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“Although several of its main features – including the health insurance exchanges, Medicaid expansion, accountable care organizations and further oversight of insurance companies and their pricing practices – remain works in progress, the ACA has already had a substantial impact on health care in the USA. However, in the current divisive political climate, any new initiatives to achieve universal health coverage will be difficult to legislate or implement. Furthermore, the ACA did not introduce any of the stringent spending controls found in many European health systems. Maryland is the only state that has embraced uniformly regulated prices and Massachusetts is the only state that has tied growth in health-care spending to the growth of the state’s economy.³³ In general, the USA has not introduced global budgeting or substantial federal measures to limit the supply of providers and technologies. Whereas other high-income countries have set up institutes to assess the cost–effectiveness of pharmaceuticals and health services and technologies – e.g. the National Institute for Health and Care Excellence in the United Kingdom, the Haute Autorité de Santé in France and the Pharmaceutical Benefits Advisory Committee in Australia – the ACA explicitly prohibits the creation of such institutes in the USA. While much is expected from the accountable care organizations, the evidence to date suggests that such organizations have only been moderately successful in their aim of rewarding quality and low cost rather than production.^34,35 Perhaps the major challenge facing the ACA in the coming years can be traced back to the utter lack of crossparty political consensus. The performance of the ACA and its resulting acceptability to the American public will be critical to the Act’s future.”

Source: Rice, Thomas et al. “Challenges facing the United States of America in implementing universal coverage.” Bulletin of the World Health Organization vol. 92,12 (2014): 894-902. doi:10.2471/BLT.14.141762

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“Over the course of the twentieth century, as the field of health services research in the US developed,² analysts began generating empirical research that documented serious deficiencies in access, quality, costs, efficiency and equity in the US healthcare system.^3,4 Since 1980, during the administration of President Ronald Reagan, when the nation first embraced market competition and deregulation as its preferred path to health system improvement, US health care spending as a percent of gross domestic product (GDP) has catapulted well beyond that of all other advanced economies, as shown in Figure 1. Though the US spent far more than any other advanced society on medical services, its health system’s quality, effectiveness, efficiency, equity, and public health indicators were mediocre at best by international standards.⁵ Further, the nation was alone among OECD nations in not providing financial protection to all its citizens from the cost of serious illness or injury, with an estimated 48 million uninsured residents or 15% of the US population in 2012.⁶ Before the ACA, the health reform legislation advanced by President Bill Clinton in 1993 was the most comprehensive prior proposal to address the US health system’s numerous flaws. That effort’s failure in 1994 provided numerous lessons, both policy and political, that informed the later Obama health reform effort, including how to navigate the dense and intense US stakeholder community that holds enormous financial stakes in preserving the status quo.⁷“

Source: John E. McDonough (2015) The United States Health System in Transition, Health Systems & Reform, 1:1, 39-51, DOI: 10.4161/23288604.2014.969121.

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“The path to reform at the federal level in the United States was made easier because of passage of a law in the state of Massachusetts in 2006. This law achieved near-universal health insurance coverage using a public/private framework that attracted broad bipartisan support from the state’s Democratic Senior Senator Edward M. Kennedy and its staunchly Democratic state legislature, while also drawing firm backing from Republican Governor Mitt Romney and President George W. Bush whose Administration provided essential financial support for the scheme.¹¹ This legislative success in Massachusetts showed that a politically viable policy pathway to universal coverage could be achieved with support—though not unanimous—from both parties. The core policy innovation of the Massachusetts reform was to create a health insurance exchange where citizens could purchase insurance plans, combined with subsidies for low and lower-middle income families, a mandate for everyone to purchase insurance or pay a penalty, and systemic regulatory reform of the health insurance market. Successful implementation of the Massachusetts law in 2007 and 2008 further emboldened universal coverage advocates to embrace this market plus mandate-based approach at the national level.¹²“

Source: John E. McDonough (2015) The United States Health System in Transition, Health Systems & Reform, 1:1, 39-51, DOI: 10.4161/23288604.2014.969121.

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“The final route to passage of the Affordable Care Act was characterized by bitter rancor and controversy right up to the law’s signing on March 23, 2010, by President Obama. Part of the opposition reflected stakeholder objections to key elements of the law, especially relating to its financing; other opposition reflected a growing backlash from Tea Party and other conservative groups to President Obama and his broader agenda.

“Three key political themes characterized the passage of the ACA and shaped the implementation of the law. First, the US Congress approved the ACA with no Republican votes, exacerbating sharp partisan differences over implementation. Second, ACA opponents spent an unprecedented amount of money to convince large segments of the US public of the law’s demerits, outspending supporters by about 15 to one according to one study, leaving supporters less able to successfully explain or to present a positive message.¹⁵ Third, because of the law’s unpopularity, Republicans used opposition to “Obamacare” as their principal point of political attack against President Obama and Democrats. Since the law’s passage, intense partisan opposition and conflict from the same forces that opposed the ACA’s enactment have also influenced its implementation.”

Source: John E. McDonough (2015) The United States Health System in Transition, Health Systems & Reform, 1:1, 39-51, DOI: 10.4161/23288604.2014.969121.

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World Health Systems Facts is a project of the Real Reporting Foundation. We provide reliable statistics and other data from authoritative sources regarding health systems in the US and sixteen other nations.

Page last updated July 17, 2023 by Doug McVay, Editor.