In 1912, former President Theodore Roosevelt championed national health insurance in his unsuccessful bid to return to the White House. This year, a century after Roosevelt first proposed national health insurance, the U.S. Supreme Court upheld the Patient Protection and Affordable Care Act (ACA), signed into law by President Barack Obama in 2010.
Ken Thorpe has followed the arc of health care reform for more than three decades. During the 1990s, he advised the Clinton administration as U.S. deputy assistant secretary for health policy. Since 1999, he has grown Rollins School of Public Health's programs in health policy and management as Robert W. Woodruff Professor and department chair, all the while serving as one of the nation's go-to experts on ways to control health care spending. He also leads the Partnership to Fight Chronic Disease, a national coalition that has positioned obesity and related illnesses as a top health priority with a focus on prevention.
In the following Q&A, Thorpe shares his thoughts on the ACA and how Rollins faculty and students are shaping the health care reform landscape.
During the Clinton administration, you advised the President and First Lady on health care reform. What are the differences between the Clinton and Obama plans?
There are more similarities than differences. They both tried to achieve universal coverage. The penalties for not enrolling were steeper in the Clinton plan than what the ACA requires. The biggest difference is that the Clinton plan built in serious cost containment. It included a set of goals in terms of the growth of private insurance premiums that mirrored the growth of the economy plus one percentage point. Essentially, there were some controls for premiums that grew faster than that. Basically, the plans were taxed at 100% of excess growth. So a very tight cost control system was built into the Clinton plan.
Why was the Clinton plan unsuccessful?
Congress was not engaged from the beginning. The proposal was written in the White House from A to Z. No one obtained buy-in from the Congressional committees that were going to have to introduce and pass the legislation. The process and strategy derailed it, and the length of time that it took to put the plan together. Had it gone faster, the White House would have had a better chance of passing health care reform.
The passage of the Affordable Care Act was a historic achievement. What is working well under the current law?
Several important provisions now in place are working well. For example, parents can cover their children up to age 26. That's reduced the number of uninsured adults by 6.6 million people. So the ACA has had a major impact on increasing insurance coverage among young adults. It's provided a range of benefits to seniors in the Medicare program, especially for people who have multiple chronic health conditions. It's eliminated the so-called donut hole in the prescription drug program and provided better preventive benefits for those covered by Medicare. It's provided tax credits to small businesses that offer insurance, making it more affordable for employers to offer coverage. It eliminates bans on pre-existing conditions among children. It eliminates the ability of insurance companies to discriminate based on health status—the community rating provision. Everybody will have access to health insurance even with a pre-existing condition—the guaranteed issue provision.
The major elements of the ACA are scheduled to take effect in 2014. When that happens, it will reduce the number of uninsured in the United States by 30 million people. Originally, 17 million of those people were to be covered through an expansion of state Medicaid programs. The Supreme Court decision now leaves it up to states to decide whether or not to expand their Medicaid programs. Regardless, the ACA will expand coverage to Americans who currently do not have health insurance.
What isn't working well under the ACA?
There's nothing major. The biggest structural change requires putting together state insurance exchanges to provide an online marketplace where people can buy health insurance. Today, 11 states and the District of Columbia are moving ahead to do that. These exchanges must be up and running by 2013 for them to work by 2014 under the ACA. By default, the federal government will establish exchanges for states that do not set up their own. Past November, if Obama is re-elected, you'll see a lot of activity because states will want to design and shape how these exchanges operate.