Protests follow US Congress’s passing of health reform billBMJ 2010; 340 doi: https://doi.org/10.1136/bmj.c1771 (Published 30 March 2010) Cite this as: BMJ 2010;340:c1771
Violent local protests took place after President Barack Obama signed into law the health reform bill passed on 21 March by the House of Representatives (BMJ 2010;340:c1635, 22 Mar, doi:10.1136/bmj.c1635). Days later, on 25 March, the House passed the reconciliation bill to finalise changes, bringing the different bills passed by the Senate and the House in line. The president will sign the reconciliation bill this week.
Republicans moved immediately to repeal health reform. The attorneys general of 14 states began legal fights to declare the bill unconstitutional.
Republicans said they would campaign on the issue in the November elections, when all members of the House of Representatives and a third of the Senate will be running for re-election.
President Obama dared the Republicans to try that tactic. “If they want a fight we can have it,” he said to a supportive crowd in Iowa.
In the past, important social legislation such as Social Security (pensions for elderly people) and Medicare and Medicaid (health insurance for elderly and poor people) met objections at first but then was widely accepted. Several polls have shown increasing support for health reform.
Republicans said that health reform was unconstitutional because it forced people to buy health insurance or face penalties. They also said it was expensive, would cause job loss, would hurt small businesses, and would mean a leftist, socialist government takeover of a significant part of the US economy.
The influential conservative talk show host Rush Limbaugh said, “We need to defeat these bastards. We need to wipe them out.” Another conservative talk show host, John Gambling, suggested that the healthcare reform bill was “an ‘ism’—communism, socialism, fascism, whatever you call it, not what this country is about.”
Several Democrats have received death threats. Windows and glass doors of local offices of several Democrats were shattered. The local office of a New York Congressional representative received a white powder in the mail, a reminder of the anthrax attacks in 2001 that killed several people. It turned out to be harmless.
Sarah Palin, who ran for vice president with John McCain on the losing Republican ticket in the 2009 election, joined Mr McCain at a “Tea Party” rally supporting his re-election campaign and called for the repeal of health reform. The Tea Party movement is a loosely organised conservative group. Its name recalls American patriots who threw chests of tea into Boston harbour in 1773 in protest against the Stamp Act, a key event in the build up to the American revolution.
As health reform slowly takes effect, Americans whose insurance coverage is already provided by their employers will see little change. However, employers who do not provide insurance will be required to or else pay a penalty.
People who do not have insurance through their employer will have to buy a policy. They will receive subsidies and tax credits but face a penalty if they do not buy a policy. They will be able to choose a policy from those offered in “exchanges,” which will be like internet shopping malls for policies.
People on high incomes will be more highly taxed in future, to help pay for the reforms, and high benefit health plans will be taxed.
Health reform will benefit health insurance companies, because about 32 million people who are currently uninsured will have to buy health insurance. However, companies will face more regulation. They are required to insure people with pre-existing conditions and are forbidden from ceasing people’s coverage if they become ill. Women will no longer pay higher health insurance premiums than men. People will no longer lose their insurance if they change jobs, because they will be able to buy a policy through an exchange.
Doctors are expected to see more patients because more people will have health insurance. Medicaid (the federal insurance programme for poor people and children) will be expanded to cover more people. However, Medicaid payments to doctors are notoriously low, so doctors may be reluctant to accept more patients with low insurance reimbursement.
Under separate legislation, Medicare payments to doctors who care for elderly people will be reduced unless Congress acts soon. Doctors can refuse to accept patients on Medicare or Medicaid, and many do so.
Hospitals will see more patients with health insurance, rather than uninsured people who come to the emergency room with severe health problems. Under US law hospitals are obliged to treat emergency patients, even if they are uninsured, but are not obliged to provide continuing care.
Experts say that it is difficult to predict how the changes will affect hospitals’ budgets. On one hand, hospitals will carry fewer losses for providing emergency treatment to people without insurance, but on the other hand hospitals are usually reimbursed less than the actual cost of treating Medicaid patients, so treating more newly insured Medicaid patients might increase hospitals’ losses.
Drug companies will benefit because more people will be prescribed drugs. Provisions in the reform bill will reduce the “doughnut hole” gap in Medicare, which requires elderly people to pay thousands of dollars out of their own pocket when they have exhausted their drug benefits but before catastrophic drug coverage takes over. Some elderly patients reduce or stop their prescription drugs when caught in the gap; so, as the gap is reduced, their use of prescription drugs may rise.
States will see an increasing burden because they share the cost of Medicaid.
Many provisions in the health reform legislation will not take effect for several years, but some changes will take place this year.
For individuals, the first benefit will be a federally funded insurance pool for high risk individuals, which is to be set up within three months. Women will be able to receive preventive care services without paying part of the cost (so called co-payments) within six months. People aged over 65 who are receiving Medicare will receive a rebate on their drug costs in the “doughnut hole.” Some small businesses will get tax credits to help them cover the cost of insuring their employees.
Cite this as: BMJ 2010;340:c1771
See Observations, BMJ 2010;340:c1778, doi:10.1136/bmj.c1778.