The Affordable Care Act and the transformation of us health care/La ley de Cuidado de la Salud Asequible y la transformacion del sistema de cuidado de la salud estadounidense.

AutorGaffney, Adam
CargoTexto en ingles - Ensayo

Summary. 1. Introduction. 2. Historical Backdrop. 3. Roots of the Affordable Care Act. 4. Passage of the ACA. 5. The ACA and the "Three-Legged Stool". 6. The Uninsured and the ACA. 7. The ACA and the Rise of Consumerist Health Care. 8. An Age of Consolidation? 9. Conclusions. 10. References.

  1. Introduction

    The "neoliberal era"--typically described as beginning sometime in the 1970s and continuing to the present--has witnessed great changes in the health systems of nations throughout the world. Some nations in Europe have seen efforts to rollback the universal scope, or privatize the delivery, of their universal public health systems, trends that may now be accelerating (Reeves, McKee, and Stuckler 2015, Pollock and Roderick 2015, Maarse 2006). The United States, in contrast, entered the twenty first century without a system of "universal health care," with millions excluded from health care and many more with inadequate or second-tier care. The passage of the Affordable Care Act (ACA) in 2010 has been described by some as the long-deferred realization of the goal of a right to health care in the United States (Obama 2015). However, for reasons we will explore, this characterization is, unfortunately, inapt.

    In this article, we will explore the transformation of the American health care system, with an emphasis on the recent reforms of the ACA. Our aim is to elucidate the major historical and structural features of the American health care system for an international audience, and we do so by taking the following course. First, we will succinctly summarize some of the important historical currents that explain how and why the United States entered the twenty-first century with a rising number of uninsured, despite our uniquely high health care expenditures. Second, we will describe the political and health policy origins of the ACA. Third, we will describe the factors leading to the passage of the ACA, with a particular emphasis on the role of key corporate health interests. Fourth, we will discuss the fundamentals of the ACA-model of "universal health coverage." Fifth, we will assess the current landscape of US healthcare, emphasizing important quantitative trends, including the persistent problems of uninsurance and underinsurance. Sixth, we will examine how a process of corporate consolidation--in part through the emergence of "accountable care organizations"--is unfolding within the American health care landscape. We will conclude by briefly contrasting the ACA model of reform with a potential alternative, namely a single payer national health insurance program.

    Though these are US developments, they are highly relevant on the international level. The dynamics of health care in America have become increasingly important outside of the nation's boundaries as politicians and policy makers in other countries have, to varying extents, interpreted the ACA (or elements within it) as a possible model for health care reform (Pollock and Roderick 2015). By exploring the political processes that led to the ACA and highlighting the shortcomings of the law from the perspective of policy, we hope to demonstrate the pitfalls of a health system reform approach centered on the conciliation of corporate healthcare interests.

  2. Historical Backdrop

    During the twentieth century, the US diverged from most nations in Europe in its failure to create a system of universal health care. Understanding the US health care landscape today requires contextualizing it within the political history of health care reform. To do this, we can turn to a number of books which examine this history, and which highlight the key episodes within it (Numbers 1978, Poen 1979, Starr 1982, Hoffman 2001, Funigiello 2005, Gordon 2005, Quadagno 2005, Hoffman 2012, Starr 2013). The first episode occurred during the "Progressive Era," essentially during a short period around World War I. The second episode occurred during the "New Deal" of Franklin Delano Roosevelt, a time that otherwise saw a major successful expansion of the welfare state. The third episode occurred during the presidency of Harry S. Truman in the post-War II era, which corresponded to a crucial moment for welfare state expansion in Europe. The fourth episode is somewhat less well defined, but might be described as stretching from the successful passage of Medicaid and Medicare in 1965 to the failure of a national reform effort in the first half of the 1970s. A rightwing shift in national politics caused the next episode to be deferred for decades: health reform as a major national concern didn't again emerge until the Presidency of Bill Clinton in the 1990s. The final, fifth episode was that of the recent health reform struggle during the presidency of Barack Obama. Only two of these episodes resulted in major legislation: the passage of Medicare and Medicaid in 1965 (public health insurance programs for the elderly and the poor, respectively) and the ACA in 2010.

    The relative power of the constituencies favoring and opposing reform in each episode slowly shifted over time, reflecting larger changes in the US political economy. It's worth briefly mentioning the reasons for the failure of the first moment--the Progressive-era movement towards "compulsory health insurance"--because the dynamics of this first "failure" would play out again and again, in differing ways, in subsequent health care reform efforts up to the present. These dynamics thus help explain the current state of the American health care system.

    Progressive-era "compulsory health insurance," as it was known, would have created systems at the state level roughly similar (with some differences) to Otto von Bismarck's 1883 Health Insurance law in Germany or Lloyd George's 1911 National Insurance Act in Britain (Lubove 1986, 67-68). Historians have identified a number of factors leading to the failure of this campaign, and the resultant historical divergence of the US from Europe with respect to health policy. One factor was a shift in opinion among physicians, who moved from a position of potential openness to reform to one of relentless hostility, the history of which is described by Ronald Numbers in his Almost Persuaded (Numbers 1978). A second important factor was the emergence of opposition from the insurance industry. Though health insurance was essentially nonexistent, the insurance industry presciently saw its interests threatened by the reform movement and joined the campaign against the bill (Gordon 2005, 212-213). A third factor was the relative isolation, and elitism, of the reform movement: health insurance never became linked to a broader popular movement (Hoffman 2001, 44, Gordon 2005, 262). Indeed, the cause of compulsory health insurance actually split organized labor, with the powerful mainstream American Federation of Labor opposed (Starr 1982, 249-251, Hoffman 2001, 4). Finally, US entry into World War I and the Bolshevik revolution provided a useful ideological weapon for those who opposed the campaign, insofar as health insurance could be characterized as both German and communist in inspiration (Hoffman 2001, 56, 163).

    We outline the factors that resulted in the eventual destruction of the first effort at "compulsory" health insurance in the United States because they can be largely traced forward, albeit in changed form and circumstances, throughout the coming decades. The opposition of the conservative physicians' lobby, for instance, would remain an important factor into the post-World War II era. The post-World War II Wagner-Murray-Dingell bill, which would have established a single payer type of national health insurance on more European-lines, was vigorously and successfully opposed by the powerful American Medical Association, as described by Monte Poen in Harry S. Truman Versus the Medical Lobby (Poen 1979). However, the relative power of physicians waned while the role of larger commercial and corporate health interests--hospitals, insurance companies, and the pharmaceutical industry--rose over the course of the twentieth century. The fate of future health care reform efforts, it might be reasonably argued, increasingly hinged less on the posture of physicians and more on the lobbying muscle of these corporate interests. The third factor we outlined--the fact that movements towards universal health care were frequently distanced or isolated from larger social movements--would continue to play a role in subsequent failures, but also in shaping the form of reform efforts themselves. For instance, the historian Alan Derickson, who has explored the role of organized labor in early health reform battles, notes that though labor supported the post-World War II campaign, this never developed into a grass-roots campaign. "As a result," he writes, "no protest movement arose among the millions of uninsured and underinsured workers to counterbalance the AMA and its allies" (Derickson 1994, 1343). With the failure of post-World War II universal health care efforts, labor would increasingly embrace, earn, and expand upon private health benefits from their employers (Derickson 1994, 1354-1356). And finally, though the German roots of "compulsory" health insurance would quickly lose its propaganda value following the end of World War I, the "red-baiting" of the Progressive era fight for health care reform--i.e. the defaming of reformists as dangerous, foreign, or even traitorous communists--would be carried forward into future fights for health care reform, to some extent to the present day.

    These various factors--among others--help explain why, as the United States entered the twenty-first century, it continued to lack a system of universal health care. Different historians and scholars emphasize some of these factors over others as the "deciding" elements in this history, and arrive at different broad theses explaining the status quo. In Vicente Navarro's Marxian interpretation, for example...

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