Thus far, we have discussed various pieces of legislation passed by the
federal government in attempt to regulate health care. In this module, we
will briefly review the most significant pieces of legislation. Before we begin
our exploration of major pieces of legislation, keep in mind that most
presidents have viewed health care as “a private matter in which
government should not become involved” (President Franklin Pierce, 1854).
1935: Social Security Act. While not directly related to health care at the
time, it is interesting to note that there was a provision in the act to provide
national health insurance; however, it was removed due to opposition.
1965: Medicare and Medicaid passed into law as a compromise to national
health insurance. Medicare was discussed previously; however, one thing
that is interesting to note is the Medicaid program and the current plan to
increase the enrollment numbers (discussed a little later).
1977: The Health Care Financing Administration (HCFA) was created to
manage both Medicare and Medicaid separately from the Social Security
Administration.
1985: Consolidated Omnibus Budget Reconciliation Act (COBRA) passed,
which amended the Employee Retirement Income Security Act (ERISA), IRS,
and the Public Health Service Act. Signed by President Reagan, this act was
created to allow for the continuation of health coverage at group rates.
Before COBRA was enacted, individuals who had insurance found it difficult
to change employers due to pre-existing conditions. Under COBRA, it was
unlawful for an insurance company to deny insurance to an individual based
on the pre-existing conditions of that individual who maintained insurance
coverage. COBRA was the vehicle to enable employees to transfer positions
or employers.
1986: Emergency Medical Treatment and Active Labor Act (EMTALA). As
mentioned previously, this act was passed to ensure that individuals,
regardless of ability to pay, with emergent needs (including active labor)
would not be refused access to medical services. It is worthwhile to mention
that in the late 1970s, the government enacted initiatives that were
designed to increase the proliferation of health maintenance organizations.
Managed care was viewed as the saving grace of the health care system.
Unfortunately, the public was not as accepting. They were not impressed
with the strict rules of access of the primary care physician, and the HMOs
did not grow as expected. Nevertheless, many managed care organizations
opened their own respective health systems which included everything
from ambulatory centers to metropolitan-based hospital centers. A few of
the systems became very large. Before EMTALA, these hospitals had the
ability to refuse medical services to individuals. There were highly publicized
instances of individuals in need of emergency services who were rerouted
to other health care systems simply because they were not in network.
Several of them died while en route to other hospital systems. Upset over
the already restrictive measures enforced by the HMOs, the public was up
in arms. In response, EMTALA was passed. If a hospital received
government payments, it had to provide care under the EMTALA legislation.
Where private insurance has decreased, the millions of Americans without
insurance have sought primary care through the emergency rooms.
1997: State Children’s Health Insurance Program—later referred to as CHIP
(Children’s Health Insurance Program). With its passing, CHIP was the
largest expansion of health insurance coverage for children since the
passing of Medicaid in the 1960s. What makes CHIP important is its less
restrictive eligibility compared to traditional Medicaid. Those families who
made too much to qualify for state assistance, yet could not afford private
insurance, now had an alternative source of coverage. The mentality behind
this insurance was to enable children to receive important immunizations
and ensure access to primary care. In 2009, President Obama signed the
Children’s Health Insurance Reauthorization Act of 2009 which expanded
coverage to an additional 4 million children, bringing total enrollees to
approximately 10 million.
2003: Health Insurance Portability and Accountability Act of 1996 (HIPAA).
While passed in 1996, HIPAA was not required by providers until April 14,
2003. Key provisions of the act were as follows: Patients now had greater
access to see and obtain copies of their medical records. All providers had
to disclose how patients’ medical records would be used and who, if
anyone, would have access. New limits were placed on how providers were
to use medical information. Increased safeguards were enacted that
required providers to take reasonable steps to increase the confidentiality
of their patients’ records. The act also encouraged that providers switch to
electronic health records (EHR). Many providers lacked the resources to
upgrade their systems to support EHR and thus the lengthy timeframe from
passing of the act to actual enforcement. Lastly, the act required that
providers establish intensive staff training in relation to the main points of
the law and also required that providers identify a privacy officer who
would ultimately be responsible for the act’s provisions.
2009: Unimpressed with the development of electronic health records, the
federal government, as part of the American Recovery and Reinvestment
Act of 2009, enacted the Health Information Technology for Economic and
Clinical Health Act (HITECH). This piece of legislation earmarked a
whopping $22 billion to be used to increase the use of EHR. The goal of this
initiative was to provide the framework for the development of a
nationwide health information technology (HIT) network. The government
believes that such a system will increase medical proficiency, decrease
medical errors, and as a result of both, save billions of dollars.
2010: The Patient Protection and Affordable Care Act. Please see
PowerPoint in module resources for details.
Globalization and Its Impact on Health Services
It is difficult to find a starting point to this lecture as there are numerous
factors that currently play into health on a large scale. However, as was
mentioned in Module Ten, the fundamental argument here is whether or
not access to health services is a right or a privilege. If it is a privilege, this
lecture is relatively short. If it is a right, this lecture could become a full
blown course in itself. For example, imagine walking down the park and
seeing a child drowning in a body of water. The vast majority of us would
jump in to save the child without much thought. In fact, many of us would
go to great lengths and even put ourselves in jeopardy to come to the
child’s rescue. Yet, every year, millions upon millions of children die in third
world countries as they do not have even basic access to immunizations.
In Sub-Saharan Africa, there is an estimated 25% of the world’s global
disease burden, yet it only has 3% of the world’s health care workforce
(Snyder, Dharamsi, & Crooks, 2011). Despite this shocking inequality, the
problem related to world health may not be a lack of resources; rather, it
may be a lack of unified decision making. Returning back to the idea of
witnessing an event, there is a type of mental paralysis that occurs when
there are multiple individuals witnessing the same event. Termed “the
bystander effect,” individuals fail to call for assistance or fail to intervene as
they believe that someone else has already called for help (for an interesting
example, read the account of the murder of “Kitty” Genovese). In essence,
the global community has the resources, yet we are all currently immobile
based on the lack of decision-making capacity. We are all falling victim to
the bystander effect.
Although there was great progress made in the early 2000s, the current
economic crisis on a global level has caused a major setback in global
assistance efforts. Global funding for many of the United Nations
Millennium Development Goals has decreased by 10% or more. In 2011, the
United States cut their contribution to health funding by 20%; other
countries are expected to follow suit. Again, we find ourselves back to the
unanswered question: basic health care access, right or privilege?
References
HHS Press Office (2003). HIPAA summary, fact sheet, published by the U.S.
Department of Health and Human Services.
Johri, M., Chung, R., Dawson, A., & Schrecker, T. (2012). Global health and
national borders: The ethics of foreign aid in a time of financial
crisis. Globalization and Health, 8 (19).
Kaiser (2010). Summary of new health reform law. Retrieved from
http://www.kff.org/healthreform/upload/8061.pdf
Martin, G., Grant, A., & D’Agostino, M. (2012). Global health funding and
economic development. Globalization and Health, 8 (8).
Snyder, J., Dharamsi, S., & Crooks, V. (2011). Fly-by medical care:
Conceptualizing the global and local social responsibilities of medical
tourists and physician voluntourists. BMC International Health and Human
Rights, 7 (6).
