United States: National Health Care—The Debate Continues (On And On . . .)

At this early point in the 2020 presidential race, it appears that a key issue for the candidates will be a push for national health insurance, or some variation thereof, possibly even including proposals that Medicare or Medicaid be extended beyond their traditionally covered populations, or even "Medicare [or Medicaid] for All." While most people recog¬nize some limitations in our current national health care system, concepts suggesting a more unified approach, with more governmental funding, are sometimes characterized as rather radical. Looking at the historical background of the federal health care programs, however, debates about government-operated health insurance have been occurring in the United States for more than 100 years.

The organizational component closest to a government health plan administrator is, of course, the Centers for Medicare & Medicaid Services (CMS). CMS, and its prede¬cessors, have been instrumental in bringing Medicare and Medicaid to their current design points. CMS has detailed some of the history of national health care on its website, including a listing of key milestones by year. A review of that list demonstrates just how far the federal health care programs have come in the past 100 years.

As described in another CMS publication, support for the concept of health insurance grew in the 1930s, with the main issue under dispute at that time what it still is today—whether health insurance should be publicly or privately financed. During World War II, employee fringe benefits, including employer-provided health insurance, grew rapidly because the government limited direct wage increases. Congressional proposals for national health insurance, financed by payroll taxes, were introduced in the 1940s, but none was ever brought to a vote. In 1950, Congress acted to provide federal participation in the financing of state payments made directly to the providers of medical care for costs incurred for public assistance recipients.

Legislation passed in 1965 created Medicare and Medicaid. Initially, Medicare coverage was limited to the elderly, with coverage for the disabled and those with end stage renal disease added in 1973. Part C (now called Medicare Advantage), which allows beneficiaries to receive Medicare benefits through the auspices of approved health plans, was added in 1997. Part D, the Prescription Drug Benefit, was added in 2003. In 1997, Congress added the State Children's Health Insurance Program (now called the Children's Health Insurance Program) to the federal funding already being provided to the states under Medicaid. The Afford¬able Care Act (ACA) made many changes for both publicly and privately funded health care programs when it was enacted in 2010. Some, or all, of the ACA changes are still being challenged today.

The "CMS History Page Quiz," prepared by CMS, is an interesting exercise that illuminates some of the signifi¬cant challenges that the federal health care programs have faced over the years. For example, the Civil Rights Act was enacted in 1964, just one year before Medicare, and prohib¬ited recipients of federal funds from discrimination based on race, color, or national origin. The Medicare program required integration of hospitals and nursing homes before providers could participate in the program (an early use of provider enrollment as an enforcement tool), with the Public Health Service charged with working with these institutions to ensure that facilities were integrated.

The Medicare and Medicaid programs have evolved and improved as the result of a long and winding road of continuing issues subject to repeated debates of actual and potential stakeholders. Change has been largely incremental over many years, but the history of these programs reflects clear points of disruption that rapidly and successfully expanded the programs beyond the status quo, and some¬times in surprising directions. It remains to be seen how the presidential candidates, and ultimately the Congress, respond to suggestions that we are due for another disruption.

The content of this article is intended to provide a general guide to the subject matter. Specialist advice should be sought about your specific circumstances.

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