Chapter 9.A: Sources of Health Insurance

Updates on coverage and spending statistics can be found in  Chapter 1.B.1 and on the web pages of CMS and the Census Bureau.

One good source for learning about state and local obligations to provide or fund care for the indigent is Community Catalyst’s Free Care Compendium

Health Care Reform

The copious sources of information about health care reform are far more than any normal person can keep up with.  But, a good starting point is the government’s main portal:  and the Center for Consumer Information & Insurance Oversight

Here’s a graphic that captures at least a 1000 words re. ACA coverage

Links to a series of reports from the Congressional Research Service explaining various provisions of the new law in detail can be found here

Other more-or-less neutral sources of information include:,,,,,,

For thoughtful advocacy perspectives, see   

Additional sources are listed here:  An Online Guide to Tracking Healthcare Reform

An accurate and entertaining video about reform: []

More pointed advocacy and amusing videos: and (start with one’s at bottom first)

One reason that cost containment measures are so subdued in the Affordable Care Act was to avoid the fevered opposition from major industry and professional groups that doomed the Clinton reform efforts 15 years early.  This was largely successful.  Muted support, or at least absence of overt opposition, came from the AMA, the hospital industry, and larger insurers.  The pharmaceutical industry went so far as to pay for adds extolling the need for health care reform, featuring none other than the exact same “Harry and Louise” actors whom the insurance industry famously used to raise widespread public anxiety about the Clinton reform proposal.

The following is a useful timeline and summary of major federal legislation affecting health care. It originally was produced by Prof. Kenneth Wing at Seattle Univ., in connection with his Aspen casebook, The Law and American Health Care (with Michael Jacobs and Patricia Kuszler).  This is an excerpted and updated version.


Hospital Survey & Construction Act (Hill-Burton program) assisted states in constructing hospitals; 1954 amendment added long-term facilities, rehabilitation centers and outpatient departments; Hill-Harris amendments of 1964 set precedent for use of public funds to subsidize planning by voluntary health agencies. Terminated in 1974.


Internal Revenue Code amended to exempt employer-purchased health benefits from taxable income.


Migrant Health Act provided federal funding for health services for migrants; Appalachian Regional Development Act of 1965 supported projects to provide comprehensive health care for the Appalachian poor.


Social Security Amendments of 1963, 1965 and 1967 assisted states and local health departments by paying up to 75% of the costs of maternal & child health programs.


Economic Opportunity Act provided OEO funding for three neighborhood health centers in Boston, New York City & Denver; five others funded in 1965; 1966 amendment provided $50 million to develop Comprehensive Health Service Projects in urban and rural areas of poverty and inadequate health service.


Social Security Amendments authorized Medicare and Medicaid programs.


Heart Disease, Cancer & Stroke Amendments to Public Health Service Act created Regional Medical Programs to provide planning grants and operational grants for projects associated with the disease listed in act; 55 RMPs were approved. Program was replaced by 1974 health planning legislation.


Comprehensive Health Planning & Public Health Service Amendments (also known as "Partnership for Health" Act) provided federal grants for state and areawide health planning and grants-in-aid to support health services.


Early Periodic Screening, Diagnosis and Treatment Program (EPSDT) created to provide screening and health services for needy children under Medicaid.


Federal government assumed licensing and regulatory authority over clinical laboratories.


Family Planning Services & Population Research Act established nationwide program of family planning and research.


Economic Stabilization Program (Cost of Living Council) initiated control on prices (including hospitals) which continued until 1974.


The largest set of Social Security amendments in U.S. history passed by 92nd Congress. They added 1.7 million disabled to Medicare eligibility and expanded eligibility to include anyone with end-stage renal disease. Professional Standards Review Organizations (PSROs) created to review medical necessity, quality of care, and cost of Medicare and Medicaid services.


Both presidential candidates (Nixon and McGovern) included broad national health insurance proposals in their party platforms.


Health Maintenance Organization Act provided $375 million in federal subsidies over five years to prepaid group practices; all employers with 25 or more employees providing health insurance as a benefit were required to make HMO enrollment available where HMOs exist.


90 separate bills dealing in some manner with national health insurance were introduced in 93rd Congress.


Employee Retirement Income Security Act authorized extensive federal control over employee benefits, preempting state regulatory schemes. Health benefits included within scope of legislation.


National Health Planning & Resources Development Act created system of national health planning and development; eventually, there were over 200 HSAs throughout the U.S.


1973 HMO Act amended to relax requirements for "qualified" HMOs; 1978 amendments extended HMO assistance program for 3 years; 1981 legislation eliminated almost all requirements. 


Office of Inspector General created in DHEW to investigate fraud and inefficiency in all DHEW programs.


During 95th Congress, Carter administration introduced hospital cost containment proposal designed to temporarily limit hospital revenues; no legislation adopted, but private hospitals agreed to undertake the "Voluntary Effort," a nationwide voluntary program to contain health care costs; effects of this effort noticed only for about a year.


President Carter issued 10 principles for a "National Health Plan" which should "assure that all Americans have comprehensive health care." No action taken on these principles. 


Omnibus Budget Reconciliation Act (OBRA) mandated significant reductions in funding for virtually all federal health programs; scope of PSRO federal certificate of need program and all other federal regulatory efforts reduced.


Tax Equity and Fiscal Responsibility Act (TEFRA) mandated further reductions in many federal health programs; replaced PSRO program with Professional Review Organizations (PRO) program; mandated Medicare as secondary payer to any employer-sponsored health insurance; required DHHS to develop plan for prospective reimbursement of hospitals.


Social Security Amendments (following recommendations by a bipartisan commission) enacted major revisions of Social Security financing that indirectly affected Medicare financing; included mandate for Medicare prospective payment scheme on a diagnostic-related group basis (PPS/DRG).

Several Reagan Administration proposals for stimulating competition in health care financing (e.g., eliminating the tax exclusion of employer-paid health benefits and vouchers for Medicare) considered but not enacted.

(Congressional deadlock over future of federal health planning program resulted in expiration of the program's authorization. Program was re-funded as part of a continuing resolution -- a practice that was continued until the program was finally eliminated from the FY 1988 budget.)


Deficit Reduction Act included a number of amendments to Medicaid and Medicare designed to limit expenditures. The most notable amendment was a freeze on increases in rates of Medicare physician reimbursement for fifteen months and financial incentives to encourage physicians to accept assignment. The rate freeze/incentives were extended for an additional year in 1985.


Emergency Deficit Control Act ("Gramm-Rudman") required limits on federal spending and a balanced budget by FY 1991. Medicaid and maternal and child health program exempted from required cuts in spending. Medicare reductions limited to no more than 2% per year.


Consolidated Omnibus Budget Reconciliation Act (COBRA) and Sixth Omnibus Budget Reconciliation Act (SOBRA) included a variety of changes in Medicaid and Medicare. Among the changes were the following: 

-- controversial "adjustments" in PPS/DRG reimbursement (e.g., raising reimbursement for "disproportionate share" hospitals and reducing reimbursement for medical education);

-- very limited increases in reimbursement for physicians participating in Medicare; a maximum ceiling on reimbursement for non-participating physicians serving Medicare patients;

-- federal penalties for hospitals that transfer poor patients or deny care in emergencies;

-- significant expansions in Medicaid eligibility for children and pregnant women.


Omnibus Budget Reconciliation Act (OBRA) scheduled major reductions in federal spending including $6 billion (over two years) in Medicare spending reductions to be accomplished largely by limits on increases in physician and hospital reimbursement rates.


Medicare Catastrophic Coverage Act of 1988 (MCCA) eliminated most cost-sharing requirements for Part A and added coverage for prescription drugs and a few other services, representing the largest expansion of Medicare since 1972. The revenues for the expansions were to be drawn from a surtax on the income tax liability of beneficiaries and an increase in Part B premiums. States required to buy Part B for eligible Medicaid recipients and to expand coverage for pregnant women. Although MCCA was enacted with virtually unanimous approval, the upheaval over the new taxes resulted in the repeal of the taxes and the new Medicare benefits in 1989.


1973 HMO Act rewritten to allow experience rating by HMOs and to allow employers to contribute less to HMO plans than to indemnity options.


Omnibus Budget Reconciliation Act of 1989 (OBRA 1989) included $2.7 billion in Medicare reductions. Most of the savings were achieved by delays or restrictions in the increases for PPS/DRG payments. OBRA 1989 also included:

-- authorization for resource-based, relative value scale (RB-RVS) reimbursement of physicians under Part B of Medicare (to be fully implemented by 1996);

-- limits on charges by all physicians to Medicare patients to more than 115% of Medicare payment and a ban on "balance billing" to all indigent Medicare patients;

-- authorization of "volume performance standards" that effectively allowed maximum limits on annual increases in Part B spending.

-- authorization to repeal "Section 89" of the federal tax law which prohibited employers from discriminating between categories of employees in health benefits.

-- a requirement that states provide Medicaid to pregnant women and to children within 133% of the poverty line. 1990 Budget Reconciliation Act of 1990 (for FY 1991) included:

* A series of Medicare reforms intended to save over $40 billion in 5 years including: an increase in the Part B deductible was raised from $75 to $100; annual increases in the Part B premium were scheduled through 1995 (intended to make total premiums equal 25 percent of Part B expenditures); and severe limits on annual increases and other adjustments to Part A and Part B reimbursement;

* A requirement that states provide Medicaid coverage for all children born after September 30, 1983 by the year 2002;

* A requirement that the states expand their Part B "buy-in" for poor elderly;

* Medi-Gap insurance regulation including limits on exclusions for pre-existing conditions, requirements for uniformity in policies, civil penalties for duplicative services, mandatory rebates if policies failed to return specified percentages of each premium dollar, and rules for "simplification" and standardization of policies.


Legislation enacted requiring the overhaul of the FDA program for approving the safety of medical devices (originally authorized in 1976).


Budget Reconciliation Act of 1993 included various limits on coverage and reimbursement under both Medicaid and Medicare.


Major revision of federal SSI, food stamps, and AFDC programs enacted, but with only minor changes in Medicaid (although provisions converting Medicaid to a block grant were included in earlier versions of the bill.)


Health Insurance Portability and Accountability Act of 1996 enacted requiring private insurers to offer group and in some cases individual policies to people who have had prior coverage, prohibiting the use of pre-existing condition exclusions, and imposing other requirements on private health financing arrangements. Other provisions of the legislation authorized up to 750,000 people (over four years) to establish tax deductible medical savings accounts.


Balanced Budget Act of 1997 added new Part C to Medicare, expanding options for enrollment in managed care plans; scheduled $30-40 billion in reimbursement cost-savings; and set Part B premiums at 25 percent of program costs through FY 2003.


Rules pursuant to Health Insurance Portability and Accountability Act, governing privacy and security of medical information and data, promulgated by DHHS.


Medicare Modernization Act adopted, which provides prescription drug coverage and fosters partial privatization of Medicare


The American Recovery and Reinvestment Act (ARRA) pumped hundreds of billions of dollars into electronic medical records, medical research, and community health centers.


Enactment of the Patient Protection and Affordable Care Act, which fundamentally changes the regulation and availability of health insurance, and contains countless other provisions important to all aspects of health policy.