Journal of health politics, policy and law
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J Health Polit Policy Law · Feb 2014
Right-wing conspiracy? Socialist plot? The origins of the Patient Protection and Affordable Care Act.
On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act (ACA). Did the ACA signify a government takeover of the health care system, a first step on the road to socialism, as conservative critics charged? Or was it, rather, a sellout to the right wing, as liberal single-payer advocates proclaimed? The ACA's key provisions, the employer mandate and the individual mandate, were Republican policy ideas, and its fundamental principles were nearly identical to the Health Equity and Access Reform Today Act of 1993 (HEART), a bill promoted by Republican senators to deflect support for President Bill Clinton's Health Security plan. Yet the ACA was also a policy legacy of the Clinton administration in important ways that rarely are acknowledged, notably Medicaid expansion and insurance company regulation. Although the ACA departed from the liberal vision of a single-payer plan and adhered closely to the objectives of those who believed that the health care system should encourage the free market, it included provisions that will make coverage more affordable, reliable, and accessible.
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J Health Polit Policy Law · Feb 2014
Consumer choice in health insurance exchanges: can we make it work?
Under the Patient Protection and Affordable Care Act (ACA), consumer choice plays a critical role: it drives the competitive market in health insurance plans that will operate through health insurance exchanges. As the 2014 deadline for establishing exchanges approaches, states face choices: they can either allow the federal government to manage an exchange on their behalf; take on a minimalist role by managing a state exchange or partnering with the federal exchange; or assume an activist role--by aiming to influence the price, design, and quality of the health insurance options available through exchanges and taking steps to support consumers' ability to choose among these options. This article discusses states' choices and the governance issues that they raise, first by describing the extent of discretion that states have in shaping the range of health plans on offer as well as the issues they will need to consider in choosing an exchange model. We then discuss the considerable body of evidence that addresses how people behave in individual insurance markets, concluding that it strongly supports the need for states to take an active role in shaping health insurance exchanges and ensuring that they support consumer choice.
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J Health Polit Policy Law · Feb 2014
Pascal's Wager: health insurance exchanges, Obamacare, and the Republican dilemma.
Enactment of the Patient Protection and Affordable Care Act (ACA) created a dilemma for Republican policy makers at the state level. States could maximize control over decision making and avoid federal intervention by establishing their own health insurance exchanges. Yet GOP leaders feared that creating exchanges would entrench a law they intensely opposed and undermine legal challenges to the ACA. ⋯ Out of thirty states with Republican governors in 2013, only four launched their own exchange. Why did many Republican-led states that initially appeared open to establishing exchanges ultimately reverse course? Drawing on interviews with state policy makers and secondary data, we trace the evolution of Republican responses to the exchange dilemma during 2010-13. We explore how exchanges became controversial and explain why so few Republican-led states opted for their own exchange, focusing on the intensifying resistance to Obamacare amid a rightward shift in state politics, partisan polarization, and uncertainty over the ACA's fate.