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The lack of health insurance among a substantial group of Americans is not a new issue, but as the recession hit and more people lost jobs and younger people had trouble finding jobs initially, the issue of the link between employment and health care became clearer and problematic. Also, there were concerns for older people who either planned an early retirement before the age of 65 or who lost a job in their fifties and discovered how difficult it was, in a time of recession, to find new jobs with health insurance or to be able to purchase a private health insurance policy. For people who already had health problems, many insurance companies would not provide coverage for preexisting conditions.

There were also discussions about how programs such as Medicaid did not cover all of the poor and about the groups of people with low incomes who nevertheless earned too much or had too many assets to qualify for Medicaid in many states. The percentage of people in poverty has been increasing and was 13.2 percent in 2008, up from 12.5 percent in 2007. The number of people without health care insurance has been increasing over the past decade. About 39.8 million people had no insurance in 2000, and this increased to more than 45 million people with no coverage in 2005, a 13 percent increase from 2000. The number of people without health insurance coverage continued to rise, though not as rapidly, from 45.7 million in 2007 to 46.3 million in 2008, while the percentage of uninsured remained unchanged at 15.4 percent (DeNavas-Walt, Proctor, and Smith 2008). In addition, during this period, there was a decrease in employer-provided health care coverage, from 69 percent of employers providing coverage in 2000 to 60 percent in 2005. The number of people covered by all types of private health insurance continued to decrease from 2007 to 2008, with absolute numbers decreasing from 202 million to 201 million. The number covered by employment-based health insurance declined from 177.4 million to 176.3 million. Numbers of uninsured overall did not increase more, because the number covered by government health insurance climbed from 83 million to 87.4 million. These figures and concerns are the backdrop for some of the renewed push for health care reform after the election of Obama.

Shortly after the election, discussion began about health care reform. One initial approach of the Obama administration was to try and have Congress work through and develop the legislation. Partially, this was a reaction to the failure of the Clinton plan and the consensus that the administration in that case had become too involved in the details and Congress did not feel invested in the plan being developed. During 2009, some criticism of this approach arose, with people arguing that, to pass controversial, major legislation, the president had to become more involved. At one point, there was a feeling that Obama and the Democratic party would have the votes available to pass major legislation, especially given the conversion of the formerly Republican senator from Pennsylvania, Arlen Specter, to the Democratic party, which gave the Democrats a veto-proof majority in the Senate. Things moved slowly, however, and no legislation had been passed by the time of the elections in November 2009, when the Democratic Senate seat held for decades by Ted Kennedy in Massachusetts was open due to Kennedy's death. A shock occurred in that election, with a Republican capturing the seat. This meant that passage of the bill might not be possible without use of the so-called reconciliation approach, which required only a majority of votes (the Democrats still had 59 seats in the Senate). The initial Senate version of the bill was passed in late 2009. The U.S. House of Representatives passed the bill to reform health care in March 2010 by a vote of 220 to 211. The House also passed a bill, which then was sent back to the Senate to modify some versions of the Senate bill. That bill was also passed in March 2010. The bill was signed by President Obama on March 23, 2010.

When fully phased in, the legislation will cover around 32 million Americans who are currently uninsured. Major coverage expansion begins in 2014, with exchanges being created and the requirement that most people have health insurance. Beginning in 2010, insurers must remove lifetime dollar limits on policies, and some subsidies to small businesses to provide coverage to employees will become available. Insurance companies will be barred from denying coverage to children with preexisting conditions. Children will be allowed to stay on their parents' insurance policies until their 26th birthday.

Gradually, a number of other changes will be put into place. Medicaid will be expanded, the doughnut hole in the Medicare drug plan will gradually disappear, and certain preventive services in Medicare will be available without a copayment. There will be reductions in Medicare advantage plan payments that will help to extend the life of the Medicare trust fund. An independent advisory board will be created to make recommendations for other cost savings. The legislation will establish the Community First Choice Option, which will create a state plan option under section 1915 of the Social Security Act to provide community-based attendant supports and services to individuals with disabilities who are Medicaid eligible and who require an institutional level of care, to try and begin to deal with some of the needs of the elderly and disabled for less intensive community-based services. There will be the creation of some demonstration programs for certain types of home care and modifications to some of the rules for nursing homes that receive Medicare payments. A number of new taxes and fees--some on people through Medicare taxes and others on drug makers and employers--will begin in various years, such as 2011 for drug makers and fines on employers mostly beginning in 2014. Taxes on high-cost health plans will not begin until 2017.

Although there are high hopes that the new reforms in health insurance--a more accurate description of the Obama changes than "health care reform"--will lower the rates of the uninsured, many problems were not dealt with. In much of the discussion, there was talk of a public option, a way to be sure that there was an affordable option for everyone. This did not end up in the legislation, and, while insurance companies will have to offer coverage to a person and there will be health care exchanges, there is not a limit on what can be charged, so costs of health insurance may not be well controlled. In addition, the bill has few mechanisms in place to control rising costs of health care and of drugs, so that some experts fear that, as happened with the passage of Medicare and Medicaid in the 1960s, costs will increase and there will be need for additional reforms to deal with costs. Some issues in Medicare were dealt with (the doughnut hole in the drug plan and some beginnings of experimentation with aspects of long-term care), but the major issue of long-term care for the elderly, a growing program as the large baby boom group in the population begins to age, is not really covered. How the new taxes will actually work and how fines and mechanisms to ensure that all people purchase coverage remain to be seen as the different provisions of the Obama plan come into effect in future years.

Bibliography:

Andersen, Ronald M., and Pamela L. Davidson, "Measuring Access and Trends." In Changing the U.S. Health Care Delivery System, ed. by Ronald M. Andersen, Thomas H. Rice, and Gerald F. Kominski. San Francisco: Jossey-Bass, 1996.

DeNavas-Walt, Carmen, Bernadette D. Proctor, and Jessica C. Smith, Income, Poverty, and Health Insurance Coverage in the United States: 2007. U.S. Census Bureau, Current Population Reports, P60-235, Washington, DC: U.S. Government Printing Office, 2008.

Federal Interagency Forum on Child and Family Statistics, America's Children: Key National Indicators of Well-Being, 2001.

Greenwald, Howard P., Health Care in the United States: Organization, Management, Policy. San Francisco: Jossey-Bass, 2010.

Kronenfeld, Jennie Jacobs, Expansion of Publicly Funded Health Insurance in the United States: The Children's Health Insurance Program and Its Implications. Lanham, MD: Lexington Books, 2006.

Kronenfeld, Jennie Jacobs, and Michael Kronenfeld, Health Care Reform in America. Santa Barbara, CA: ABC-CLIO, 2004.

Marmor, Theodore H., The Politics of Medicare, 2d ed. New York: Aldine De Gruyer, 2000.

Quadagno, Jill, One Nation Uninsured: Why The U.S. Has No National Health Insurance. New York: Oxford University Press, 2005.

Skocpol, Theda, Protecting Soldiers and Mothers: The Political Origins of Social Policy in the United States. Cambridge, MA: Harvard University Press, 1992.

Starr, Paul, The Social Transformation of American Medicine: The Rise of a Sovereign Profession and the Making of a Vast Industry. New York: Basic Books, 1982.

Zhang, Yuting, Julie Marie Donohue, Joseph P. Newhouse, and Judith R. Lave, "The Effects of the Coverage Gap on Drug Spending: A Closer Look at Medicare Part D." Health Affairs 28, no. 2 (2009): w317-w325.

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