Personnel Management is a case where lawfully married same-sex couples in Massachusetts sued for denied benefits like federal employee health insurance, joint income tax filing, and social security benefits. In July 2010, a federal district judge ruled in their favor. The case is currently on appeal to the US Court of Appeals for the First Circuit (HRC para, 10). Similar to Gill is the Pederson v. Office of Personnel Management case involving couples from Connecticut, Vermont, and New Hampshire and is currently in federal district court in Connecticut. Another type of case dealing with estate tax is Windsor v. United States. The case involves a New York widow who is “subject to a significant estate tax burden that would not apply if her spouse was male” (HRC, para 11). In all of these cases the people involved have felt real injustice simply because of who they love.
In 2011 President Obama along with Attorney General Eric Holder issued statements officially reversed the position long held by the federal government regarding the Defense of Marriage Act. “The president and I have concluded that classifications based on sexual orientation” should be subjected to a strict legal test intended to block unfair discrimination, Mr. Holder wrote. As a result, he said, a crucial provision of the Defense of Marriage Act “is unconstitutional” (Savage, et al. para 2). The President additional instructed the Department of Justice to stop actively defending the law in court (Savage, para 1). The sudden shift in policy was welcome news to the LGBT community half way into Obama’s first term; the Obama candidacy promised repeal of DOMA, but had consistently defended the law for the prior two years since taking office.
It is fair to say that after the Defense of Marriage Act was signed into law public opinion began to shift even more in favor of, at the very least, tolerance for LGBT Americans and their rights. Many taboos were being exposed in pop culture during the mid to late 1990’s. There is no question that television shows like Ellen, and Will and Grace changed how middle-america viewed homosexuality. In the millennium, shows like Queer as Folk, pushed the envelope even further. Now seventeen years after the Defense of Marriage Act was enacted, there is movement from the grassroots of LGBT activism to the halls of Congress and the White House for repeal of the existing law. For now the Respect for Marriage Act sits in the House Judiciary Committee awaiting a mark-up hearing (LOC). If history is our guide to future events, the Defense of Marriage Act will be repealed, eventually.
Reference
Alliance Alert (2011). Lambda Legal: DOMA Under Fire in Equal Benefits Case. Retrieved March 25 2011 from http://www.alliancealert.org/2011/04/15/lambda-legal-doma-under fire-in-equal-benefits-case/
Bob Barr 2008. (2011). YouTube Video of Acceptance Speech for Libertarian Party Nomination for President. Retrieved March 25 2011 from http://www.youtube.com/watch? v=mjfDSPfL02w
Concerned Women for America (2011). CWA Defends The Defense of Marriage Act. Retrieved March 23 2011 from http://www.cwfa.org/content.asp?id=19878
DOMAwatch.org (2011). Legal Resource for News On Defense of Marriage Act. Retrieved March 25 2011 from http://www.domawatch.org/index.php
Family Research Counsel (2011). Search Results: Defense of Marriage Act. Retrieved March 23 2011 from http://www.frc.org/washingtonupdate/defending-doma-pros-and-leprechauns
Heritage Foundation (2011). Memo To White House, Don’t Stop, Start Defending DOMA. Retrieved March 24 2011 from http://blog.heritage.org/?p=52412
Human Rights Campaign (2011). Defense of Marriage Act FAQ. Retrieved March 22 2011 from
http://www.hrc.org/issues/marriage/15364.htm
Human Rights Campaign (2011). Respect for Marriage Act. Retrieved March 23 2011 from
http://www.hrc.org/issues/marriage/13530.htm
Lambda Legal (2011). Pending Legal Cases: Defense of Marriage Act. Retrieved March 22 2011 from http://www.lambdalegal.org/in-court/cases/baehr-v-miike.html
Lectric Law (2011). Summary of Defense of Marriage Act. H.R 3396. Retrieved March 20 2011 from http://www.lectlaw.com/files/leg23.htm
Library of Congress (2011). Bill Summary and Status of 104th Congress (95’-96’)
H.R 3396 Retrieved March 20 2011 from http://thomas.loc.gov/cgi-bin/bdquery/z d104:h3396:
Savage, Charlie and Stolberg, Gay Sheryl (2011). NY Times Online: In Shift, US Says Marriage Act Blocks Gay Rights. Retrieved March 23 2011 from http://www.nytimes.com/ 2011/02/24/us/24marriage.html_r=1&scp=1&sq=Defense%20of%20Marriage %20Act&st=cse
The Defense of Marriage Act was introduced on May 7, 1996 to the 104th Congress of the United States (LOC). The original sponsor of the bill was Rep. Bob Barr of Georgia’s 7th District (LOC). The Defense of Marriage Act is split into two distinct sections, the first provides states with the authority to deny Full Faith and Credit of one states’ “effects” - in this case a marriage certificate given to a same-sex couple - by another state. “No State, territory, or possession of the United States, or Indian tribe, shall be required to give effect to any public act, record, or judicial proceeding of any other State, territory, possession, or tribe respecting a relationship between persons of the same sex that is treated as a marriage under the laws of such other State, territory, possession, or tribe, or a right or claim arising from such relationship (LOC). This language allows the states to decided for themselves wether it wants to grant Full Faith and Credit on the status of marriage; but only to same-sex unions, heterosexual marriages cannot be denied.
According to Lectic Law, the Congress has exercised its power under the “Effect” Clause of Article IV (Full Faith and Credit) before, declaring what “effect” one State’s acts, records, and judicial proceedings shall have in another state (Lectric Law). The Parental Kidnaping Prevention Act of 1980 and the Full Faith and Credit for Child Support Act of 1994, are both instances where Congress has regulated how one State must act in accordance with another States’ action. The Defense of Marriage Act in essence says that the Full Faith and Credit clause found in the Constitution does not apply (unless States’ so choose) to LGBT Americans living in committed, loving, relationships who have a marriage license from another state.
The second portion of the Defense of Marriage Act is very straight forward, no pun intended. It amends the U.S. Code to define marriage for all federal purposes as a legal union of a man and a woman as husband and wife. DOMA also defines what the term spouse is for federal purposes. “In determining the meaning of any Act of Congress, or of any ruling, regulation, or interpretation of the various administrative bureaus and agencies of the United States, the word 'marriage' means only a legal union between one man and one woman as husband and wife, and the word 'spouse' refers only to a person of the opposite sex who is a husband or a wife” (LOC).
The Defense of Marriage Act’s definition of “marriage” can be rooted back to a 1974 Washington State case, where it was cited that over a century ago the US Supreme Court spoke of the “union for life of one man and one woman in the holy estate of matrimony” (Lectric Law). Using similar words and holding similar sentiment the proponents of the language in the Defense of Marriage Act, choose to cast a dark cloud over thousands of federal employees and their partners who happen to be identify as LGBT.
In the mid-90’s the partisan divide was tremendous. We had divided government much like we do today; with a Republican controlled House of Representatives and centrist Democrat as President. With the threat of a progressive interpretation of marriage pushing up against notions of federalism, it was Robert Barr, a libertarian-leaning Republican from Georgia’s 7th District that began to author legislation that would become the Defense of Marriage Act which preemptively deny rights afforded in the US Constitution to gays and lesbians. Barr along with 120 Democrats and 219 Republican passed H.R 3396 - The Defense of Marriage Act in the House on July 12, 1996. There were 342 yea votes, 67 nay votes, and 22 who did not vote on the bill. On September 10, 1996 the Senate passed the bill 85 (yea) to 14 (nay) and President Clinton signed it into law eleven days later September 21, 1996.
Social views of homosexuality were not as tolerant then as they are now. Visceral fears of AIDS still dominated much of how the public viewed gay Americans; especially gay men. About a year before Ellen Degeneres came out of the closet on prime time television, Democrats and Republicans from all eight Maryland Congressional districts voted for the Defense of Marriage Act. However, Govtrack, an online Congressional clearinghouse website, notes there was one Republican, Steven Gunderson of Wisconsin’s 3rd District who voted no. Other notable “nay” votes came from progressives Democrats like both Kennedy’s in Congress, Edward Markey (MA), Charlie Rangel (NY) , John Conyers (MI), Bernie Sanders (VT), Henry Waxman (CA), Maxine Waters (CA), and surprisingly even my representative (at the time) James Moran (VA).
The issue of LGBT rights comes with a host of emotion from both proponents and opponents alike. In support of their cause many different advocacy groups have begun the work to repeal the Defense of Marriage Act or fight to keep it existing law. Pro-gay rights groups come in many sizes, however, the Human Rights Campaign and Lambda Legal are two well organized groups actively lobbying and litigating , respectively, to end the Defense of Marriage Act. Lobbying efforts by HRC and Equality Maryland, a Baltimore-based LGBT rights group, have worked to get repeal legislation through Congress. In September 2009 Rep. Jerrold Nadler of New York introduced H.R 1116 - The Respect for Marriage Act to the 111th Congress. California Senator Diane Feinstein introduced S. 598 to the Senate and Rep Nadler re-introduced The Respect for Marriage Act in the House on March 16, 2011.
Opponents to repeal of the Defense of Marriage Act are familiar and should not come as a surprise. The same conservative, typically religious right wing organizations include; Family Research Counsel, Heritage Foundation, and Concerned Women of America, amongst others. All of these organizations have released statements defending the Defense of Marriage Act, however, I was unable to find direct funding to legislators attempting to kill the Respect for Marriage Act, which would effectively repeal the discriminatory DOMA law. It is noteworthy to mention that the original sponsor and drafter of the so-called Defense of Marriage Act, Robert Barr, now opposes the Defense of Marriage Act, as well as, the Federal Marriage Amendment, and supports the Respect for Marriage Act (Barr Youtube Video).
The affect the Defense of Marriage Act has had on the LGBT community has been hard not to notice. Since the federal government adopted the policy in 1994, and up until the Obama administration, gay federal employees with partners were denied offering health benefits to their spouse because of the language directly associated with the so-called Defense of Marriage Act. Since 1994 five states including the District of Columbia issue marriage licenses to same-sex couples (HRC). Because of this reality federal courts have heard and decided cases brought forth by gay-rights advocacy groups. A recent example is a 2011 case brought forth from Lambda Legal, representing Karen Golinski. Ms. Golinski is a federal court employee who is challenging the constitutionality of the Defense of Marriage Act on the grounds that her wife was denied spousal benefits (Alliance). “As part of an internal HR adjudication process, Chief Judge Alex Kozinski ruled that denying the benefits violated the court’s EEO policy and ordered that they be provided to the employee’s wife. The Office of Personnel Management, which administers federal employee health benefits, refused to comply and the employee filed suit in federal district court in California” (HRC, para 9).
According to the Human Rights Campaign, approximately five more cases are pending across the country challenging the Defense of Marriage Act. Gill v. Office of Personnel Management is a case where lawfully married same-sex couples in Massachusetts sued for denied benefits like federal employee health insurance, joint income tax filing, and social security benefits. In July 2010, a federal district judge ruled in their favor. The case is currently on appeal to the US Court of Appeals for the First Circuit (HRC para, 10). Similar to Gill is the Pederson v. Office of Personnel Management case involving couples from Connecticut, Vermont, and New Hampshire and is currently in federal district court in Connecticut. Another type of case dealing with estate tax is Windsor v. United States. The case involves a New York widow who is “subject to a significant estate tax burden that would not apply if her spouse was male” (HRC, para 11). In all of these cases the people involved have felt real injustice simply because of who they love.
In 2011 President Obama along with Attorney General Eric Holder issued statements officially reversed the position long held by the federal government regarding the Defense of Marriage Act. “The president and I have concluded that classifications based on sexual orientation” should be subjected to a strict legal test intended to block unfair discrimination, Mr. Holder wrote. As a result, he said, a crucial provision of the Defense of Marriage Act “is unconstitutional” (Savage, et al. para 2). The President additional instructed the Department of Justice to stop actively defending the law in court (Savage, para 1). The sudden shift in policy was welcome news to the LGBT community half way into Obama’s first term; the Obama candidacy promised repeal of DOMA, but had consistently defended the law for the prior two years since taking office.
It is fair to say that after the Defense of Marriage Act was signed into law public opinion began to shift even more in favor of, at the very least, tolerance for LGBT Americans and their rights. Many taboos were being exposed in pop culture during the mid to late 1990’s. There is no question that television shows like Ellen, and Will and Grace changed how middle-america viewed homosexuality. In the millennium, shows like Queer as Folk, pushed the envelope even further. Now seventeen years after the Defense of Marriage Act was enacted, there is movement from the grassroots of LGBT activism to the halls of Congress and the White House for repeal of the existing law. For now the Respect for Marriage Act sits in the House Judiciary Committee awaiting a mark-up hearing (LOC). If history is our guide to future events, the Defense of Marriage Act will be repealed, eventually.
Reference
Alliance Alert (2011). Lambda Legal: DOMA Under Fire in Equal Benefits Case. Retrieved March 25 2011 from http://www.alliancealert.org/2011/04/15/lambda-legal-doma-under fire-in-equal-benefits-case/
Bob Barr 2008. (2011). YouTube Video of Acceptance Speech for Libertarian Party Nomination for President. Retrieved March 25 2011 from http://www.youtube.com/watch? v=mjfDSPfL02w
Concerned Women for America (2011). CWA Defends The Defense of Marriage Act. Retrieved March 23 2011 from http://www.cwfa.org/content.asp?id=19878
DOMAwatch.org (2011). Legal Resource for News On Defense of Marriage Act. Retrieved March 25 2011 from http://www.domawatch.org/index.php
Family Research Counsel (2011). Search Results: Defense of Marriage Act. Retrieved March 23 2011 from http://www.frc.org/washingtonupdate/defending-doma-pros-and-leprechauns
Heritage Foundation (2011). Memo To White House, Don’t Stop, Start Defending DOMA. Retrieved March 24 2011 from http://blog.heritage.org/?p=52412
Human Rights Campaign (2011). Defense of Marriage Act FAQ. Retrieved March 22 2011 from
http://www.hrc.org/issues/marriage/15364.htm
Human Rights Campaign (2011). Respect for Marriage Act. Retrieved March 23 2011 from
http://www.hrc.org/issues/marriage/13530.htm
Lambda Legal (2011). Pending Legal Cases: Defense of Marriage Act. Retrieved March 22 2011 from http://www.lambdalegal.org/in-court/cases/baehr-v-miike.html
Lectric Law (2011). Summary of Defense of Marriage Act. H.R 3396. Retrieved March 20 2011 from http://www.lectlaw.com/files/leg23.htm
Library of Congress (2011). Bill Summary and Status of 104th Congress (95’-96’)
H.R 3396 Retrieved March 20 2011 from http://thomas.loc.gov/cgi-bin/bdquery/z d104:h3396:
Savage, Charlie and Stolberg, Gay Sheryl (2011). NY Times Online: In Shift, US Says Marriage Act Blocks Gay Rights. Retrieved March 23 2011 from http://www.nytimes.com/ 2011/02/24/us/24marriage.html_r=1&scp=1&sq=Defense%20of%20Marriage %20Act&st=cse
Monday, July 18, 2011
Sunday, July 17, 2011
Health Insurance Exchanges: Final Recommendations
Introduction
The Patient Protection and Affordable Care Act is a law which has changed health care in the United States. Yet over a year after the bill became law plenty of people still do not realize what has changed and how the law will affect their lives. Its name is long, but speaks to what the bill hopes provides; protection and affordability. After researching the health reform law over the semester, combined with course lectures and readings I have come to believe that the current health care law, but one including a strong public health insurance option, serves as the proper framework for health policy in America. I say this firmly believing in the ideals of federalism, and the fundamentals of public policy that I have learned. By that I mean the structure of reform being implemented in the current law is proper. It provides broad regulations and a minimum standard of care for States to follow, at the same allows for States to create their own rules governing the insurance exchanges created in the PPACA. Current health care law, but one including a strong public option, fits the logical, structural needs and the ideologically cautious political mood of the nation.
Why The Structure Of PPACA Works
Something was needed in order to gain bipartisan support of the health reform bill and the insurance exchanges are the basis for that support. As Robert Pear noted in his piece on health exchanges “the idea of an insurance exchange has bipartisan appeal” adding “liberals and conservatives alike see it as a way to concentrate the purchasing power of individuals and small businesses” (Pear, para 8, 9). The exchanges are “envisioned as a kind of ‘bazzar’ where insurers offer products side by side” (Pear, para 14). The bazzar Robert Pear refers to are in fact “structured web-based [insurance] markets” according to the Kansas Health Policy Authority (Allison). This website will be free and accessible to all and be required to be in operation in the States by 2014. Once functioning, all existing insurance regulations are to be required to be enforced (Allison).
The states have been granted the authority to decide how and who will run the insurance exchanges (Allison). This fact is far under reported and is important because the core purpose of the entity that runs the exchange will be to manage and rate plans according to quality and cost. Moreover the requirement of the exchange management entity to facilitate web-based determinations of eligibility for premium subsidies, as well as web-based selection and enrollment in health plans can work for or against public opinion of the health exchange depending on how they are managed.
The reasoning behind my position on this portion of my argument is two fold. First, this type of structure has worked at the state level before. There is a working model for a successful implementation of a health exchange for all 50 states. We also have two types of working models to choose to model from both offering distinct differences in approach; Utah and Mass (Pear). Second, the PPACA’s implementation is incremental in its approach according to Deborah Stone. If serious fluctuations were to happen quickly in the process of how health care became administered, the deductive argument against it is certainly the potential for a reduction in quality of care could occur (Stone). Frankly, The chance of that happening are just to great for any politician to take.
The Climate; Then And Now
A major factor in my decision to advocate for the current policy other all others was influenced by the highly partisan political environment the nation is currently experiencing. Ideology seems to have trumped practical reasoning in terms of crafting solutions to the problems the country faces. A Pew Research poll from April 2010 asked what issues US families talking about; second to the economy was health care reform. With health care consistently being one of the top issues Americans are interested in, something needed to be done to address the concerns of the public. Pew research again cites twenty seven percent, almost a quarter of the public polled, said they followed news of health reform closer than any other news story of 2009. This number accounts for all viewpoints, ideologies, and biases. I mention these figures to make the point that rancor from both Republicans and Democrats have seriously stunted the ability of our leaders to solve public policy problems Americans want solved.
The current implementation of the Patient Protection and Affordable Care has been undercut by a lack of enthusiasm from Democrats who were instrumental in its formulation. This current yet familiar reality is compounded by Republicans, who after the midterm elections, passed a health reform repeal bill which has gone nowhere in the Democratically controlled Senate. Moreover, the current partisan battle and concurrent House vote for Rep. Paul Ryan’s budget has pinned congressional Republicans against older constituents concerned about the future of the American Medicare system. The Ryan plan would fundamentally change the social contract from a premium for service structure to a voucher program. This is significant because the same anger and vitriol held toward Democrats before reform became law, is the same anger now held towards Republicans for their vote. A serious change to how health care is administered is a tough political, and practical policy to implement especially in the current climate.
A Strong Public Option
The position for a strong public option to be a insurance plan within the exchange framework was fought for by progressives and the President over the health care reform debate. I am one, however, who does feel that President Obama did not come out strong enough for the public option. As mentioned before, the debate over provisions in the final bill centered on falsehoods like “death panels” and the fake charge that the public option would amount to a government take-over of health care. The Pew Research found that over the debate fifty percent of people polled heard about the public option. The problem I feel is what they heard was not from the administration, but from surrogates or opponent. President Obama did make statements to the public specifically about health care fifty two times, most of which I saw. The public option was not the rallying cry for the President which I feel hurt the chances of it being established under the Patient Protection and Affordable Care Act.
My reasoning behind adding a public option to the current health care framework as the best course of action isn’t proven by an active model but my intimate involvement with the health care system. Due to medical conditions I am frequently having to make appointments, pay co-pays, and be seen by physician. Working or being a full time student with out a 9 - 5 job to help cover my health expenses have both proven difficult in dealing with insurance companies over the years. The loss of my employee-based health coverage and now being a part the Medicaid program in Maryland has been a decent experience, so my feeling about being on a federal instead of a state run plan is held in a favorable light.
Conclusion
Over the course of the semester I have been a student of the Patient Protection and Affordable Care Act while engaged in a intellectual conversation over how public policy is created in America. The redistributive nature of the policy tends to make it a progressive reform attempt. The PPACA has both positive and negative inducements to spur movement from the states and individuals to be proactive regarding compliance to the new law. The law is being implemented incrementally and holds true to the federalist system American public policy is known for. I am all for the current law and hope that progressive members are able to add a strong public option for Americans like me.
References Antos, Grace-Marie, Turner, Joseph R. (May 20, 2009) The GOP Health Alternative. Retrieved March 21, 2011 from http://online.wsj.com/article/SB124277551107536875.html
Catastrophic Health Insurance Plans (2011) Catastrophic Health Insurance Plans And Resources. Retrieved March 19, 2011 from http://www.catastrophichealthinsuranceplans.net catastrophiccoverage-explained
Conrad, Peter (2009) The Sociology Of Health And Illness. Eighth Edition. Retrieved March 21, 2011 New York, NY Worth Publishing.
CNNPolitics. (Aug 16, 2011) Democratic Senator: Public Insurance Option Dead. Retrieved March 19, 2011 from http://articles.cnn.com/2009-08-16/politics/us.healthcare_1_public option-insurance-option-health-care?_s=PM:POLITICS
Green Party of the United States. (2011) Green Party Platform. Retrieved March 17, 2011 from http://www.gp.org/platform/2004/socjustice.html#1004611
FamiliesUSA (2011) HSA’a Shop Til You Drop. Retrieved March 20, 2011 from
http://www.familiesusa.org/issues/private-insurance/hsas/health-savings-accounts.html
Heathcare.gov. (2011) Health Care.gov Glossary. Retrieved March 16, 2011 from
http://www.healthcare.gov/glossary/c/catastrophic.html
Health Care-now.org. (2011) What Is Single-Payer? Retrieved March 17, 2011 from
http://www.healthcare-now.org/hr-676/whats-single-payer/
Health Savings Account Info. (2011) Health Saving Info. Retrieved March 20, 2011 from
http://www.healthsavingsinfo.com/
Library of Congress. THOMAS. (2011) Bill Summary and Status of 111th & 112th Congress (2009-20012) H.R 676 Major Congressional Actions. Retrieved March 16 2011 from
http://thomas.loc.gov/cgi-bin/thomas
Mokhiber, Russell (Apr 16, 2009.) Top 10 Enemies of Single-Payer Retrieved March 15, 2011 from http://www.counterpunch.org/mokhiber04162009.html
O’Connor, Patrick. (Aug 4, 2009.) Liberal House Dems Hold Their Ground. Retrieved March 18, 2011 from Congressional Progressive Caucasus http://cpc.grijalva.house.gov/ index.cfm?sectionid=68&parentid=5§iontree=5,68&itemid=189
Rasmussen Reports (Jan 1, 2009) 34% Favor Single-Payer Health Care System. Retrieved March 19, 2011 from http://www.rasmussenreports.com/public_content/politics/current_events /healthcare/december_2009/34_favor_single_payer_health_care_system
Rasmussen Reports (Feb 25, 2010) 47% Opposed Public Option Health Plan. Retrieved March 19, 2011 http://www.rasmussenreports.com/public_content/politics/currentevents-
healthcarefebruary_2010/47oppose_public_option_health_plan_58_oppose_
if_workers_forced_to_change_coverage
Rubin, Donny (Mar 3, 2011) Health Savings Accounts. Retrieved March 20, 2011 from
http://www.therubins.com/ideas/hsa.htm
Shaw, Donny (Aug 20, 2009) What Is The Public Option. Retrieved March 16, 2011 from
http://www.opencongress.org/articles/view/1174--What-is-the-Public-Option-
Sreeizzle2012. (Dec 3, 2010) Single-Payer Is Ready To Go! Retrieved March 18, 2011 from http://www.dailykos.com/story/2010/12/03/925362/-Attention-Daily-kos-members-and -progressives!-single-payer-is-ready-to-go!
Stewart, et al. (2011) Public Policy: An Evolutionary Approach. Third Edition. Retrieved March 19, 2011 Thomas Wadsworth
WPTZ.com (March 25 2011) Vt. House Passes Single-Payer Health Care Bill. Retrieved March 19, 2011 from http://www.wptz.com/r/27317316/detail.html
The Patient Protection and Affordable Care Act is a law which has changed health care in the United States. Yet over a year after the bill became law plenty of people still do not realize what has changed and how the law will affect their lives. Its name is long, but speaks to what the bill hopes provides; protection and affordability. After researching the health reform law over the semester, combined with course lectures and readings I have come to believe that the current health care law, but one including a strong public health insurance option, serves as the proper framework for health policy in America. I say this firmly believing in the ideals of federalism, and the fundamentals of public policy that I have learned. By that I mean the structure of reform being implemented in the current law is proper. It provides broad regulations and a minimum standard of care for States to follow, at the same allows for States to create their own rules governing the insurance exchanges created in the PPACA. Current health care law, but one including a strong public option, fits the logical, structural needs and the ideologically cautious political mood of the nation.
Why The Structure Of PPACA Works
Something was needed in order to gain bipartisan support of the health reform bill and the insurance exchanges are the basis for that support. As Robert Pear noted in his piece on health exchanges “the idea of an insurance exchange has bipartisan appeal” adding “liberals and conservatives alike see it as a way to concentrate the purchasing power of individuals and small businesses” (Pear, para 8, 9). The exchanges are “envisioned as a kind of ‘bazzar’ where insurers offer products side by side” (Pear, para 14). The bazzar Robert Pear refers to are in fact “structured web-based [insurance] markets” according to the Kansas Health Policy Authority (Allison). This website will be free and accessible to all and be required to be in operation in the States by 2014. Once functioning, all existing insurance regulations are to be required to be enforced (Allison).
The states have been granted the authority to decide how and who will run the insurance exchanges (Allison). This fact is far under reported and is important because the core purpose of the entity that runs the exchange will be to manage and rate plans according to quality and cost. Moreover the requirement of the exchange management entity to facilitate web-based determinations of eligibility for premium subsidies, as well as web-based selection and enrollment in health plans can work for or against public opinion of the health exchange depending on how they are managed.
The reasoning behind my position on this portion of my argument is two fold. First, this type of structure has worked at the state level before. There is a working model for a successful implementation of a health exchange for all 50 states. We also have two types of working models to choose to model from both offering distinct differences in approach; Utah and Mass (Pear). Second, the PPACA’s implementation is incremental in its approach according to Deborah Stone. If serious fluctuations were to happen quickly in the process of how health care became administered, the deductive argument against it is certainly the potential for a reduction in quality of care could occur (Stone). Frankly, The chance of that happening are just to great for any politician to take.
The Climate; Then And Now
A major factor in my decision to advocate for the current policy other all others was influenced by the highly partisan political environment the nation is currently experiencing. Ideology seems to have trumped practical reasoning in terms of crafting solutions to the problems the country faces. A Pew Research poll from April 2010 asked what issues US families talking about; second to the economy was health care reform. With health care consistently being one of the top issues Americans are interested in, something needed to be done to address the concerns of the public. Pew research again cites twenty seven percent, almost a quarter of the public polled, said they followed news of health reform closer than any other news story of 2009. This number accounts for all viewpoints, ideologies, and biases. I mention these figures to make the point that rancor from both Republicans and Democrats have seriously stunted the ability of our leaders to solve public policy problems Americans want solved.
The current implementation of the Patient Protection and Affordable Care has been undercut by a lack of enthusiasm from Democrats who were instrumental in its formulation. This current yet familiar reality is compounded by Republicans, who after the midterm elections, passed a health reform repeal bill which has gone nowhere in the Democratically controlled Senate. Moreover, the current partisan battle and concurrent House vote for Rep. Paul Ryan’s budget has pinned congressional Republicans against older constituents concerned about the future of the American Medicare system. The Ryan plan would fundamentally change the social contract from a premium for service structure to a voucher program. This is significant because the same anger and vitriol held toward Democrats before reform became law, is the same anger now held towards Republicans for their vote. A serious change to how health care is administered is a tough political, and practical policy to implement especially in the current climate.
A Strong Public Option
The position for a strong public option to be a insurance plan within the exchange framework was fought for by progressives and the President over the health care reform debate. I am one, however, who does feel that President Obama did not come out strong enough for the public option. As mentioned before, the debate over provisions in the final bill centered on falsehoods like “death panels” and the fake charge that the public option would amount to a government take-over of health care. The Pew Research found that over the debate fifty percent of people polled heard about the public option. The problem I feel is what they heard was not from the administration, but from surrogates or opponent. President Obama did make statements to the public specifically about health care fifty two times, most of which I saw. The public option was not the rallying cry for the President which I feel hurt the chances of it being established under the Patient Protection and Affordable Care Act.
My reasoning behind adding a public option to the current health care framework as the best course of action isn’t proven by an active model but my intimate involvement with the health care system. Due to medical conditions I am frequently having to make appointments, pay co-pays, and be seen by physician. Working or being a full time student with out a 9 - 5 job to help cover my health expenses have both proven difficult in dealing with insurance companies over the years. The loss of my employee-based health coverage and now being a part the Medicaid program in Maryland has been a decent experience, so my feeling about being on a federal instead of a state run plan is held in a favorable light.
Conclusion
Over the course of the semester I have been a student of the Patient Protection and Affordable Care Act while engaged in a intellectual conversation over how public policy is created in America. The redistributive nature of the policy tends to make it a progressive reform attempt. The PPACA has both positive and negative inducements to spur movement from the states and individuals to be proactive regarding compliance to the new law. The law is being implemented incrementally and holds true to the federalist system American public policy is known for. I am all for the current law and hope that progressive members are able to add a strong public option for Americans like me.
References Antos, Grace-Marie, Turner, Joseph R. (May 20, 2009) The GOP Health Alternative. Retrieved March 21, 2011 from http://online.wsj.com/article/SB124277551107536875.html
Catastrophic Health Insurance Plans (2011) Catastrophic Health Insurance Plans And Resources. Retrieved March 19, 2011 from http://www.catastrophichealthinsuranceplans.net catastrophiccoverage-explained
Conrad, Peter (2009) The Sociology Of Health And Illness. Eighth Edition. Retrieved March 21, 2011 New York, NY Worth Publishing.
CNNPolitics. (Aug 16, 2011) Democratic Senator: Public Insurance Option Dead. Retrieved March 19, 2011 from http://articles.cnn.com/2009-08-16/politics/us.healthcare_1_public option-insurance-option-health-care?_s=PM:POLITICS
Green Party of the United States. (2011) Green Party Platform. Retrieved March 17, 2011 from http://www.gp.org/platform/2004/socjustice.html#1004611
FamiliesUSA (2011) HSA’a Shop Til You Drop. Retrieved March 20, 2011 from
http://www.familiesusa.org/issues/private-insurance/hsas/health-savings-accounts.html
Heathcare.gov. (2011) Health Care.gov Glossary. Retrieved March 16, 2011 from
http://www.healthcare.gov/glossary/c/catastrophic.html
Health Care-now.org. (2011) What Is Single-Payer? Retrieved March 17, 2011 from
http://www.healthcare-now.org/hr-676/whats-single-payer/
Health Savings Account Info. (2011) Health Saving Info. Retrieved March 20, 2011 from
http://www.healthsavingsinfo.com/
Library of Congress. THOMAS. (2011) Bill Summary and Status of 111th & 112th Congress (2009-20012) H.R 676 Major Congressional Actions. Retrieved March 16 2011 from
http://thomas.loc.gov/cgi-bin/thomas
Mokhiber, Russell (Apr 16, 2009.) Top 10 Enemies of Single-Payer Retrieved March 15, 2011 from http://www.counterpunch.org/mokhiber04162009.html
O’Connor, Patrick. (Aug 4, 2009.) Liberal House Dems Hold Their Ground. Retrieved March 18, 2011 from Congressional Progressive Caucasus http://cpc.grijalva.house.gov/ index.cfm?sectionid=68&parentid=5§iontree=5,68&itemid=189
Rasmussen Reports (Jan 1, 2009) 34% Favor Single-Payer Health Care System. Retrieved March 19, 2011 from http://www.rasmussenreports.com/public_content/politics/current_events /healthcare/december_2009/34_favor_single_payer_health_care_system
Rasmussen Reports (Feb 25, 2010) 47% Opposed Public Option Health Plan. Retrieved March 19, 2011 http://www.rasmussenreports.com/public_content/politics/currentevents-
healthcarefebruary_2010/47oppose_public_option_health_plan_58_oppose_
if_workers_forced_to_change_coverage
Rubin, Donny (Mar 3, 2011) Health Savings Accounts. Retrieved March 20, 2011 from
http://www.therubins.com/ideas/hsa.htm
Shaw, Donny (Aug 20, 2009) What Is The Public Option. Retrieved March 16, 2011 from
http://www.opencongress.org/articles/view/1174--What-is-the-Public-Option-
Sreeizzle2012. (Dec 3, 2010) Single-Payer Is Ready To Go! Retrieved March 18, 2011 from http://www.dailykos.com/story/2010/12/03/925362/-Attention-Daily-kos-members-and -progressives!-single-payer-is-ready-to-go!
Stewart, et al. (2011) Public Policy: An Evolutionary Approach. Third Edition. Retrieved March 19, 2011 Thomas Wadsworth
WPTZ.com (March 25 2011) Vt. House Passes Single-Payer Health Care Bill. Retrieved March 19, 2011 from http://www.wptz.com/r/27317316/detail.html
Health Exchanges - Policy Alternatives, Actor, Interests & Implementation
Policy Alternatives, Actor, Interests & Implementation
The health care policy debate was by no means a settled issue after President Obama signed the Patient Protection and Affordable Care Act (PPACA). Policy alternatives to the PPACA are insignificant and in just over a years time has pretty much come full circle. Using Stewart, Hedge & Lester’s political and ideological continuum, listing from left to right; a single-payer system, a “public option”, catastrophic coverage insurance, and private health savings accounts have at one point been seriously proposed as a policy solution to expand coverage, and to cut rising costs (Stewart, et al). Health insurance exchanges with an individual mandate fit tightly in the middle of those four alternatives. Republican’s control of message in the health care debate and gains in the 2010 elections have brought some of the more conservative alternatives to serious public debate. The following is an analysis of each of those alternative policy proposals, the vested actors and interests, and the likelihood of implementation.
Single-Payer
Since health care has been an issue on the popular (policy) agenda as a recurrent issue, the alternative proposals titles are for the most part familiar to most of Americans. The proposals are those that characterized the health care debate over the 2008 presidential election and heated health care town hall summer of 2009, except one - Single-Payer. Non-profit organization Healthcare-Now explains a single-payer system as “one entity—a government run organization—[that] would collect all healthcare fees, and pay out all healthcare costs (Healthcare-Now. para 1). “In a single-payer system, all hospitals, doctors, and other healthcare providers would bill one entity for their services” adding “everyone would receive comprehensive medical benefits” (Healthcare-Now, para 4 ). Using this framework the need for an easily accessible insurance exchange market wouldn’t exist because the government would be the sole insurer. It is noteworthy to mention that because most policy is implemented incrementally, shifting to single-payer would undoubtedly cause disruptions.
Traditionally it is the more progressive political parties, like the Green Party that favor a single-payer structure to receiving health care in the United States (Green, sec F, para 1.) Liberal Democrats too support a single-payer system. "A majority of [Progressive Caucasus] members prefer single payer," said liberal Democrat, Raul Grijalva of Arizona. In 2009 H.R 676 the “Expanded & Improved Medicare For All Act” was introduced to the 111th Congress in the House of Representatives by John Conyers of Michigan with 87 co-sponsors, including Grijalva on January 26th (Library of Congress). The following day it was referred to the House subcommittee on Health where it eventually died. Two years later, the same bill was introduced by Rep. Conyers Jr. to the 112th Congress and referred to the same committee where it “sits” currently with only 39 co-sponsors; including Rep Cummings of Maryland 7th District (Library of Congress).
Activists bloggers on left-wing sites like the Daily Kos mince no words about what will be needed to obtain a single-payer health care system. “Obviously, getting to single payer is a long-term project. It's not just about moving a piece of legislation; it's a movement. It's going to require ongoing commitment, an enormous amount of effort, organizing, and education (Kos, para 3). The sentiment expressed speaks to the hard work needed to fulfill implementation of a single-payer system for all. An “enemies of single-payer” list was comprised with organizations like AARP, Kaiser Family Foundation, Lewin Group, PHRMA each of whom has a vested interest to keep the current private insurance market (Mokhiber). In terms of public opinion, in a January 1st 2010 Rasmussen Poll reports 34% of voters nationwide favor a single-payer health care system, 54% oppose and 14% are not sure (Rasmussen). However Vermont has chosen to reject that framework completely, by their House passing single-payer legislation (WPTZ) .
The “Public Option”
The public option [...] is a government-run health insurance plan, like Medicare, that would compete along side private insurers in a new health insurance exchange that the [PPACA] set up” (Shaw, para 2). A government insurance option has been on popular agenda for about as long as Medicare for all has been on the agenda. What’s the distinction? Health exchanges. “With a significant feature of the insurance exchanges [being] a public plan, the controversy [...] centers upon the extent to which [the public option] could compete with private insurance plans (Shaw, para ?). It was broad agreement between centrist Democrats and moderate Republicans in Congress on replacing the current system with non-profit insurance co-ops (exchanges) that pushed the public plan, an “option” in the exchange(s) to the front burner of the partisan health care debate (Shaw, para 1).
In late August 2009, President Obama gave his weekly web address. In it he took time and effort to “debunk” myths surrounding the health care debate. By that time the public option had the stained “government takeover of health care” perception, and Mr. Obama was trying to clear it up (Obama video). “This is one idea among many to provide more competition and choice especially in the many places where one insurer dominates the market place” (Obama video). “This alternative would have to operate like other insurers on the basis of the premiums it collects” adding “let me repeat, this is just and option” (Obama video). Interestingly, health exchanges did not arise to the level of controversy and were not discussed; most members of Congress who were honest brokers in the negotiations agreed health exchanges were a bridge to achievement.
The controversial “public option” was advocated for by President Obama’s in his health care reform attempt of 2009/2010 . The Democratic controlled House of Representatives of the 111th Congress passed their version of health care reform H.R 3962 that included a public option on November 7th 2009 (Library of Congress). However, most senate Republicans and a handful of conservative senate Democrats were not sure that voting for a “public option” was in their political interest. H.R 3962 was not working model for the senate bill. The “public option” so hoped for by progressives died in the US Senate. “The fact of the matter is there are not the votes in the United States Senate for a public option” (Conrad, para 1). “There never have been", conservative Democrat Kent Conrad in August 2009 (Conrad, para 1). Last month in a public opinion poll, Rasmussen reports (a significantly high) 47% opposed the public option (Rassmuen).
Catastrophic Coverage
“Cost of catastrophic illness” language found its way into a 1986 proposal during the second Reagan administration attempt to expand Medicare (Conrad, p. 311). In February 1987, a catastrophic care plan was sent to Congress with endorsement of the major provider groups like The American Hospital Association (Conrad, p. 311). On July 1st 1988 Congress enacted the Medicare Catastrophic Coverage Act with huge bi-partisan majorities in both houses of Congress (Conrad, p. 311). The bill capped the amount beneficiaries would have to pay for hospital and physician care, amongst other provisions (Conrad, p. 311). While the term is the same from the late 80’s the definition has since evolved.
Catastrophic insurance coverage currently is an option in the private insurance market. According to Catastrophic Health Insurance Plans, an online informational source, catastrophic coverage is also called a “high deductible health plan” (CHIP.net) because it’s characterized by low monthly premiums, but deductibles that can range between $1,500 and $5000, with a minimum of $500 (CHIP.net, para 2). “Some insurers describe these plans as those that only cover certain types of expensive care, like hospitalizations” (Healthcare.gov).
“There are two basic types of catastrophic plan: comprehensive and supplemental” (Jeffries, para 4). A comprehensive plan offers coverage comparable to more traditional health care plans” adding” there is still a high deductible and monthly fees are still relatively low” (Jeffries, para 4). A supplemental plan [...] acts as a supplement to other insurance plans (Jeffries, para 4). This type of alternative does not directly challenge health exchanges, but neither does the public option. In fact, catastrophic coverage would likely challenge the public option in terms of cost cutting for healthy individuals within the exchange structure. A hard number of exactly how many Americans currently hold catastrophic coverage has remained elusive in my research.
Private Health Savings Accounts
“A health savings account (HSA) are tax sheltered savings accounts coupled with high deductible health insurance plans (FamiliesUSA, para 1). [A]n alternative to comprehensive health insurance [like catastrophic coverage]; it is a savings vehicle that allows people a different way to pay for their health care (HSAI.com, para 1). However, in many cases “you must be covered by a High Deductible Health Plan (HDHP) to be able to take advantage of HSAs (HSAI.com, para 5). Using a Guy Peters typology, HSA’s would fall under a craftsmen type of policy due to a low knowledge level of the number of people who would actually participate positively and effectively in the plan, couple with the high knowledge of causation of why a different approach is need to address the current systems problems.
In the past Health Savings Accounts (HSAs) [were] promoted by President Bush and conservatives in Congress as a way to bring down spiraling health care costs. “Only if consumers have "skin in the game," they argue, will Americans start to shop around for cheaper health care” (FamiliesUSA, para 1). Currently, “four Republicans in Congress -- Sens. Tom Coburn (Oklahoma) and Richard Burr (North Carolina) and Reps. Paul Ryan (Wisconsin) and Devin Nunes (California) introduced [the] Patients' Choice Act, it provides a path to universal coverage by redirecting current subsidies for health insurance to individuals. It also provides a new safety net that guarantees access to insurance for those with pre-existing conditions by redirecting the $300 billion annual tax subsidy for employment-based health insurance to individuals in the form of refundable, advance-able tax credits. Families would get $5,700 a year and individuals $2,300 to buy insurance and invest in HSAs (Antos and Turner, para, 3).
In 2008 Sen. John McCain offered a similar plan as his health reform proposals when he ran for the presidency (webMD). That model was roundly rejected for a more ideological, liberal, procedural, redistributive, and (controversially) regulatory policy approach. Again health savings accounts in terms of a true alternative to the exchanges of the PPACA do not match up. Chances are they will be offered as in option within the state exchange framework. Whereas “the [...] debate in Congress reform generated many proposals [on both sides] to change the rules on HSA’s, nothing seriously was done to the fundamentally change the structure and understanding of HSA’s Allan Rubin notes that “more than 10 million people are enrolled in high-deductible health plans linked to HSA, up from 6.1 million in 2008, according to a recent survey by America's Health Insurance Plans, an industry trade group (Rubins, para 7).
Conclusion
In an issue area as large as health care, when so many stakeholders and interest groups jockey to control the crafting of policy, legislators prefer to formulate incremental implementation. The common yet different alternatives to the health exchanges of the current health care reform law, with exception of single-payer, do not remove health exchanges as the compromise framework for health reform. The reason health exchanges trumped all others is due to both positive and negative inducement found in the law. Having both types of inducements in the PPACA it won enough bi-partisan support to pass both houses of Congress.
References Antos, Grace-Marie, Turner, Joseph R. (May 20, 2009) The GOP Health Alternative. Retrieved March 21, 2011 from http://online.wsj.com/article/SB124277551107536875.html
Catastrophic Health Insurance Plans (2011) Catastrophic Health Insurance Plans And Resources. Retrieved March 19, 2011 from http://www.catastrophichealthinsuranceplans.net catastrophiccoverage-explained
Conrad, Peter (2009) The Sociology Of Health And Illness. Eighth Edition. Retrieved March 21, 2011 New York, NY Worth Publishing.
CNNPolitics. (Aug 16, 2011) Democratic Senator: Public Insurance Option Dead. Retrieved March 19, 2011 from http://articles.cnn.com/2009-08-16/politics/us.healthcare_1_public option-insurance-option-health-care?_s=PM:POLITICS
Green Party of the United States. (2011) Green Party Platform. Retrieved March 17, 2011 from http://www.gp.org/platform/2004/socjustice.html#1004611
FamiliesUSA (2011) HSA’a Shop Til You Drop. Retrieved March 20, 2011 from
http://www.familiesusa.org/issues/private-insurance/hsas/health-savings-accounts.html
Heathcare.gov. (2011) Health Care.gov Glossary. Retrieved March 16, 2011 from
http://www.healthcare.gov/glossary/c/catastrophic.html
Health Care-now.org. (2011) What Is Single-Payer? Retrieved March 17, 2011 from
http://www.healthcare-now.org/hr-676/whats-single-payer/
Health Savings Account Info. (2011) Health Saving Info. Retrieved March 20, 2011 from
http://www.healthsavingsinfo.com/
Library of Congress. THOMAS. (2011) Bill Summary and Status of 111th & 112th Congress (2009-20012) H.R 676 Major Congressional Actions. Retrieved March 16 2011 from
http://thomas.loc.gov/cgi-bin/thomas
Mokhiber, Russell (Apr 16, 2009.) Top 10 Enemies of Single-Payer Retrieved March 15, 2011 from http://www.counterpunch.org/mokhiber04162009.html
O’Connor, Patrick. (Aug 4, 2009.) Liberal House Dems Hold Their Ground. Retrieved March 18, 2011 from Congressional Progressive Caucasus http://cpc.grijalva.house.gov/ index.cfm?sectionid=68&parentid=5§iontree=5,68&itemid=189
Rasmussen Reports (Jan 1, 2009) 34% Favor Single-Payer Health Care System. Retrieved March 19, 2011 from http://www.rasmussenreports.com/public_content/politics/current_events /healthcare/december_2009/34_favor_single_payer_health_care_system
Rasmussen Reports (Feb 25, 2010) 47% Opposed Public Option Health Plan. Retrieved March 19, 2011 http://www.rasmussenreports.com/public_content/politics/currentevents-
healthcarefebruary_2010/47oppose_public_option_health_plan_58_oppose_
if_workers_forced_to_change_coverage
Rubin, Donny (Mar 3, 2011) Health Savings Accounts. Retrieved March 20, 2011 from
http://www.therubins.com/ideas/hsa.htm
Shaw, Donny (Aug 20, 2009) What Is The Public Option. Retrieved March 16, 2011 from
http://www.opencongress.org/articles/view/1174--What-is-the-Public-Option-
Sreeizzle2012. (Dec 3, 2010) Single-Payer Is Ready To Go! Retrieved March 18, 2011 from http://www.dailykos.com/story/2010/12/03/925362/-Attention-Daily-kos-members-and -progressives!-single-payer-is-ready-to-go!
Stewart, et al. (2011) Public Policy: An Evolutionary Approach. Third Edition. Retrieved March 19, 2011 Thomas Wadsworth
WPTZ.com (March 25 2011) Vt. House Passes Single-Payer Health Care Bill. Retrieved March 19, 2011 from http://www.wptz.com/r/27317316/detail.html
The health care policy debate was by no means a settled issue after President Obama signed the Patient Protection and Affordable Care Act (PPACA). Policy alternatives to the PPACA are insignificant and in just over a years time has pretty much come full circle. Using Stewart, Hedge & Lester’s political and ideological continuum, listing from left to right; a single-payer system, a “public option”, catastrophic coverage insurance, and private health savings accounts have at one point been seriously proposed as a policy solution to expand coverage, and to cut rising costs (Stewart, et al). Health insurance exchanges with an individual mandate fit tightly in the middle of those four alternatives. Republican’s control of message in the health care debate and gains in the 2010 elections have brought some of the more conservative alternatives to serious public debate. The following is an analysis of each of those alternative policy proposals, the vested actors and interests, and the likelihood of implementation.
Single-Payer
Since health care has been an issue on the popular (policy) agenda as a recurrent issue, the alternative proposals titles are for the most part familiar to most of Americans. The proposals are those that characterized the health care debate over the 2008 presidential election and heated health care town hall summer of 2009, except one - Single-Payer. Non-profit organization Healthcare-Now explains a single-payer system as “one entity—a government run organization—[that] would collect all healthcare fees, and pay out all healthcare costs (Healthcare-Now. para 1). “In a single-payer system, all hospitals, doctors, and other healthcare providers would bill one entity for their services” adding “everyone would receive comprehensive medical benefits” (Healthcare-Now, para 4 ). Using this framework the need for an easily accessible insurance exchange market wouldn’t exist because the government would be the sole insurer. It is noteworthy to mention that because most policy is implemented incrementally, shifting to single-payer would undoubtedly cause disruptions.
Traditionally it is the more progressive political parties, like the Green Party that favor a single-payer structure to receiving health care in the United States (Green, sec F, para 1.) Liberal Democrats too support a single-payer system. "A majority of [Progressive Caucasus] members prefer single payer," said liberal Democrat, Raul Grijalva of Arizona. In 2009 H.R 676 the “Expanded & Improved Medicare For All Act” was introduced to the 111th Congress in the House of Representatives by John Conyers of Michigan with 87 co-sponsors, including Grijalva on January 26th (Library of Congress). The following day it was referred to the House subcommittee on Health where it eventually died. Two years later, the same bill was introduced by Rep. Conyers Jr. to the 112th Congress and referred to the same committee where it “sits” currently with only 39 co-sponsors; including Rep Cummings of Maryland 7th District (Library of Congress).
Activists bloggers on left-wing sites like the Daily Kos mince no words about what will be needed to obtain a single-payer health care system. “Obviously, getting to single payer is a long-term project. It's not just about moving a piece of legislation; it's a movement. It's going to require ongoing commitment, an enormous amount of effort, organizing, and education (Kos, para 3). The sentiment expressed speaks to the hard work needed to fulfill implementation of a single-payer system for all. An “enemies of single-payer” list was comprised with organizations like AARP, Kaiser Family Foundation, Lewin Group, PHRMA each of whom has a vested interest to keep the current private insurance market (Mokhiber). In terms of public opinion, in a January 1st 2010 Rasmussen Poll reports 34% of voters nationwide favor a single-payer health care system, 54% oppose and 14% are not sure (Rasmussen). However Vermont has chosen to reject that framework completely, by their House passing single-payer legislation (WPTZ) .
The “Public Option”
The public option [...] is a government-run health insurance plan, like Medicare, that would compete along side private insurers in a new health insurance exchange that the [PPACA] set up” (Shaw, para 2). A government insurance option has been on popular agenda for about as long as Medicare for all has been on the agenda. What’s the distinction? Health exchanges. “With a significant feature of the insurance exchanges [being] a public plan, the controversy [...] centers upon the extent to which [the public option] could compete with private insurance plans (Shaw, para ?). It was broad agreement between centrist Democrats and moderate Republicans in Congress on replacing the current system with non-profit insurance co-ops (exchanges) that pushed the public plan, an “option” in the exchange(s) to the front burner of the partisan health care debate (Shaw, para 1).
In late August 2009, President Obama gave his weekly web address. In it he took time and effort to “debunk” myths surrounding the health care debate. By that time the public option had the stained “government takeover of health care” perception, and Mr. Obama was trying to clear it up (Obama video). “This is one idea among many to provide more competition and choice especially in the many places where one insurer dominates the market place” (Obama video). “This alternative would have to operate like other insurers on the basis of the premiums it collects” adding “let me repeat, this is just and option” (Obama video). Interestingly, health exchanges did not arise to the level of controversy and were not discussed; most members of Congress who were honest brokers in the negotiations agreed health exchanges were a bridge to achievement.
The controversial “public option” was advocated for by President Obama’s in his health care reform attempt of 2009/2010 . The Democratic controlled House of Representatives of the 111th Congress passed their version of health care reform H.R 3962 that included a public option on November 7th 2009 (Library of Congress). However, most senate Republicans and a handful of conservative senate Democrats were not sure that voting for a “public option” was in their political interest. H.R 3962 was not working model for the senate bill. The “public option” so hoped for by progressives died in the US Senate. “The fact of the matter is there are not the votes in the United States Senate for a public option” (Conrad, para 1). “There never have been", conservative Democrat Kent Conrad in August 2009 (Conrad, para 1). Last month in a public opinion poll, Rasmussen reports (a significantly high) 47% opposed the public option (Rassmuen).
Catastrophic Coverage
“Cost of catastrophic illness” language found its way into a 1986 proposal during the second Reagan administration attempt to expand Medicare (Conrad, p. 311). In February 1987, a catastrophic care plan was sent to Congress with endorsement of the major provider groups like The American Hospital Association (Conrad, p. 311). On July 1st 1988 Congress enacted the Medicare Catastrophic Coverage Act with huge bi-partisan majorities in both houses of Congress (Conrad, p. 311). The bill capped the amount beneficiaries would have to pay for hospital and physician care, amongst other provisions (Conrad, p. 311). While the term is the same from the late 80’s the definition has since evolved.
Catastrophic insurance coverage currently is an option in the private insurance market. According to Catastrophic Health Insurance Plans, an online informational source, catastrophic coverage is also called a “high deductible health plan” (CHIP.net) because it’s characterized by low monthly premiums, but deductibles that can range between $1,500 and $5000, with a minimum of $500 (CHIP.net, para 2). “Some insurers describe these plans as those that only cover certain types of expensive care, like hospitalizations” (Healthcare.gov).
“There are two basic types of catastrophic plan: comprehensive and supplemental” (Jeffries, para 4). A comprehensive plan offers coverage comparable to more traditional health care plans” adding” there is still a high deductible and monthly fees are still relatively low” (Jeffries, para 4). A supplemental plan [...] acts as a supplement to other insurance plans (Jeffries, para 4). This type of alternative does not directly challenge health exchanges, but neither does the public option. In fact, catastrophic coverage would likely challenge the public option in terms of cost cutting for healthy individuals within the exchange structure. A hard number of exactly how many Americans currently hold catastrophic coverage has remained elusive in my research.
Private Health Savings Accounts
“A health savings account (HSA) are tax sheltered savings accounts coupled with high deductible health insurance plans (FamiliesUSA, para 1). [A]n alternative to comprehensive health insurance [like catastrophic coverage]; it is a savings vehicle that allows people a different way to pay for their health care (HSAI.com, para 1). However, in many cases “you must be covered by a High Deductible Health Plan (HDHP) to be able to take advantage of HSAs (HSAI.com, para 5). Using a Guy Peters typology, HSA’s would fall under a craftsmen type of policy due to a low knowledge level of the number of people who would actually participate positively and effectively in the plan, couple with the high knowledge of causation of why a different approach is need to address the current systems problems.
In the past Health Savings Accounts (HSAs) [were] promoted by President Bush and conservatives in Congress as a way to bring down spiraling health care costs. “Only if consumers have "skin in the game," they argue, will Americans start to shop around for cheaper health care” (FamiliesUSA, para 1). Currently, “four Republicans in Congress -- Sens. Tom Coburn (Oklahoma) and Richard Burr (North Carolina) and Reps. Paul Ryan (Wisconsin) and Devin Nunes (California) introduced [the] Patients' Choice Act, it provides a path to universal coverage by redirecting current subsidies for health insurance to individuals. It also provides a new safety net that guarantees access to insurance for those with pre-existing conditions by redirecting the $300 billion annual tax subsidy for employment-based health insurance to individuals in the form of refundable, advance-able tax credits. Families would get $5,700 a year and individuals $2,300 to buy insurance and invest in HSAs (Antos and Turner, para, 3).
In 2008 Sen. John McCain offered a similar plan as his health reform proposals when he ran for the presidency (webMD). That model was roundly rejected for a more ideological, liberal, procedural, redistributive, and (controversially) regulatory policy approach. Again health savings accounts in terms of a true alternative to the exchanges of the PPACA do not match up. Chances are they will be offered as in option within the state exchange framework. Whereas “the [...] debate in Congress reform generated many proposals [on both sides] to change the rules on HSA’s, nothing seriously was done to the fundamentally change the structure and understanding of HSA’s Allan Rubin notes that “more than 10 million people are enrolled in high-deductible health plans linked to HSA, up from 6.1 million in 2008, according to a recent survey by America's Health Insurance Plans, an industry trade group (Rubins, para 7).
Conclusion
In an issue area as large as health care, when so many stakeholders and interest groups jockey to control the crafting of policy, legislators prefer to formulate incremental implementation. The common yet different alternatives to the health exchanges of the current health care reform law, with exception of single-payer, do not remove health exchanges as the compromise framework for health reform. The reason health exchanges trumped all others is due to both positive and negative inducement found in the law. Having both types of inducements in the PPACA it won enough bi-partisan support to pass both houses of Congress.
References Antos, Grace-Marie, Turner, Joseph R. (May 20, 2009) The GOP Health Alternative. Retrieved March 21, 2011 from http://online.wsj.com/article/SB124277551107536875.html
Catastrophic Health Insurance Plans (2011) Catastrophic Health Insurance Plans And Resources. Retrieved March 19, 2011 from http://www.catastrophichealthinsuranceplans.net catastrophiccoverage-explained
Conrad, Peter (2009) The Sociology Of Health And Illness. Eighth Edition. Retrieved March 21, 2011 New York, NY Worth Publishing.
CNNPolitics. (Aug 16, 2011) Democratic Senator: Public Insurance Option Dead. Retrieved March 19, 2011 from http://articles.cnn.com/2009-08-16/politics/us.healthcare_1_public option-insurance-option-health-care?_s=PM:POLITICS
Green Party of the United States. (2011) Green Party Platform. Retrieved March 17, 2011 from http://www.gp.org/platform/2004/socjustice.html#1004611
FamiliesUSA (2011) HSA’a Shop Til You Drop. Retrieved March 20, 2011 from
http://www.familiesusa.org/issues/private-insurance/hsas/health-savings-accounts.html
Heathcare.gov. (2011) Health Care.gov Glossary. Retrieved March 16, 2011 from
http://www.healthcare.gov/glossary/c/catastrophic.html
Health Care-now.org. (2011) What Is Single-Payer? Retrieved March 17, 2011 from
http://www.healthcare-now.org/hr-676/whats-single-payer/
Health Savings Account Info. (2011) Health Saving Info. Retrieved March 20, 2011 from
http://www.healthsavingsinfo.com/
Library of Congress. THOMAS. (2011) Bill Summary and Status of 111th & 112th Congress (2009-20012) H.R 676 Major Congressional Actions. Retrieved March 16 2011 from
http://thomas.loc.gov/cgi-bin/thomas
Mokhiber, Russell (Apr 16, 2009.) Top 10 Enemies of Single-Payer Retrieved March 15, 2011 from http://www.counterpunch.org/mokhiber04162009.html
O’Connor, Patrick. (Aug 4, 2009.) Liberal House Dems Hold Their Ground. Retrieved March 18, 2011 from Congressional Progressive Caucasus http://cpc.grijalva.house.gov/ index.cfm?sectionid=68&parentid=5§iontree=5,68&itemid=189
Rasmussen Reports (Jan 1, 2009) 34% Favor Single-Payer Health Care System. Retrieved March 19, 2011 from http://www.rasmussenreports.com/public_content/politics/current_events /healthcare/december_2009/34_favor_single_payer_health_care_system
Rasmussen Reports (Feb 25, 2010) 47% Opposed Public Option Health Plan. Retrieved March 19, 2011 http://www.rasmussenreports.com/public_content/politics/currentevents-
healthcarefebruary_2010/47oppose_public_option_health_plan_58_oppose_
if_workers_forced_to_change_coverage
Rubin, Donny (Mar 3, 2011) Health Savings Accounts. Retrieved March 20, 2011 from
http://www.therubins.com/ideas/hsa.htm
Shaw, Donny (Aug 20, 2009) What Is The Public Option. Retrieved March 16, 2011 from
http://www.opencongress.org/articles/view/1174--What-is-the-Public-Option-
Sreeizzle2012. (Dec 3, 2010) Single-Payer Is Ready To Go! Retrieved March 18, 2011 from http://www.dailykos.com/story/2010/12/03/925362/-Attention-Daily-kos-members-and -progressives!-single-payer-is-ready-to-go!
Stewart, et al. (2011) Public Policy: An Evolutionary Approach. Third Edition. Retrieved March 19, 2011 Thomas Wadsworth
WPTZ.com (March 25 2011) Vt. House Passes Single-Payer Health Care Bill. Retrieved March 19, 2011 from http://www.wptz.com/r/27317316/detail.html
Sunday, April 3, 2011
Health Exchanges and the Affordable Care Act of 2010
Health Exchanges and the Affordable Care Act of 2010
Health care policy, depending on which side of the political idealogical line one falls on, is typically accompanied by a viewpoint of the current system and also how government affects it. Liberals have historically viewed health care as a “right”. Conservatives favor the status quo; health care as a luxury. However both sides do broadly agree the current system needs reform. The question becomes what, if anything, could be the policy solution? Ezra Kline, columnist for the Washington Post notes that the health exchange provisions in the Affordable Care Act “attempt to bridge the gap between the healthcare most want to have, and the healthcare we have now” (Kline, 2009. para 2). Healthcare.gov (2011) describe an exchange as “[...] a mechanism for organizing the health insurance marketplace to help consumers and small businesses shop for coverage in a way that permits easy comparison of available plan options based on price, benefits and services, and quality (para 2).
Using Deborah Stone’s policy solution definitions; a state insurance exchange in essence are new federal “rules” governing (organizing) how states offer an individual health insurance. So the problem health exchanges seek to address are two fold. First, health exchanges provide individuals and small businesses shut out of the market more purchasing power, “represent[ing] the core of the insurance market reforms” (Allison, p. 1). Second, exchanges “are also a lynchpin for the coverage expansions in health reform" which address overhead cost to the nation (Allison, p. 1). What’s the history of health care public policy leading up to health exchanges in the ACA, you ask? Briefly:
After World War II most industrialized nations adopted universal health care systems while the United States opted for a employer-based private insurance market (Clemmit, p. 11). In 1943 the “Wagner-Murray-Dingell bill for compulsory national health insurance is introduced in Congress (Clemmit, p. 11). Around that time [the] “National War Labor Board declares employer contributions to insurance are income-tax free, opening the way for companies to use health insurance packages to attract workers” (Clemmit, p. 11). Still then “members of Congress made unsuccessful attempts to launch discussion of health coverage for all in 1943, 1945, 1947, 1949 and 1957, and Presidents Franklin D. Roosevelt, Harry S. Truman, Richard M. Nixon [...] all proposed guaranteed universal coverage.(Clemmit, p. 11).
Since the late 1950’s Congress has passed laws, though narrowly in most cases, regulating insurance coverage to elderly, and low income children. President Johnson signed the Social Security Act of 1965 establishing the Medicare and Medicaid systems (Clemmit, p. 11). In 1993, First Lady Hillary Clinton failed in her attempt to help pass sweeping healthcare reform (Clemmit, p. 11). Four years later President Clinton signed the State CHIP bill in 1997, extending health insurance through state programs to qualified children of low-income, but insured families (Clemmit, p. 11). Over fifty years, the health care policy debate evolved from just examining the proper role of government in providing health care, to how it can better address the “spill over” effects like rising cost created by the nations current health care system.
CQ Researcher Marcia Clemmit penned a lengthy journal on health care in 2010. She summed up the problem of cost to the nation in chronology of policy on health care. According to Clemmit, in the 1960’s health care spending [totaled] $28 billion, or 5.2 percent of gross domestic product (Clemmit, p.11). By the 1980‘s “health spending [totaled] $255 billion, or 9.1 percent of GDP (Clemmit, p.11). And by the year 2000, “health spending [totaled] $1.4 trillion, or 13.8 percent of GDP (Clemmit, p.11). These figures expose forty years of rising national expense in health care in the United States.
To expose the rising cost to individuals in addition to the nation, advocate groups (HealthCareProblems.org, 2011) began to document “accounts of problems with the U.S. health care system from people involved in every aspect of the system”(HCP.org). Ten years after the failed Clinton attempt, “a Kaiser Family Foundation poll reported 28 percent of middle income families (annual family income between $30,000 and $75,000) stated that they were currently having a serious problem paying for healthcare or health insurance” (HCP.org). Another report states “in 2007, nearly 50 million Americans did not have health insurance, while another 25 million were underinsured”, and that “Healthcare expenditures in the United States exceed $2 trillion a year (HCP.org). “Healthcare is one of the top social and economic problems facing Americans today”; adding “the inability to pay for necessary medical care is no longer a problem affecting only the uninsured, but is increasingly becoming a problem for those with health insurance as well” (HCP.org).
By 2007, most invested politicians, political interest groups, and Americans agreed that there was a problem surrounding rising cost in association with uninsured Americans receiving (in most cases) emergency, triage medical assistance. The problem was how to extend coverage to the uninsured and reduce out-of-pocket expense without a complete revamping of the current system? Barack Obama’s successful candidacy for president in 2008 initiated speculation in the medical community and the American public about the future of healthcare reform proposals. (Boyles, 2008, para 1.). In a webMD article dated November 5th 2008 by Salynn Boyles, she signifies that Obama “ushers in a new administration that is all but certain to include some level of health care reform. Less clear is how extensive that reform [will be]” (Boyles, 2008, para 2). She added that Obama “has proposed sweeping changes in the health care system designed to provide health coverage to millions of uninsured” (Boyles, 2008, para 3). In her webMD piece, Boyles mentions the health insurance exchanges as part of the reforms Obama wants enact. After taking office in January 2009, President Obama called the five Congressional Committees that govern the legislative areas of health care to offer bills (Obama, 2009 para 15.).
By June 2009 Ezra Kline points out that “the most important aspect of [Obama’s] health reform [...] would be the health insurance exchanges” (Kline, 2009 para. 1). “Massachusetts has a variant called the ‘Connector’(Kline, 2009 para 2.) . “Ted Kennedy's bill talked about Gateways. Ron Wyden and Bob Bennett's legislation calls for Health Help Agencies”(Kline, 2009 para 2.). “But the concept itself is [the same] (Kline, 2009. para 2). President Obama push hard for health insurance reform in a special address to a joint session of Congress on September 9th 2009. He began by acknowledging the work Congress has done, saying that four out of the five committees had “finished there work, and the Senate Finance Committee will call a vote next week” (Obama, 2009 para 15.). Signaling that the legislative process had never reach that point before. Mr. Obama began to make the case for why healthcare reform was so important to the nation. “ Simply put”, he said, “our health care problem is are deficit problem; nothing else comes close” (Obama, 2009 para 12.). Adding “we know we must reform this system. The question is how” (Obama, 2009. para 16.). He laid out to the American people the three points he sees as a solution and wants to see in the final bill. His second point was the insurance exchange provision for all uninsured Americans.
A Democratic Policy Committee (2009) bulletin lays out the legislative history of the final bill. Starting “on September 17, 2009, Rep. Rangel introduced H.R. 3590, (para 71). “On October 8, 2009, the House passed H.R. 3590 by a vote of 416-0, and [...] was placed on the Senate Legislative Calendar” (para 71). “H.R. 3590 is the legislative vehicle for consideration of the Patient Protection and Affordable Care Act of 2009” (para 72). “On November 18, 2009, Senators Reid, Baucus, Dodd, and Harkin proposed the Patient Protection and Affordable Care Act as an amendment in the nature of a substitute to H.R. 3590” (para 72). “Senator Reid filed cloture on the motion to proceed to the bill on November 19, 2009 and the Senate began consideration of the motion on November 20, 2009” (para 72). According to the Library of Congress, the Senate voted to pass H.R. 3590 on December 24th 2009 with changes, to the House for final passage (Thomas.loc.gov) On March 21st 2010 the House passed H.R 3590 with Senate changes and on March 23rd 2010 President Obama sign it into law (Thomas.loc.gov). What emerged through the policy process was the Patient Protection and Affordable Care Act. Under Section 1311(b) of the ACA is a provision to require states to establish Health Insurance Exchanges (Healthcare.gov).
Prior to becoming law, heated rhetoric on health care reform was primarily directed at other provisions of the reform bill like the ‘end of life counseling’ proposal - demonized as ‘death panels’ by right-wingers. But especially the individual mandate “which requires all individuals to purchase government-controlled health insurance” (Kibbe para 8). Fox News’ Matt Kibbe, wrote that “Obamacare’s core elements -- the mandates, exchanges, and subsidies (including the massive Medicaid expansion) -- are all interconnected” (Kibbe para 8). The individual mandate, affectionally called ‘The Death Star’ by Kibbe, is the “one critical weakness [of the law]” adding “[R]epeal just this section, and the rest of the law comes apart” (Kibbe para 9). To those who oppose the reform bill the exchanges are ‘guilty by association’. Vested corporate opponents of the ACA, according to Money and Politics, include the following organizations: American Petroleum, Pharmaceutical Research and Manufactures of America, U.S Chamber of Commerce, and National Retail Federation, amongst many others (MAPLight.org). In general they opposed the individual mandate, first, then the exchanges.
However as noted in a NY Times article the idea of an insurance exchange as a public policy solution is not new and carries bi-partisan support in Congress (Pear 2010. para 11). NY Times writer Robert Pear cites agreement about exchanges among “liberals and conservatives [...] as a way to concentrate the purchasing power of individuals and small businesses (Pear 2010. para 12). President Obama characterized the exchanges as a “a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices.”(Obama 2009. para 19). The real battle over health exchanges did not come from Congressional Republicans, it’s coming from GOP Governors.
In a letter from twenty one conservative governors to the Obama administration they write “we believe the system proposed by the PPACA is seriously flawed, favors dependency over personal responsibility, and will ultimately destroy the private insurance market (Bentley et al., 2011). The letter lists several changes they would like to see to the exchange provisions. They include more authority for states to choose benefits that meet there citizens needs, waive[r] provisions that discriminate against health insurance arrangements that include health savings accounts or reimbursement, a plan for verifying incomes and subsidy for exchange participants, [and] calls for neutral third-party research organization to conduct a study to asses how many people will “offload” into the exchanges (Bentley et al., 2011) “The governors are warning that [they] will give HHS full responsibility for setting up and running the exchanges in their states”(Postal 2010 para 2).
How would insurance exchanges affect the market place and look in operation? In Massachusetts and Utah their are functioning models with different approaches. In an October 2010 NY Times column by Robert Pear, comparing them he wrote “In Utah, employees of small businesses can go to a state Web site and sign up for insurance over the Internet, almost as easily as they download music from iTunes”(Pear 2010. para 7). “In the Massachusetts exchange [... ] the state serves as an active purchaser, soliciting bids from insurance companies and negotiating prices and benefits in an effort to secure the best value for state residents (Pear 2010. para 10). “The Utah Health Exchange organizes the market, allowing consumers to compare a wide variety of health plans sold by any insurers that want to participate (Pear 2010. para 9). According to Robert Pear, “health plans cannot be sold through the Connector unless they receive its seal of approval (Pear 2010. para 8); adding “Massachusetts and Utah provide a glimpse of the future, and they offer radically different models for other states (Pear 2010 para 4).
So what, exactly, is a health insurance exchange? To help state health officials in Kansas in the coming years, Andrew Allison, executive director of the Kansas Health Policy Authority, wrote about how states will be affected by the new law. “A Health Insurance Exchange are structured web-based markets for health insurance, and the core purpose of the entity that runs the exchange will be to manage these markets” (Allison, 2009 para 7). “The exchange is to rate plans according to quality and cost, must group plans into four tiers’ (Allison, 2009 para 7) and be “required to facilitate web-based determinations of eligibility for premium subsidies, as well as web-based selection and enrollment in health plans” (Allison, 2009 para 7) ”The exchange will qualify health plans for participation based on minimum standards to be set by the HHS, but states will be free to add criteria as well” (Allison, 2009 para 7). The exchange will need to enforce new and existing insurance regulations, including side-payments across plans that are intended to ensure that health risks are borne fairly by all competitors” (Allison, 2009 para 7).
How would the exchanges directly increase coverage to millions of American citizens? The Affordable Care Act articulates in Section 1413 and 2201, requirements to ensure [...] integration in eligibility and enrollment between Medicaid and the exchange (Allison 2009 para 11). “States must make available a common web-based application for Medicaid, CHIP and the subsidies and cost-sharing protections available in the exchange”(Allison 2009 para 12). “State exchanges must screen applicants for Medicaid and CHIP eligibility, and state Medicaid and CHIP programs must accept these referrals and enroll these individuals in the appropriate program without further review of eligibility” (Allison 2009 para 12). “State Medicaid programs must ensure that ineligible applicants are screened for eligibility for subsidies in state exchanges, and that those found eligible are enrolled in a plan through the exchange” (Allison 2009 para 12). These are examples of how the insurance exchanges will increase access to America’s uninsured.
How will the health insurance exchanges help reduce cost overall? According to The Congressional Budget Office, the estimated budgetary impact of the ACA combined with the reconciliation act - “would produce a net reduction in federal deficits of $138 billion over the 2010–2019 period as result of changes in direct spending and revenue” (CBO 2010 para 7). Devising “that figure comprises $85 billion of the total reduction would be on- budget [...]”(CBO 2010 para 7). While these figures are widely viewed as accurate by public policy analyst, their are critics. In a Health Affairs piece, Douglas Holtz-Eakin and Michael J. Ramlet (2010) wrote “a more comprehensive and realistic projection suggests that the new reform law will raise the deficit by more than $500 billion during the first ten years and by nearly $1.5 trillion in the following decade”.
Since the 1960‘s health care for the average-income American citizen has been largely a privilege for those who can afford it. The employer-based system provided for some time, the needed scope of insurance to the general public. However, times have changed. In America, health care as a function of what government should be doing for it’s citizens is still debated. But from a public policy standpoint, the new federally required health insurance exchange programs give (state) government, a web-based infrastructure that expands coverage, increases access, and reduces cost for the individual, business, and nation
Thanks for reading. Any comments are appreciated :)
Cheers,
CW Hardy
References
Allison, Andrew. (2010) Health Insurance Exchanges: States Role In Health Care Reform [Electronic Version]. Policy and Practice, October 2010, p. 20-24
Bentley et al., (2011). Open Letter to HHS from 21 GOP Governors on Affordable Care Act. Retrieved Feb 24 2011 from http://www.scribd.com/doc/48604494/GOP-Governors-
Letter-To-Sebelius-%E2%80%98Flexibility-On-Exchanges%E2%80%99
Boyles, Salynn. (2008, November 5). Obama Wins: What It Means for Health Care. WebMD Retrieved February 8 2011 from http://www.webmd.com/healthy-aging/news/20081104/
obama-wins-what-it-means-for-health-care
Clemmit, Marcia. (2010) Health Care Reform: Is The Landmark New Plan A Good Idea?, p 1-24. Retrieved on February 14, 2011, from Academic Premiere database.
Elmendorf, Douglas W. Congressional Budget Office and Joint Committee on Taxation Preliminary Estimate of H.R. 3590 and H.R. 4872. Retrieved February 15 2011 from http://www.cbo.gov/doc.cfm?index=11379&zzz=40823
Healthcareproblems.org. (2011) Health Care Statistics. & Terms of Use. Retrieved February 15, 2011, from http://www.healthcareproblems.org/health-care-statistics.htm.
Holtz-Eakin, Douglas., Ramlet, Michael J. (2010) Health Reform Likely To Widen Federal Budget Deficits, Not Reduce Them. Retrieved February 20 2011 from Academic Premier database.
Kibbe, Matt. (2010, December 22). 5 Reasons Why We Can Repeal Obamacare in 2011. Fox News. Retrieved February 18 2011 from http://www.freedomworks.org/news/5-reasons-
why-we-can-repeal-obamacare-in-2011
Kline, Ezra. (2009, June 16). Health Insurance Exchanges: The Most Important, Under-noticed Part of Health Reform . Washington Post on the web, p. 1. Retrieved February 18 2011 from http://voices.washingtonpost.com/ezra-klein/2009/06/ health_insurance_exchanges_the.html
Lampert, Jacqueline Garry. (2009, November 21). H.R 3590, The Legislative Vehicle for the Patient Protection and Affordable Care Act of 2009. Retrieved on February 11 2011 from http://dpc.senate.gov/dpcdoc.cfm?doc_name=lb-111-1-151
Library of Congress. THOMAS. (2011) Bill Summary and Status 111th Congress (2009-2010) H.R.3590 Major Congressional Actions. Retrieved February 10 2011 from http:// thomas.loc.gov/cgi-bin/bdquery/D?d111:3:./temp/~bdqPjR:@@@R|/home/ LegislativeData.php?n=BSS;c=111
Pear, Robert. (2010, October 23th) Health Care Overhaul Depends on States’ Insurance Exchanges. NY Times on the web. Retrieved February 12 2011 from http:// www.nytimes.com/2010/10/24/health/policy/24exchange.html? _r=1&scp=6&sq=Insurance%20Exchanges&st=Search
Postal, Arthur D. (2011, February 8th). PPACA: GOP Governors Blast Exchange Procedures. Retrieved February 20 2011 from http://schealthbenefits.net/content/ppaca-gop- governors-blast-exchange-procedures
Money and Politics. (2011) H.R. 3590 - Patient Protection and Affordable Care Act. Contributions by Vote. Retrieved February 24 2011 from http://maplight.org/us congress/
bill/111-hr-3590/423082/contributions-by-vote
U.S Department of Health and Human Services (2011, February). Implementation Center Regulations. Initial Guidance to States on Exchanges. Retrieved February 10 2011 from http://www.healthcare.gov/center/regulations/guidance_to_states_on_exchanges.html
White House. Office of the Press Secretary. (2009). Remarks by the President to a joint session of Congress on Heath Care. Retrieved February 12 2011 from http:// www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-
Congress-on-Health-Care/
Health care policy, depending on which side of the political idealogical line one falls on, is typically accompanied by a viewpoint of the current system and also how government affects it. Liberals have historically viewed health care as a “right”. Conservatives favor the status quo; health care as a luxury. However both sides do broadly agree the current system needs reform. The question becomes what, if anything, could be the policy solution? Ezra Kline, columnist for the Washington Post notes that the health exchange provisions in the Affordable Care Act “attempt to bridge the gap between the healthcare most want to have, and the healthcare we have now” (Kline, 2009. para 2). Healthcare.gov (2011) describe an exchange as “[...] a mechanism for organizing the health insurance marketplace to help consumers and small businesses shop for coverage in a way that permits easy comparison of available plan options based on price, benefits and services, and quality (para 2).
Using Deborah Stone’s policy solution definitions; a state insurance exchange in essence are new federal “rules” governing (organizing) how states offer an individual health insurance. So the problem health exchanges seek to address are two fold. First, health exchanges provide individuals and small businesses shut out of the market more purchasing power, “represent[ing] the core of the insurance market reforms” (Allison, p. 1). Second, exchanges “are also a lynchpin for the coverage expansions in health reform" which address overhead cost to the nation (Allison, p. 1). What’s the history of health care public policy leading up to health exchanges in the ACA, you ask? Briefly:
After World War II most industrialized nations adopted universal health care systems while the United States opted for a employer-based private insurance market (Clemmit, p. 11). In 1943 the “Wagner-Murray-Dingell bill for compulsory national health insurance is introduced in Congress (Clemmit, p. 11). Around that time [the] “National War Labor Board declares employer contributions to insurance are income-tax free, opening the way for companies to use health insurance packages to attract workers” (Clemmit, p. 11). Still then “members of Congress made unsuccessful attempts to launch discussion of health coverage for all in 1943, 1945, 1947, 1949 and 1957, and Presidents Franklin D. Roosevelt, Harry S. Truman, Richard M. Nixon [...] all proposed guaranteed universal coverage.(Clemmit, p. 11).
Since the late 1950’s Congress has passed laws, though narrowly in most cases, regulating insurance coverage to elderly, and low income children. President Johnson signed the Social Security Act of 1965 establishing the Medicare and Medicaid systems (Clemmit, p. 11). In 1993, First Lady Hillary Clinton failed in her attempt to help pass sweeping healthcare reform (Clemmit, p. 11). Four years later President Clinton signed the State CHIP bill in 1997, extending health insurance through state programs to qualified children of low-income, but insured families (Clemmit, p. 11). Over fifty years, the health care policy debate evolved from just examining the proper role of government in providing health care, to how it can better address the “spill over” effects like rising cost created by the nations current health care system.
CQ Researcher Marcia Clemmit penned a lengthy journal on health care in 2010. She summed up the problem of cost to the nation in chronology of policy on health care. According to Clemmit, in the 1960’s health care spending [totaled] $28 billion, or 5.2 percent of gross domestic product (Clemmit, p.11). By the 1980‘s “health spending [totaled] $255 billion, or 9.1 percent of GDP (Clemmit, p.11). And by the year 2000, “health spending [totaled] $1.4 trillion, or 13.8 percent of GDP (Clemmit, p.11). These figures expose forty years of rising national expense in health care in the United States.
To expose the rising cost to individuals in addition to the nation, advocate groups (HealthCareProblems.org, 2011) began to document “accounts of problems with the U.S. health care system from people involved in every aspect of the system”(HCP.org). Ten years after the failed Clinton attempt, “a Kaiser Family Foundation poll reported 28 percent of middle income families (annual family income between $30,000 and $75,000) stated that they were currently having a serious problem paying for healthcare or health insurance” (HCP.org). Another report states “in 2007, nearly 50 million Americans did not have health insurance, while another 25 million were underinsured”, and that “Healthcare expenditures in the United States exceed $2 trillion a year (HCP.org). “Healthcare is one of the top social and economic problems facing Americans today”; adding “the inability to pay for necessary medical care is no longer a problem affecting only the uninsured, but is increasingly becoming a problem for those with health insurance as well” (HCP.org).
By 2007, most invested politicians, political interest groups, and Americans agreed that there was a problem surrounding rising cost in association with uninsured Americans receiving (in most cases) emergency, triage medical assistance. The problem was how to extend coverage to the uninsured and reduce out-of-pocket expense without a complete revamping of the current system? Barack Obama’s successful candidacy for president in 2008 initiated speculation in the medical community and the American public about the future of healthcare reform proposals. (Boyles, 2008, para 1.). In a webMD article dated November 5th 2008 by Salynn Boyles, she signifies that Obama “ushers in a new administration that is all but certain to include some level of health care reform. Less clear is how extensive that reform [will be]” (Boyles, 2008, para 2). She added that Obama “has proposed sweeping changes in the health care system designed to provide health coverage to millions of uninsured” (Boyles, 2008, para 3). In her webMD piece, Boyles mentions the health insurance exchanges as part of the reforms Obama wants enact. After taking office in January 2009, President Obama called the five Congressional Committees that govern the legislative areas of health care to offer bills (Obama, 2009 para 15.).
By June 2009 Ezra Kline points out that “the most important aspect of [Obama’s] health reform [...] would be the health insurance exchanges” (Kline, 2009 para. 1). “Massachusetts has a variant called the ‘Connector’(Kline, 2009 para 2.) . “Ted Kennedy's bill talked about Gateways. Ron Wyden and Bob Bennett's legislation calls for Health Help Agencies”(Kline, 2009 para 2.). “But the concept itself is [the same] (Kline, 2009. para 2). President Obama push hard for health insurance reform in a special address to a joint session of Congress on September 9th 2009. He began by acknowledging the work Congress has done, saying that four out of the five committees had “finished there work, and the Senate Finance Committee will call a vote next week” (Obama, 2009 para 15.). Signaling that the legislative process had never reach that point before. Mr. Obama began to make the case for why healthcare reform was so important to the nation. “ Simply put”, he said, “our health care problem is are deficit problem; nothing else comes close” (Obama, 2009 para 12.). Adding “we know we must reform this system. The question is how” (Obama, 2009. para 16.). He laid out to the American people the three points he sees as a solution and wants to see in the final bill. His second point was the insurance exchange provision for all uninsured Americans.
A Democratic Policy Committee (2009) bulletin lays out the legislative history of the final bill. Starting “on September 17, 2009, Rep. Rangel introduced H.R. 3590, (para 71). “On October 8, 2009, the House passed H.R. 3590 by a vote of 416-0, and [...] was placed on the Senate Legislative Calendar” (para 71). “H.R. 3590 is the legislative vehicle for consideration of the Patient Protection and Affordable Care Act of 2009” (para 72). “On November 18, 2009, Senators Reid, Baucus, Dodd, and Harkin proposed the Patient Protection and Affordable Care Act as an amendment in the nature of a substitute to H.R. 3590” (para 72). “Senator Reid filed cloture on the motion to proceed to the bill on November 19, 2009 and the Senate began consideration of the motion on November 20, 2009” (para 72). According to the Library of Congress, the Senate voted to pass H.R. 3590 on December 24th 2009 with changes, to the House for final passage (Thomas.loc.gov) On March 21st 2010 the House passed H.R 3590 with Senate changes and on March 23rd 2010 President Obama sign it into law (Thomas.loc.gov). What emerged through the policy process was the Patient Protection and Affordable Care Act. Under Section 1311(b) of the ACA is a provision to require states to establish Health Insurance Exchanges (Healthcare.gov).
Prior to becoming law, heated rhetoric on health care reform was primarily directed at other provisions of the reform bill like the ‘end of life counseling’ proposal - demonized as ‘death panels’ by right-wingers. But especially the individual mandate “which requires all individuals to purchase government-controlled health insurance” (Kibbe para 8). Fox News’ Matt Kibbe, wrote that “Obamacare’s core elements -- the mandates, exchanges, and subsidies (including the massive Medicaid expansion) -- are all interconnected” (Kibbe para 8). The individual mandate, affectionally called ‘The Death Star’ by Kibbe, is the “one critical weakness [of the law]” adding “[R]epeal just this section, and the rest of the law comes apart” (Kibbe para 9). To those who oppose the reform bill the exchanges are ‘guilty by association’. Vested corporate opponents of the ACA, according to Money and Politics, include the following organizations: American Petroleum, Pharmaceutical Research and Manufactures of America, U.S Chamber of Commerce, and National Retail Federation, amongst many others (MAPLight.org). In general they opposed the individual mandate, first, then the exchanges.
However as noted in a NY Times article the idea of an insurance exchange as a public policy solution is not new and carries bi-partisan support in Congress (Pear 2010. para 11). NY Times writer Robert Pear cites agreement about exchanges among “liberals and conservatives [...] as a way to concentrate the purchasing power of individuals and small businesses (Pear 2010. para 12). President Obama characterized the exchanges as a “a marketplace where individuals and small businesses will be able to shop for health insurance at competitive prices.”(Obama 2009. para 19). The real battle over health exchanges did not come from Congressional Republicans, it’s coming from GOP Governors.
In a letter from twenty one conservative governors to the Obama administration they write “we believe the system proposed by the PPACA is seriously flawed, favors dependency over personal responsibility, and will ultimately destroy the private insurance market (Bentley et al., 2011). The letter lists several changes they would like to see to the exchange provisions. They include more authority for states to choose benefits that meet there citizens needs, waive[r] provisions that discriminate against health insurance arrangements that include health savings accounts or reimbursement, a plan for verifying incomes and subsidy for exchange participants, [and] calls for neutral third-party research organization to conduct a study to asses how many people will “offload” into the exchanges (Bentley et al., 2011) “The governors are warning that [they] will give HHS full responsibility for setting up and running the exchanges in their states”(Postal 2010 para 2).
How would insurance exchanges affect the market place and look in operation? In Massachusetts and Utah their are functioning models with different approaches. In an October 2010 NY Times column by Robert Pear, comparing them he wrote “In Utah, employees of small businesses can go to a state Web site and sign up for insurance over the Internet, almost as easily as they download music from iTunes”(Pear 2010. para 7). “In the Massachusetts exchange [... ] the state serves as an active purchaser, soliciting bids from insurance companies and negotiating prices and benefits in an effort to secure the best value for state residents (Pear 2010. para 10). “The Utah Health Exchange organizes the market, allowing consumers to compare a wide variety of health plans sold by any insurers that want to participate (Pear 2010. para 9). According to Robert Pear, “health plans cannot be sold through the Connector unless they receive its seal of approval (Pear 2010. para 8); adding “Massachusetts and Utah provide a glimpse of the future, and they offer radically different models for other states (Pear 2010 para 4).
So what, exactly, is a health insurance exchange? To help state health officials in Kansas in the coming years, Andrew Allison, executive director of the Kansas Health Policy Authority, wrote about how states will be affected by the new law. “A Health Insurance Exchange are structured web-based markets for health insurance, and the core purpose of the entity that runs the exchange will be to manage these markets” (Allison, 2009 para 7). “The exchange is to rate plans according to quality and cost, must group plans into four tiers’ (Allison, 2009 para 7) and be “required to facilitate web-based determinations of eligibility for premium subsidies, as well as web-based selection and enrollment in health plans” (Allison, 2009 para 7) ”The exchange will qualify health plans for participation based on minimum standards to be set by the HHS, but states will be free to add criteria as well” (Allison, 2009 para 7). The exchange will need to enforce new and existing insurance regulations, including side-payments across plans that are intended to ensure that health risks are borne fairly by all competitors” (Allison, 2009 para 7).
How would the exchanges directly increase coverage to millions of American citizens? The Affordable Care Act articulates in Section 1413 and 2201, requirements to ensure [...] integration in eligibility and enrollment between Medicaid and the exchange (Allison 2009 para 11). “States must make available a common web-based application for Medicaid, CHIP and the subsidies and cost-sharing protections available in the exchange”(Allison 2009 para 12). “State exchanges must screen applicants for Medicaid and CHIP eligibility, and state Medicaid and CHIP programs must accept these referrals and enroll these individuals in the appropriate program without further review of eligibility” (Allison 2009 para 12). “State Medicaid programs must ensure that ineligible applicants are screened for eligibility for subsidies in state exchanges, and that those found eligible are enrolled in a plan through the exchange” (Allison 2009 para 12). These are examples of how the insurance exchanges will increase access to America’s uninsured.
How will the health insurance exchanges help reduce cost overall? According to The Congressional Budget Office, the estimated budgetary impact of the ACA combined with the reconciliation act - “would produce a net reduction in federal deficits of $138 billion over the 2010–2019 period as result of changes in direct spending and revenue” (CBO 2010 para 7). Devising “that figure comprises $85 billion of the total reduction would be on- budget [...]”(CBO 2010 para 7). While these figures are widely viewed as accurate by public policy analyst, their are critics. In a Health Affairs piece, Douglas Holtz-Eakin and Michael J. Ramlet (2010) wrote “a more comprehensive and realistic projection suggests that the new reform law will raise the deficit by more than $500 billion during the first ten years and by nearly $1.5 trillion in the following decade”.
Since the 1960‘s health care for the average-income American citizen has been largely a privilege for those who can afford it. The employer-based system provided for some time, the needed scope of insurance to the general public. However, times have changed. In America, health care as a function of what government should be doing for it’s citizens is still debated. But from a public policy standpoint, the new federally required health insurance exchange programs give (state) government, a web-based infrastructure that expands coverage, increases access, and reduces cost for the individual, business, and nation
Thanks for reading. Any comments are appreciated :)
Cheers,
CW Hardy
References
Allison, Andrew. (2010) Health Insurance Exchanges: States Role In Health Care Reform [Electronic Version]. Policy and Practice, October 2010, p. 20-24
Bentley et al., (2011). Open Letter to HHS from 21 GOP Governors on Affordable Care Act. Retrieved Feb 24 2011 from http://www.scribd.com/doc/48604494/GOP-Governors-
Letter-To-Sebelius-%E2%80%98Flexibility-On-Exchanges%E2%80%99
Boyles, Salynn. (2008, November 5). Obama Wins: What It Means for Health Care. WebMD Retrieved February 8 2011 from http://www.webmd.com/healthy-aging/news/20081104/
obama-wins-what-it-means-for-health-care
Clemmit, Marcia. (2010) Health Care Reform: Is The Landmark New Plan A Good Idea?, p 1-24. Retrieved on February 14, 2011, from Academic Premiere database.
Elmendorf, Douglas W. Congressional Budget Office and Joint Committee on Taxation Preliminary Estimate of H.R. 3590 and H.R. 4872. Retrieved February 15 2011 from http://www.cbo.gov/doc.cfm?index=11379&zzz=40823
Healthcareproblems.org. (2011) Health Care Statistics. & Terms of Use. Retrieved February 15, 2011, from http://www.healthcareproblems.org/health-care-statistics.htm.
Holtz-Eakin, Douglas., Ramlet, Michael J. (2010) Health Reform Likely To Widen Federal Budget Deficits, Not Reduce Them. Retrieved February 20 2011 from Academic Premier database.
Kibbe, Matt. (2010, December 22). 5 Reasons Why We Can Repeal Obamacare in 2011. Fox News. Retrieved February 18 2011 from http://www.freedomworks.org/news/5-reasons-
why-we-can-repeal-obamacare-in-2011
Kline, Ezra. (2009, June 16). Health Insurance Exchanges: The Most Important, Under-noticed Part of Health Reform . Washington Post on the web, p. 1. Retrieved February 18 2011 from http://voices.washingtonpost.com/ezra-klein/2009/06/ health_insurance_exchanges_the.html
Lampert, Jacqueline Garry. (2009, November 21). H.R 3590, The Legislative Vehicle for the Patient Protection and Affordable Care Act of 2009. Retrieved on February 11 2011 from http://dpc.senate.gov/dpcdoc.cfm?doc_name=lb-111-1-151
Library of Congress. THOMAS. (2011) Bill Summary and Status 111th Congress (2009-2010) H.R.3590 Major Congressional Actions. Retrieved February 10 2011 from http:// thomas.loc.gov/cgi-bin/bdquery/D?d111:3:./temp/~bdqPjR:@@@R|/home/ LegislativeData.php?n=BSS;c=111
Pear, Robert. (2010, October 23th) Health Care Overhaul Depends on States’ Insurance Exchanges. NY Times on the web. Retrieved February 12 2011 from http:// www.nytimes.com/2010/10/24/health/policy/24exchange.html? _r=1&scp=6&sq=Insurance%20Exchanges&st=Search
Postal, Arthur D. (2011, February 8th). PPACA: GOP Governors Blast Exchange Procedures. Retrieved February 20 2011 from http://schealthbenefits.net/content/ppaca-gop- governors-blast-exchange-procedures
Money and Politics. (2011) H.R. 3590 - Patient Protection and Affordable Care Act. Contributions by Vote. Retrieved February 24 2011 from http://maplight.org/us congress/
bill/111-hr-3590/423082/contributions-by-vote
U.S Department of Health and Human Services (2011, February). Implementation Center Regulations. Initial Guidance to States on Exchanges. Retrieved February 10 2011 from http://www.healthcare.gov/center/regulations/guidance_to_states_on_exchanges.html
White House. Office of the Press Secretary. (2009). Remarks by the President to a joint session of Congress on Heath Care. Retrieved February 12 2011 from http:// www.whitehouse.gov/the_press_office/Remarks-by-the-President-to-a-Joint-Session-of-
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