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Decades of Bending the Arc toward Health Coverage Justice – with the Destination Still Ahead

By Ron Pollack

Starting in 1965, when Medicare and Medicaid were enacted into law, our nation incrementally bent the arc toward the crowning achievement in health coverage justice: universal health insurance. That progress has been substantial – with enhancements in people gaining coverage occurring throughout the years thereafter, culminating in the historic Affordable Care Act (ACA). But we still have a long way to go.

The adoption of Medicare and Medicaid, passed despite ardent opposition by the American Medical Association (with its negative advertising featuring then-actor Ronald Reagan), was a milestone achievement.

Medicare was a huge leap forward in coverage for America

Shortly before Medicare was adopted, half of America’s seniors did not have health insurance. Today, thanks to Medicare, virtually all seniors have health coverage.

Over the years since 1965, Congress has significantly improved Medicare coverage. Among the numerous coverage improvements to the program:
  • 1972: Medicare eligibility was extended to individuals under 65 with long-term disabilities as well as those with end-stage renal disease. 
  • 1980: Home health services were broadened.
  • 1983: Hospice benefits were made available. 
  • 1988, 1990: Improved help to low-income beneficiaries was provided to lower the amount people were spending on care out of pocket.
  • 2003: Prescription drug coverage was offered.

Medicaid evolved to become an essential health care safety net program

Even more significantly, the Medicaid program was enormously transformed and became the primary means of extending health coverage to those who couldn’t afford it.

When Medicaid was first established, its roots were grounded in the 16th century Elizabethan Poor Laws of England. Those Poor Laws extended welfare assistance in England not simply to impoverished people but to those who were poor and fit an arbitrarily determined “deserving” characteristic. The U.S. adopted that approach with the Social Security Act of 1935, making welfare available only to the poor who were blind, aged, permanently and totally disabled, or children missing a parent in the household.

When Medicaid was initiated three decades later in 1965, the pathway to eligibility was only available to those receiving such categorically delimited welfare assistance.

Over time, Medicaid eligibility has been extended to low-income people who do not fit any of these categories. This has resulted in significant, much-needed expansion of safety-net health coverage.

In the program’s first two decades, coverage changes were slow but steady: Early and Periodic Screening, Diagnosis, and Treatment (EPSDT) was started and offered significant preventive care for children (1967); categorical eligibility for aged, blind, and disabled persons was extended based on the new Supplemental Security Income (SSI) program (1972); waivers were made available for home and community-based care (1981); and states were allowed to opt into coverage for below-poverty mothers and infants (1986).

Thereafter, coverage expansions grew in much larger increments: Medicaid eligibility of pregnant women and children under 6 was mandated up through 133 percent of poverty (1989); coverage of children ages 6 through 18 was phased in up to the poverty line (1990); the welfare link to Medicaid eligibility was severed (1986); the Children’s Health Insurance Program (CHIP) was established, increasing coverage eligibility well above the poverty line (1987); and the ACA established income eligibility for any person or family with incomes up to 138 percent of the federal poverty line (2010).

These changes were the result of hard-fought efforts by advocates across the country. They were also the product of persistent work by key members of Congress. Ironically, the step-by-step increase in eligibility for low-income children occurred during the Reagan presidency, with Representative Henry Waxman leading the charge. The adoption of CHIP was enabled through bipartisan cooperation, especially among Senators Ted Kennedy and Orrin Hatch.

Today, remarkably, more than one out of every five people in the U.S. is participating in Medicaid. Significantly as a result, the uninsured rates for children and the overall population are at all-time lows.

The ultimate goal remains to be achieved: Too many remain uninsured

Despite these remarkable improvements, our nation still has a long way to go toward covering everyone. Today, approximately 30 million people remain uninsured. Progress towards universal coverage needs to move forward and should not be impeded by the Trump Administration’s political temptation to sabotage ACA implementation.

Indeed, immediate, effective action pursuant to the ACA would be a good start. There still are 19 states, especially in the impoverished Deep South, that have not yet extended Medicaid coverage to 138 percent of the federal poverty level, and hopefully this will soon be rectified. Vigorous outreach and enrollment assistance would no doubt also help to secure coverage for many people who are eligible for public coverage or subsidies that would make private insurance affordable.

Looking forward, we should build on the progress of the ACA. Legislation should be adopted that fixes the so-called “family glitch,” which inadvertently prevents dependents of a worker from securing affordable coverage in the individual marketplace if their employer-sponsored insurance is too expensive. Moreover, the ACA’s subsidies to make premiums more affordable and to limit out-of-pocket costs for deductibles and co-payments should be upgraded so that fewer people are priced out of coverage and care.

Additionally, a careful reappraisal should be made about vital health benefits that are generally excluded from health insurance. Oral health coverage is a key example. The ACA made a good start by requiring that pediatric oral health care be a mandatory benefit. This should now be extended to people of all ages.

Beyond that, bipartisan efforts should begin as soon as possible to make health care more effective and cost-effective. If meaningful improvements are made towards these directions, health coverage will become increasingly affordable, thereby hastening the time for securing universal health coverage.  



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