Introduction to Public Policy Analysis

Course Title: PAD 510: Introduction to Public Policy Analysis

Course Title: PAD 510:

Date:

Introduction(Assignment 1)

The paper examines the historical perspectives of the health care policies of Presidents Bill Clinton (Health Security Act) and Barack Obama (Patient Protection and Affordable Care Act) vis-a vis the social, economic, and political contexts under which the plans were discussed. The paper will also attempt a critique of the two policies.

President Bill Clinton launched his push for a comprehensive healthcare overhaul in 1993. Candidate Clinton had campaigned heavily on healthcare reform in the 1992 presidential campaign. The “managed competition” plan was designed to have private insurers compete in a regulated market. Soon after elections, a task force was created in January 1993, but its own processes were somewhat controversial and drew litigation. In the end, the reform plan died in Congress in 1994.

On the other hand, the Affordable Care Act (ACA) was signed by Barack Obama, on 23rd of March 2010 and was subsequently upheld on June 28, 2015 by the Supreme Court. The goal of the ACA was to provide Americans access to affordable and quality health by giving the opportunity to millions of uninsured Americans who hitherto had no hope of getting coverage (Healthcare.gov). And so far, over 100 million Americans have been covered under the Act.

For its part, Clinton’s Health Security Act (HSA) aimed at a comprehensive plan to provide universal health care for all Americans, which was to be a cornerstone of the administration’s first-term agenda. A major health care speech was delivered by President Clinton to the U.S. Congress in September 1993 that condemned the then prevailing policy as “bureaucratic and wasteful”(HSA,1993), and urged a comprehensive reform of the $1trillion health system accounting for about one-seventh of that based on the principles of security, simplicity, savings, choice, quality, and personal responsibility. Just like the ACA, introduced by President Obama, a core element of the proposed HSA plan by Clinton, was an enforced mandate for employers to provide health insurance coverage to all of their employees (Abbott, 2015).

The ACA for its part expands the affordability, superiority and accessibility of healthcare and health insurance through consumer regulations, taxes, subsidies, exchange, and various other reforms. This policy will support the issue by prohibiting the insurance companies from denying the coverage and charge the more based on the health status of an individual. The policy will impart affordable healthcare to everyone and impose strict restrictions on the insurance companies to drop out in the case of sickness of the individual or in the case of fair disclosure of the honest mistakes made in the application form.

Social, economic, and political environment

Two main differences account for why President Clinton’s HSA failed but Obama’s ACA passed and continues to ride on. The first is that Democrats learned from the failure of the Clinton plan and adjusted their strategy accordingly. The second is that Obama benefited from a reform consensus that had emerged in the years leading up to 2009 and that included major interest groups and Democratic congressional leaders. The Clinton plan was far more ambitious than the Affordable Care Act, particularly on cost containment. It included a system for global budgeting. Nearly all health insurance for people younger than 65 was to be offered through state insurance exchanges (then called regional health alliances). There were also limits on the rate of growth of average premiums in the exchange. ACA sets up exchanges only for the individual and some of the small-group market. There are no limits on premiums and no other means of imposing cost controls. So the ACA was less-threatening to the health-care industry (Pollack, 2012).

Critique

Despite all the rhetoric about the need for reform to control rapidly rising health costs, the Clinton Plan fails to even address the root cause of the American health system’s problems. That root cause is the perverse incentives and other consequences of the tax-supported, employer-based third-party payment system.

While the Clinton Administration claimed it was promoting choice, it was rather comparing its range of choice with that provided by private businesses and corporations, which in reality was either little or none. Likewise, the choices offered to Americans in the Clinton Plan are limited choices. While employees were guaranteed a choice of at least three plans, all available three plans offered the same standard benefits, with the limited variations in copayments and deductibles set, not by the market, responding to consumer choice, but by bureaucracy.

Furthermore, the Clinton health plan did not guarantee Americans full portability in their health insurance. If an employee moves to another region of the country for more than six months, he must sign up with another regional alliance and select another plan; otherwise he will be enrolled by regional alliance officials, and his health plan will be governed by the same set of rules and regulations, plus government spending targets and government “quality” standards, all of which are insulated from the dynamism of a real market. This is an anomaly which is catered for by the ACA with ‘out of network’ coverages. These, of course come with additional charges or premiums.

In effect, the Clinton Administration unlike the Obama Administration, imposed a top-down, command-and-control system of global budgets and premium caps, a superintending National Health Board and a vast system of government sponsored regional alliances, along with a panoply of advisory boards (HHS.gov) This appeared too complex and complicated for the comfort of stakeholders. A better way to have circumvented that complexity was by introducing real consumer choice into the system, and forcing insurance carriers to compete for their dollars in a genuine market, as has been done by the ACA.

The Affordable Care Act can be considered a better option relative to the system it replaced as it has given the opportunity to millions of uninsured Americans who hitherto had no hope of getting coverage. Additionally, the Act ensures a stronger consumer rights and protections among which include: end to pre-existing condition discrimination whereby insurance companies can no longer deny coverage or charge more because of pre-existing conditions; end to limits on care as insurance companies can no more deny coverage for persons with cancer or certain chronic illnesses who are deemed to have reached their dollar limit imposed by the insurance companies (over 105 million Americans are deemed to have benefitted from this provision); and, end to coverage cancellations where patients could no longer be dropped by insurance companies due to mistakes made by individuals during the application process (Obamacare facts, 2015).

Conclusion

From the foregoing, it could be affirmed that the difficult socio-economic and political environments prevailing at the two different eras contributed immensely to the failure of the Clinton Health care reforms in 1993 and the success of the Affordable Care Act. Despite the political differences between and among Democrats and Republicans and numerous court challenges against the ACA, the policy is still riding on, heading into its sixth year.

Introduction (Assignment 2)

The paper examines the new healthcare law, the Affordable Care Act (2010), its purpose, context of the problem, and recommendations to address the problem(s). It also seeks to unearth the players/ stakeholders involved vis-à-vis their respective roles, political influence, motives, conflicts, interrelationships, and their impact (s) on the policy.

Issue, Context, and Recommendation(s)

The issue selected for this paper is the Affordable Healthcare. The increased cost of health care has unnecessarily created a burden on the general public of the United States. There is also a rapid increase in the cost of healthcare industry noticed during the last decade and the cost is supposed to escalate even more in the coming decades. The total expenditures in the healthcare industry for the year 2012 account for $32800 billion and constitute 17.9% of GDP for the year 2013 (hhs.gov).The cost involved in healthcare has been dramatically shifted to insurance from out of the pocket expenses of the general public. In addition, there existed over 150 million Americans who did not have health insurance prior to the enactment of the ACA, hence the need for affordable healthcare as a public policy (Exchanges, Journal of Health, Politics and Law). The Affordable Care Act (ACA) was signed by President Barack Obama, on 23rd of March 2010 and was upheld on June 28, 2015 by the Supreme Court. The ACA, also known as ‘Obamacare’, was enacted in order to provide protection to patients and affordable care to them. The goal of Obama Care is to provide the Americans access to the affordable health and provide them a quality health insurance which will ultimately lead to the reduction in savings in healthcare. The ACA expands the affordability, superiority and accessibility of healthcare and health insurance through consumer regulations, taxes, subsidies, exchange, and various other reforms (Jones, Bradley& Oberlander, 2014). This policy will support the issue by prohibiting the insurance companies from denying the coverage and charge the more based on the health status of an individual. The policy will impart affordable healthcare to everyone and impose strict restrictions on the insurance companies to drop out in the case of sickness of the individual or in the case of fair disclosure of the honest mistakes made in the application form (WebMD). Recommendations/suggestions

The Affordable Care Act can be considered the best thing to happen to the health care industry in terms of providing affordable health care for millions of uninsured Americans who hitherto had no hope of getting coverage. Additionally, the Act ensures a stronger consumer rights and protections. To facilitate and consolidate the above positives, it is suggested that Health Center new access points be set up and improved in addition to increased public education about the Law.

Furthermore, it is imperative that relevant supervisory and regulatory bodies keep the tabs on insurance companies in order to avert arbitrary hikes in premiums even though the Law provides that they notify and justify such increased rates.

Players- Official, Unofficial, and Interest Groups

An official actor is the Department of Health and Human Services (DHHS). Throughout the initiation and implementation of the Act, the DHHS working in collaboration with its affiliates and resource persons, had to develop the framework for the bill to be presented to the White House for study and subsequent adjustments and fine-tuning prior to the bill landing in Congress for the whole process to commence. The internal politics in Congress is a whole different ball game which dragged on and attracted inputs, comments, castigations, uproars, lobbying and above all insinuations from all spectrum of the political divide, as well as from interest groups. After the passage of the Act, the DHHS still had to work with its collaborators like the CMS, respective States (in setting up the Health Exchanges)in coming up with modalities for the implementation of the Act which is still on-going.

An unofficial actor would be the citizens or individuals who also exerted great influence in feedback regarding their fears in hike in insurance premiums, co-pays, limited drug availability, and or cuts in Medicare. These fears aroused great interest in the general citizenry who raised questions at various public fora and sites, demanding answers. These prompted answers and clarifications from officialdom most times even coming from President Obama and the White House.

Interest groups like the Pharmaceutical industry and insurance companies of course would not be left out as they also intensified their lobbying tactics on the Act through Congress, especially the Republican Congressmen and Senators who were primarily opposed to the Bill. They used all means of misinformation, distractions and legislative obstructionism and rumors to put off the bill. They voted en-block against the bill but the then Democratic controlled Congress led by Speaker Pelosi, managed to scrap the Bill through in 2010 and President Obama immediately signed it into law.

Political Influence, motives, conflicts, interrelationships, and impact on the Policy

One area where actors made a significant impact in changing federal or state policy was the delay in the implementation of the ‘Employer Mandate’ of the Affordable Care Act by the federal government, mainly as a result of incessant and sustained pressure from stakeholders like employers and insurance companies. The earlier effective date given by the federal government had to be put off to allow employers more time to put their acts together for a smooth and successful implementation of the mandate the push was highly successful, forcing the government to amend the law to accommodate the requests. For the second time in a year (2014), the Obama administration gave certain employers extra time before they must offer health insurance to almost all their full-time workers. Under new rules announced by Treasury Department officials, employers with 50 to 99 workers were given until 2016 — two years longer than originally envisioned under the Affordable Care Act — before they risk a federal penalty for not complying. Companies with 100 workers or more are getting a different kind of one-year grace period. Instead of being required in 2015 to offer coverage to 95 percent of full-time workers, these bigger employers can avoid a fine by offering insurance to 70 percent of them rather in 2015( hhs.gov). The definition of employer requirements remained one of the biggest remaining questions about the way the 2010 health-care law will work in practice — and has sparked considerable lobbying (Thompson, D: 2015). By providing the dual phase-ins for employers of different sizes, insurance in the past administration officials have sought to lighten the burden on the small share of affected employers that have not offered.

Patients’ perceptions of the changes, also, will largely depend on how they impact their care, their doctor and their paycheck. Deciphering and demystifying the changes for consumers will be an ongoing communications challenge (prsa.org).
Consumers view health care through an intensely personal lens with so many rhetorical questions: Will the treatment I need be covered? How can I access care? Can I trust the quality? Can I afford it? How about my kids? These questions feed into the interactions with State Representatives, Congress, and their Senate Representatives who subsequently ensure that they seek the welfare of their constituents (Hunnicutt, 2010).

Furthermore, health insurance companies are in an ironic position in the reform milieu. Their reputations will continue to suffer under withering attacks from politicians and consumer health advocates, but they also stand to reap significant financial gains as implementation of the law generates new members and market opportunities (The Atlantic.com).

The way that insurers implement facets of the law for employers represents an opportunity to strengthen their brand and build customer loyalty. the industry can rebuild its reputation with state and federal governments gearing up to implement facets of the law that empower regulators to scrutinize premium requests, impose rate hike caps and enforce tough new transparency disclosures.

Conclusion

While all interest groups have tried to exercise their authority, relative power, and significance over each other, there is no doubt that Congressmen and women play a significant part in their success or otherwise since they have the final say in casting the vote. All said and done, the respective players identified above in the industry are performing their due roles to shape the ACA into a better policy. Based on the happenings on the field and judging from the remarkable success of the policy, one cannot but safely remark that ‘Obama Care’ has come to stay.

Argument for PPACA– Empirical

Anecdotal arguments being advanced by Republicans/ Conservatism groups have not deterred the President and Democrats from putting their best foot forward. They have consistently advanced empirical evidence to support the ACA. Economic research demonstrates clearly that this expansion in coverage is generating major benefits for the newly insured by increasing access to needed care, improving health, and enhancing families’ financial security. But expanding coverage also has important benefits for the labor market and the macro-economy.

Evidence gathered indicates that since the Affordable Care Act’s main coverage provisions took effect at the beginning of 2014, we have seen a precipitous decline in the uninsured rate unlike anything since the decade following the creation of Medicare and Medicaid, and the nation’s uninsured rate now stands at its lowest level ever. A recent analysis by the Department of Health and Human Services indicated that, as of the early months of 2015, an estimated 16.4 million people have gained coverage, including both people who have gained coverage since the end of 2013 and young adults who gained coverage before 2014 due to the law’s option to remain on a parent’s plan until age 26.

Above all, the ACA will impart affordable healthcare to everyone and impose strict restrictions on the insurance companies to drop out in the case of sickness of the individual or in the case of fair disclosure of honest mistakes made in the application form.

Argument Against ACA

. The definition of employer requirements remained one of the biggest remaining questions about the way the 2010 health-care law will work in practice — and has sparked considerable lobbying (Thompson, D: 2015). By providing the dual phase-ins for employers of different sizes, insurance in the past administration officials have sought to lighten the burden on the small share of affected employers that have not offered insurance to their To some extent, the skeptics were vindicated at the start of implementation of the Policy in 2014 when the Health exchange market encountered numerous website glitches. Millions of Americans and qualified enrollees were not able to sign up as a result of the technical difficulties (Healthcare.gov). That forced the Obama Administration to issue Executive Order granting extension of the deadline for enrolment. Anecdotal arguments of the Republicans have led to for instance recounting of stories of families, electorates, or even family members who got their policies cancelled for ‘non-affordability’ of their premiums due to ‘Obama Care’. Others would have it that several Physician Offices have shut down as a result of the bad policy. And yet still some will contend that small businesses are also shutting down because they cannot meet the ‘ Employer mandate’ which places additional burden on small businesses! Of course all of the above have been debunked and disproved by scientific evidence on the ground.

Again opponents of the ACA contend that between 2010-2019, under the Medicare, Medicaid, growth-trend, CLASS, and immediate reform provisions, an overall cost of $251 billion is expected to be spent by the government, before consideration of additional Federal administrative expenses (Foster, 2010).  While a majority of those uninsured would benefit through this law, many Americans believe the introduction of the new bill will add more burden on them by way of additional taxes. However, with the introduction of Patient Protection and Affordable Care Act (PPACA), in 2014, the number of people covered under private health insurance coverage was 66.0% compared the government’s coverage of 36.5% (Smith & Medalia, 2015). A majority of government funds went into covering hospital and healthcare center charges. Before the introduction of PPACA, the insurance companies were running healthcare, but with the arrival of PPACA, insurance companies could no longer dictate terms to customers. The introduction of PPACA affected public policy considerably.   

Rebuttal

Despite the ACA’s specific alteration of three different statues which had in the past shielded employees from having to contribute to the cost of their health insurance based on their achieving employer-designated health markers, it chose to leave alone recently enacted rules implementing the Genetic Non-Discrimination Act (GINA), which prohibits employers from asking employees about their family health history in any context, including assessing their risk for setting wellness targets (Bard, J.S, 2011).

about how these new laws will function and normative theories explaining the likelihood of future friction between the interests of the population of the United States as a whole who are in need of increased and affordable access to health care, and of the individuals living in this country who risk discrimination, as science and medicine continue to make advances in linking genetic make-up to risk of future illness.

Two Policy Arguments: Empirical & Positive

Empirical Evidence: Economic research demonstrates clearly that the expansion in coverage is generating major benefits for the newly insured by increasing access to needed care, improving health, and enhancing families’ financial security. But expanding coverage also has important benefits for the labor market and the macro-economy. Evidence gathered indicates that since the Affordable Care Act’s main coverage provisions took effect at the beginning of 2014, we have seen a precipitous decline in the uninsured rate unlike anything since the decade following the creation of Medicare and Medicaid, and the nation’s uninsured rate now stands at its lowest level ever. A recent analysis by the Department of Health and Human Services indicated that, as of the early months of 2015, an estimated 16.4 million people have gained coverage, including both people who have gained coverage since the end of 2013 and young adults who gained coverage before 2014 due to the law’s option to remain on a parent’s plan until age 26.

The Positives: With the exception of the politically entrenched and lob-sided pessimists on the other side of the aisle who see everything wrong with ‘Obama Care’ ( ACA), the overall consensus is that the policy has really saved millions of American lives by ensuring that many who previously were uninsured, got covered, and therefore gained some kind of health security. The case of young adults remaining on their parents policies until age 26 is indeed laudable, much more to talk about the elimination of ‘pre-existing conditions’ from the dictionary of insurance companies. The law has really brought great sanity into the previously chaotic and messy insurance market.

Conclusion

It is observed from the above that no matter the amount of empirical evidence put forward by the Obama Administration in respect of the need for the Affordable Care Act, opponents especially Republicans, insurance companies, and interested stakeholders would equally advance anecdotal evidence to rebuff the goodness and gains of the 2010 Act. Overall, the discussions and discourse have proven to be healthy as it has awaken officialdom to work tirelessly to make the Act a better one than the system it replaced.

References:

Abbott, Randall K. ‘The Impact of the Affordable Care Act on Large Employers: A Retrospective.’ Benefits Quarterly. 2015 First Quarter, vol. 31. Issue1,pp8-14

Bard, J. S. (2011), When Public Health and Genetic Privacy Collide: Positive and Normative Theories Explaining How ACA’s Expansion of Corporate Wellness Programs Conflicts with GINA’s Privacy Rules. The Journal of Law, Medicine & Ethics, 39: 469–487. doi: 10.1111/j.1748-720X.2011.00615.x

Birkland, T. A. (2011). An Introduction to the Policy Process: Theories, Concepts, and Models of Public Policy Making. (3rd ed.). Armonk, NY: M.E. Sharpe, Inc. Retrieved 02/12/16 at https://strayer.vitalsource.com/#/books/9780765627315/cfi/0!/4/4@0.00:64.8https://strayer.vitalsource.com/#/books/9780765627315/cfi/0!/4/4@0.00:64.8.

Bonagura, D.G. 2013. Liberals, Conservatives, and the New Orthodoxy. Retrieved from https://www.thecatholicthing.org/2013/03/07/liberals-conservatives-and-the-new-orthodoxy/ on February 28th, 2016.

Foster, R. (2010). Estimated Financial Effects of the “Patient Protection and Affordable Care Act,” as Amended cms.gov. Retrieved 11 February 2016, from https://www.cms.gov/Research-Statistics-Data-and-Systems/Research/ActuarialStudies/downloads/PPACA_2010-04-22.pdf

Jones, D.K., Bradley, K.W.V., Oberlander, J. (2014). Pascal’s Wager: Health Insurance, Exchanges, Obamacare and the Republican Dilemma. Journal of Health, Politics, Policy & Law, 39(1), 97-137.

Mariner, Wendy K., The Affordable Care Act and Health Promotion: The Role of Insurance in Defining Responsibility for Health Risks and Costs (April 11, 2012). Duquesne University Law Review, Vol. 54, p. 271, Spring 2012; Boston Univ. School of Law, Public Law Research Paper No. 13-10 . Available at SSRN: http://ssrn.com/abstract=2237628

ObamaCare Facts: Facts on the Affordable Care Act (n.d.). Retrieved 1/22/2016 athttp://obamacarefacts.com/obamacare-facts/

Smith, J., & Medalia, C. (2015). Health Insurance in the United States: 2014. census.gov.www.hhs.gov/healthcare/about-the-law/index.html. Retrieved 2/12/2016.