By Sheeva Azma
The modern quest for universal healthcare has been made up of many important side quests.
People talk about helping more people have healthcare when it should really also be safer, more effective, and cheaper. Simply expanding healthcare coverage to everyone doesn’t make everyone healthier if the health care system doesn’t help everyone equally.
Me? Well, I’m on ACA health coverage, which actually does all three of those things.
Unless you have Affordable Care Act coverage, you probably don’t have much to say about the ACA. I have ACA healthcare and after I was interviewed about my experience paying 87% more after the COVID-era subsidies expired at the end of 2024, people had some pretty heartless things to say about it on Facebook, such as:
- “Good. I didn’t want to pay for your health insurance anyway.”
- “My healthcare premiums have gone up so much. I don’t think ACA premiums have gone up as much.” (truly, how would you even know if you don’t have ACA insurance?) Translation: “You should be paying more than me.”
- “Guess the Affordable Care Act is not affordable, after all? Har har.”
And on and on.
Despite the many parties that tried to shut it down, largely for political reasons, the Patient Protection and Affordable Care Act of 2010 (also known as the ACA) lives on.
Unfortunately, I don’t hear too many people talking about the accomplishments of the ACA.
However, there are actually quite a few people benefitting from the ACA. At least, there were in 2016, when researchers noted the ACA’s rapid effect to increase healthcare coverage among low-income populations.
How did we get to our current spot in health care reform history? Let’s review the history of comprehensive, nationwide, federal health care programs by first going back to where they started: the creation of Medicare and Medicaid.
Medicare and Medicaid were established in 1965 by President Lyndon B. Johnson
When Medicare (and Medicaid) was established in 1965, and signed into law by Lyndon B. Johnson, TIME writes, the ultimate goal was “Medicare for all,” though the article also notes that that was not articulated. By 1970, TIME writes, it had already gotten expensive, and people were looking for ways to reduce costs. (Does that sound familiar to anyone?)
In 1970, a liberal Republican Senator from New York named Jacob Javits had an idea about expanding Medicare coverage to people of all ages. The New York Times called Javits’ plan “Medicare for all.”
Richard Nixon expanded Medicare
Universal health care also had an ally in Richard Nixon in 1974. That’s when Nixon proposed a new health care plan that would focus on providing coverage to children and people living in poverty. Because many conditions were preventable from childhood, Nixon argued, preventative care should be a priority from youth. This laid the groundwork for the ACA, which makes many forms of preventative care, such as certain vaccinations, certain screenings, and things like yearly mammograms for women to screen for breast cancer, free. There is also a list of free services available for children under the ACA, building on Richard Nixon’s ideal for health care that starts on prevention early, including childhood vaccination coverage to prevent a slew of devastating illnesses.
Nixon’s CHIP never made it to a vote before Congress — Watergate had happened by then. Even if it had, Javits might not have voted for it — his idea was simply to expand Medicare so that everyone could be part of it. Different lawmakers had different ideas. According to Wikipedia, in the 1970s, Javits (R-NY), Ted Kennedy (D-MA), and Martha Griffiths (D-MI) each had their own health care plan.
Though President Nixon’s health care plan failed to become reality, he had already worked with Congress to successfully expand Medicare by then. As quoted by the Milken Institute, one of Nixon’s stated goals in his first year as president was to “make certain, once and for all, that the retired, the disabled and the dependent never again bear the brunt of inflation.”
The Social Security Amendments of 1972 created the End Stage Renal Disease Program (ESRD) under Medicare to extend “Medicare coverage for kidney transplants and renal dialysis–the cost of which is beyond most individuals–to workers under social security, and their dependents,” as Nixon noted in a statement upon the bill’s passage.
The 1972 Social Security Amendments did much more than that, too! The Milken Institute states that the law went pretty far to address “poverty and income insecurity”: “It not only indexed benefits to the price level beginning in January 1975, but created the Supplemental Security Income program for low-income elderly, blind and disabled Americans. And it extended Social Security benefits to widows and widowers, added a minimum monthly benefit to retirees who had been in low-wage jobs, increased benefits for those retiring later than age 65, increased the limit that a beneficiary could earn and still get full benefits, gave Medicare coverage to those with disabilities and added a long list of new Medicare benefits.”
Per the Milken Institute, Nixon had gotten tired of bargaining with Congress for regular increases to benefits to keep up with inflation and the rising cost of living, so it was a relief for him and for benefits recipients to have an automatic increase codified into law. As the AARP notes on their webpage, it was a win for Social Security and other federal benefits recipients.
In 1973, President Nixon passed the Rehabilitation Act of 1973, which, under its Section 504, made discrimination illegal against persons with disabilities in federal programs like Medicare and Medicaid, or where they would be receiving federal financial assistance, such as hospitals and healthcare providers.
“The process of hammering out a compromise on this matter was long and difficult,” wrote Nixon in a statement celebrating the passage of the Rehabilitation Act of 1973.
No doubt, Watergate did not help Nixon’s chances in achieving legislative victories. His Comprehensive Health Insurance Plan, or CHIP (not the same CHIP that exists today — that is the Children’s Health Insurance Program and was thanks to Bill Clinton and Congress in 1997), tanked thanks to that.
However, the Commonwealth Fund writes, some aspects of Nixonian health reforms have stood the test of time: “While the specifics have evolved over time, the concepts of relying on competing private insurance companies, employer mandates, and opportunities to buy into federal programs remain relevant to the current debate.”
One limitation of the Nixon health care plan was that it was heavily tied to employers. Without an employer providing benefits, one’s health insurance coverage would be in jeopardy. In 1985, Ronald Reagan passed the Consolidated Omnibus Budget Reconciliation Act of 1985, or COBRA, introduced by Rep. Dan Rostenkowski (D-IL-8) which did a few things, including authorizing an insurance program (usually also called COBRA) that allows people to access health insurance after leaving an employer.
The Clinton era was largely fruitless for health care reform
In the Clinton era, Hillary Clinton was tasked with health care reform. The PBS Frontline documentary “The Choice 2016,” which talks about both Hillary Clinton and Donald Trump’s histories in the run-up to the 2016 election, spends a good amount of time on Hillary’s health care reform endeavors, which were mostly conducted in secret. Clinton-era health care reform efforts included the Health Security Express, a pro-health care reform bus tour featuring Bill and Hillary Clinton as well as both Al Gore, the vice president, and his wife, Tipper Gore. Unfortunately, both supporters and opponents of the Clintonian health care program attended these rallies.
In their efforts to reform health care, the Clintons were impeded by Republicans in Congress who did not want things like mandatory health care plan enrollment, subsidies to ensure affordability, and state-level health alliances.
George W. Bush established Medicare Part D
What I remember George W. Bush for, and something he is proud of and talks about in his memoir, is establishing Medicare Part D, which provides optional prescription drug benefits for Medicare recipients. On December 8, 2003, Bush signed the Medicare Prescription Drug, Improvement, and Modernization Act of 2003, which created Medicare Part D.
People forget that Republicans have shaped universal healthcare just as much as Democrats in the modern era. In our current era, we first had Romneycare, from a Republican Massachusetts governor, Mitt Romney, before we had the Patient Protection and Affordable Care Act of 2010 — the ACA.
The Affordable Care Act expanded health care access to more people
The ACA has a number of provisions that expand health care access. I’ve already talked about how it expands Medicaid optionally for states, but it also allows people to access healthcare without being employed or in a short-term period after leaving a job (as with COBRA). The Century Foundation, a think tank, argued in 2017 that the ACA has changed “labor force dynamics” by allowing workers to “change jobs, upgrade jobs, or find jobs with better work and family balance” as well as participate in the then-up-and-coming gig economy. “This change in work calls for a new social contract where benefits are portable and not tied to any specific employer,” wrote researcher Andrew Stettner.
In addition to expanding Medicaid coverage through the exhanges, the ACA has also improved health access for freelancers like me. Stettner writes that after the passage of the ACA, 82% of freelancers had health insurance, compared to only 64% before.
Starting in 2014, both members of Congress and their staffers are also insured by the ACA, according to Becker’s Payer Issues. This was part of the Affordable Care Act.
Patient safety provisions in the Affordable Care Act provide safer health care
Lastly, the ACA provides a framework for patient safety measures that should have been implemented decades ago to protect patients. The 2000 publication of To Err Is Human, a National Academies report, brought to light the issue that hospitals make preventable medical errors that harm patients, noting that this is a systemic, not individual, issue. Reforms from this landmark report have led directly to patient safety reforms in the ACA.
The patient safety reforms in the ACA include, but are not limited to, the following:
- Patient Safety Evaluation Systems: Section 1311(h) of the ACA requires that insurers contract only with hospitals that implement formal patient safety evaluation systems in order to track and prevent errors.
- Quality Improvement Strategies: Under Section 2717 of the ACA, health plans must submit reports annually to the Department of Health and Human Services (HHS), as well as to their enrollees, that show that they reward health care quality, and direct targeting reduction in medical errors, to improve health outcomes, using a market-based approach.
- Comprehensive Discharge Programs: Thanks to the ACA’s Section 3025, hospitals must have structured plans to prevent readmission and prevent complications post-hospital visit. The Agency for Healthcare Research and Quality, a small agency inside HHS, has written that almost one in five patients “experience adverse effects within 3 weeks of discharge, nearly three-quarters of which could have been prevented or ameliorated.” Hospitals with high 30-day readmission rates face financial penalties that can be up to 3% of their base Medicare reimbursements.
- Comparative Effectiveness Research: The ACA, in Section 6301, established the Patient-Centered Outcomes Research Institute (PCORI) to fund research that compares medical treatments on effectiveness on safety to help improve the quality of medical decision-making.
- Pay-for-Performance Reforms: The ACA mandates that the worst-performing hospitals on preventing certain hospital-acquired conditions or other provider-preventable conditions will receive reduced Medicare payments, according to Sections 3008 and 2702 of the ACA, respectively.
There is a lot of negativity about the health care system. We are on the right track with health care reform, if you ask me. We got here thanks to bipartisan efforts and that’s what we can carry into the next big health care system challenge.
If we’re going to expand health care access, we might as well ensure that the health care is high quality. The ACA lays the groundwork for that. The next challenge is making it cheaper while also ensuring that the right outcomes are rewarded. ACA lays the groundwork for that, too.
People who want “Medicare for all” can work towards that a lot easier with the ACA than without it.
Without patient-centered investments in the ACA, health care access also diminishes.
Thanks for reading this post. Read the whole ACA here!
The knowledge provided here is fact-checked to the best of my ability at the time of publication and may not be current at the time you are reading this blog. Please report any inaccuracies you find here.
