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Chapter 1 - Health Reform

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Content Last Updated: 5/21/2013 7:18:16 PM
Graphics Last Updated: 6/27/2013 3:38:35 PM
Note: Terms in green will show glossary definitions when clicked.

Originally written by Joanne Kenen, New America Foundation. Updated April 2010 by Joanne Kenen. (Research assistance from Meredith Hughes and Allison Levy.)
This chapter was made possible by the Robert Wood Johnson Foundation. 

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Fast Facts

  • The health care reform law enacted in March 2010 will reduce the number of uninsured nonelderly people by an estimated 32 million.1
  • As a result of the reform law, 94 percent of nonelderly citizens and legal residents are expected to have coverage by 2019.2
  • Some 23 million nonelderly people will remain uninsured by 2019, according to the Congressional Budget Office.3
  • As of 2008, 46.3 million nonelderly people in the U.S. lacked health coverage up from 45.7 million in 2007, according to the U.S. Census Bureau.4
  • Nearly 82 percent of the uninsured in 2009 lived in families headed by workers.5
  • In 2008, 17.2 percent of full-time employees and 25.5 percent of part-time employees age 19-64 were uninsured all year.6
  • Another 25 million Americans adults are considered by some analysts to be underinsured, up 60 percent from 2003. This means that they are exposed to high out-of-pocket health care costs relative to their incomes.7
  • An estimated $2.34 trillion was spent on health care in the United States in 2008, nearly 16.2 percent of the Gross Domestic Product (GDP).8
  • The Centers for Medicare and Medicaid Services estimates that in 2009, national health expenditure grew to $2.46 trillion, approximately 17.3 percent of the GDP.9
  • Nonetheless, the United States lags behind other industrial nations in many health care quality indicators.10
  • Health care reform is expected to save $124 billion over 10 years, and bring down the federal budget deficit by about one-half percent of GDP in the next decade
  • Researchers estimate that 30 to 40 cents of every health care dollar spent in the U.S. goes for poor quality care.11

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The Law of the Land

Health reform is now the law of the land. On March 23, 2010 President Barack Obama signed the Patient Protection and Affordable Care Act, and one week later he followed with modifications in a budget reconciliation bill.

The legislation, which will result in an estimated 32 million uninsured Americans getting health coverage by 2019, will begin to redesign a fragmented, uncoordinated and highly expensive health care system. The new law was the fulfillment of a goal sought by reformers, with varying degrees of intensity, since Theodore Roosevelt introduced the idea of coverage for all in the 1912 Progressive Platform.

As President Obama noted, it was a “remarkable and improbable” achievement.12   Yet in our current polarized environment, it remains fraught with political and policy uncertainties that could shadow implementation in the years to come.

Historically, our discussions of national health reform focused on coverage. This time, the Obama administration and its allies effectively made the case that health reform is greater than coverage alone. Coverage, cost and quality, they argued, are intrinsically entwined, and cannot be addressed by piecemeal or incremental solutions.

Our system, rooted in a mid-20th century acute care model, does not adequately meet the health care or economic needs of the 21st century, where the overarching medical challenge, and expense, is due to chronic disease in an aging population.13  

Reform advocates argued that the cost of inaction outweighed the cost of action,14 and that state and federal governments, large and small businesses, and ordinary American families needed relief from the unrelenting and unsustainable upward march of health care costs.15 And they convinced a majority of lawmakers, albeit a narrow Democrats-only majority, that covering the uninsured in a revamped and modernized high quality health care system is the morally and fiscally responsible American way. 

Health care reform is difficult because it’s big and complicated, with lots of moving parts and unintended consequences. It affects one-sixth of the economy, and touches every doctor, hospital, and community. It’s also hard because even in less volatile political times Washington debates are not always about health care per se, but about politics, power, and the size and reach of government. 

The battle over health care did not end with the votes in the House and Senate. It will play out in the political campaigns of 2010 and 2012 and possibly beyond – in state and federal courts, and in Congress and statehouses charged with setting up exchanges, writing and implementing regulations, and appropriating funds so that health reform becomes not only a law but a reality. 

The 18 months of debate and the opening phase of implementation were shaped by an interesting paradox. As Prof. Robert Blendon of the Harvard School of Public Health has explained, many in the U.S. are skeptical about “health reform” but support many of reform’s components, such as creating health insurance exchanges, subsidizing the poor, or requiring insurers to cover people with pre-existing conditions.16   Reform’s success in the long term will be determined in part by whether and when the American public decides that health reform is the sum of its reasonably popular parts.

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As noted, the health care reform law will result in coverage for an anticipated 32 million Americans and legal immigrants – 16 million through the biggest-ever expansion of Medicaid.17 The percentage of insured nonelderly residents (excluding illegal immigrants) is expected to increase from 83 percent in 2008 (the latest figure available), to 94 percent in 2019.18 About 23 million nonelderly residents (one third of whom are undocumented immigrants) will remain uninsured.

Although only Democrats voted for the final legislation, the bill itself was an amalgam of ideas from both parties. The individual mandate, for instance, was initially a Republican idea that came to prominence during President George H.W. Bush’s administration.19

The new health care law is a hybrid of public and private solutions. It maintains the current employer-based system but fills in the gaps by expanding public programs, notably Medicaid, and devotes more resources ($11 billion from FY 2010-15) to community health clinics.20 It creates “exchanges” or purchasing pools starting in 2014 to help individuals and small business purchase affordable and reliable coverage.21

The exchanges, which according to the Congressional Budget Office will cover about 29 million people by 2019, will have to follow new rules and will provide new consumer protections.22 (Not everyone who will be covered in the exchanges is currently uninsured, nor will all individuals in the exchange be subsidized. Undocumented immigrants will not be allowed to buy plans within the exchanges.)

Insurers will have to cover everyone, including people with pre-existing health conditions. They won’t be able to charge a higher premium based solely on a person’s health status.23 There will be limits on how much individuals and families will have to pay out of pocket in any year, and plans will include better coverage for preventive care. (Other consumer protections come into play earlier.)

The “public plan” – an option for a government-sponsored health plan within the state exchanges – was dropped from the final legislation. Exchanges will instead contain nonprofit co-op plans, as well as national plans negotiated by the federal government but privately run by insurers. (For more details on the exchanges and the new regulatory framework, see the Kaiser Family Foundation’s summary at

The health reform law calls for shared responsibility – government, individuals and businesses all have obligations. People who do not buy insurance, or businesses that do not cover their workers, will face penalties. Small businesses and low-income individuals will receive subsidies, and there will be some exemptions based on affordability. People can get subsidies on a sliding scale up to 400 percent of the federal poverty level. (See Chapter 2, "Cost of Health Care," for details on coverage levels and subsidies.) (For more details, go to

In addition, the legislation creates the CLASS Act (Community Living Services and Supports Act), a form of limited government-backed long-term care insurance. Participation is voluntary. The benefit won’t cover all long-term care costs, but will provide some at-home care assistance for the elderly or disabled who need help with routine daily activities such as eating or bathing. The law expands and creates several other initiatives aimed at providing community-based, rather than institutional care of the elderly and disabled. (See Chapter 9, “Long-Term Care,” for more.)

The health reform law gradually closes the “doughnut” hole or coverage gap in the Medicare prescription drug benefit,24 expands preventive care coverage in Medicare (and Medicaid), and covers annual physicals and wellness visits for some Medicare beneficiaries.25

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Cost and Financing

The nearly $1 trillion coverage expansion will be funded in part by higher Medicare payroll taxes on upper income families, excise taxes on so-called “Cadillac” health insurance policies, and fees paid by pharmaceutical companies, hospitals and insurers. Payments to Medicare Advantage, the private Medicare plans, will also be restructured to eliminate overpayment. The health reform law includes neither a cap on overall health spending, nor government-imposed rationing, although opponents of the legislation maintained that some provisions – evaluating the effectiveness of different treatments, for example -- could eventually lead to rationing.

Constraining health care spending was part of the health reform debate from the very beginning. (See chart, "Actual and Projected Health Spending for Selected Years, 1993 - 2019.") Some of the projected savings in the new reform law will come from “delivery system” reforms and changed payment incentives. These involve strategies to shift the health care system to some extent away from its acute care orientation, and more toward care of patients with chronic disease, which is responsible for 78 percent of our national health expenditures.26 The legislation includes numerous incentives, pilot projects, demonstrations and experiments designed to create a more integrated and coordinated system, while simultaneously improving quality and restraining cost growth.  New tools include medical homes, accountable care organizations, and bundled payments for episodes of care.  (See "Quality" section below and Chapter 3, "Quality of Care.")

One of the new cost containment tools will be the Independent Payment Advisory Board, which will make Medicare payment and waste-reduction recommendations to Congress (although hospitals are exempt through 2019). Another is the new Center for Medicare and Medicaid Innovation, which will allow new patient-centered care models to be tested, recalibrated, and introduced system-wide with more speed and flexibility than traditional demonstration projects.27 In addition, the legislation creates a pathway for approval of biogenerics (drugs based on biologically active substances), steps to strengthen the primary care workforce, and a new Patient-Centered Outcomes Research Institute to oversee federally sponsored comparative effectiveness research to determine what drugs, devices or procedures work best. 28   (See Chapter 2, "Cost of Health Care." )

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We all have heard the statement that the United States has the best health care in the world. We can no longer take this for granted. (See chart, "Scores for U.S. on Dimensions of a High Performance Health System, 2006 and 2008.") Our health care markers in several areas lag behind other industrialized nations, even though we spend much more per capita and a higher percentage of our GDP.29  

In a 2007 study by The Commonwealth Fund, the U.S. health care system ranked next to last in quality compared to the United Kingdom, Germany, Australia, New Zealand and Canada. The U.S. was last among the six countries in delivering safe care, and next to last in delivering the right care, coordinated care and patient-centered care.30

Another example: about half of chronic care patients in the U.S. did not fill prescriptions, get the recommended care, or see a doctor in 2008 because of cost, compared to 7 percent to 36 percent in other industrialized countries.31

In the last few years, the dialogue about health care quality has begun to change in Washington. More experts,  both liberal and conservative, have concluded that we need to shift resources and priorities into primary care, care coordination, prevention and wellness.32 The health reform legislation begins to do this, by experimenting with new ways of paying doctors and hospitals, rewarding care management and coordination, and beginning to shift the system to reward quality, not quantity. (See Chapter 3, “Quality of Care,” for details.)

Many of these provisions in the legislation are modest steps or experiments, focused on government-run programs like Medicare and Medicaid, and it is not clear how quickly or powerfully they will ripple through the whole health care system. The law, however, requires a national quality improvement strategy, which includes wellness and population health, as well as a new effort to document and address health care disparities.

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Among the tools that aim at creating a high performing health system:

Chronic disease management, medical homes and Accountable Care Organizations
The Centers for Disease Control and Prevention (CDC) estimates that 133 million Americans live with one or more chronic diseases such as hypertension, diabetes or asthma, and that chronic disease accounts for 70 percent of U.S. deaths33   and nearly 78 percent of health care spending.34 (See text box, "Four Common Causes of Chronic Disease.") The health reform law encourages the development of  "medical homes" where doctors are paid to manage and monitor chronic diseases, and while medical homes may be part of the solution, more research is still needed.35  

The legislation also encourages Accountable Care Organizations, encompassing new relationships between primary and specialty care doctors and hospitals. Using a more integrated and evidence-based approach to care, providers will have to meet quality benchmarks but can share in savings from Medicare or Medicaid. (See the quality chapter for more.)

Workforce/primary care
Fewer U.S. medical students have chosen primary care careers, such as family medicine, pediatrics, geriatrics and related fields in recent years.36 A 2007 survey of fourth-year medical students found that only 23.2 percent were considering a career in internal medicine, and only two percent were considering a career in general internal medicine.37 Fields such as radiology, orthopedics, anesthesiology and dermatology, with higher pay and easier hours, are more popular.38

To expand access to primary care services, the health reform law improves Medicare and Medicaid primary care reimbursements (although the legislation specifies these improvements only for the next five years in Medicare and only for 2013 and 2014 in Medicaid). The law also contains other incentives, including a reallocation of Graduate Medical Education residency training slots to encourage medical students to pursue careers in primary care and general surgery.

Some argue that nurse practitioners can meet part of the primary care demand.39 Nurse practitioners are registered nurses with master's or doctoral degrees and advanced clinical training. The legislation expands education, training and loan support for nurses and nurse practitioners. The legislation also establishes grants for staff training and other patient protection and quality improvements for nursing home and other long-term care facilities.40

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Payment reform
The legislation contains financial incentives for hospitals to reduce unnecessary readmissions and bring down rates of hospital-acquired infections and related conditions.

It authorizes tests of bundling, or paying a team of providers for one episode of care across several health care settings in a way that rewards quality, coordination of care among providers and outcomes.41 It creates Community-based Collaborative Care Network Programs which aim to improve chronic disease treatment and management in outpatient settings.

The law expands and creates several other initiatives aimed at providing community-based, rather than institutional-care of the elderly and disabled. 

Health Information Technology
Physicians have been slow to embrace health information technology (IT) and most still write prescriptions on paper. As of 2008, only 18 percent of physicians reported using a form of basic electronic health records even though IT is routinely used in other settings, including privacy-sensitive ones such as banking and shopping.42

Barriers to wider adoption include cost, debates over who should pay, worries about obsolescence, steep learning curve, concerns over maintaining patient privacy and lack of interoperability among health IT systems.43

The American Recovery and Reinvestment Act of 2009 pledged almost $20 billion in government funding to assist and incentivize “meaningful use” of health IT. The CMS priorities for “meaningful use” of IT include improving the quality, safety, and efficiency of health care, reducing disparities and improving public health, improving care coordination and engaging patients, and ensuring privacy protections for personal health information.44

The new health reform law provides additional support for health IT, requiring the development of national standards for the management of data collection, interoperability among HIT systems and security systems for data management.45

In the public health arena, large pools of privacy-protected data could lead to early identification of epidemics or bioterrorism, and help comparative effectiveness research.  

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Public Health
Employers and states are putting new emphasis on wellness and prevention, particularly regarding obesity, exercise, tobacco and diabetes prevention and management. The health legislation allows more leeway for employers to link workplace wellness to insurance premiums.

Bioterrorism legislation since the September 11 attacks has helped modernize the public health infrastructure in ways that enhance emergency preparedness for either a natural epidemic or a bioterrorist attack. (See Chapter 12, "Public Health," for more.) The reform legislation provides grants to help public health agencies improve surveillance of infectious diseases and other public health problems, and respond to these threats.46

Public health researchers have stepped up efforts to understand and address the persistent and sometimes perplexing racial and socioeconomic disparities in our health care system, and the health reform law encourages further work in this area. (See Chapter 10, "Disparities," for more.)

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Health reform is a massive change. Some of the forecasts about its effects are educated guesses based on models and assumptions – assumptions about economics, health and the future actions of politicians as well as health care providers. Concerns remain, in particular, about whether competition, regulation, and administrative simplification in the state insurance exchanges will make insurance affordable for the middle and lower-middle class. 

Health reform, and its implementation, is also a work in progress. Congress takes up some aspect of Medicare, Medicaid or health policy almost every year. Sometimes it’s a small tweak to payment formulas. Sometimes it’s a sea change, like covering AIDS drugs or providing Medicare to the disabled, or covering poor children under the Children’s Health Insurance Program. 

The 2010 reform legislation will need tweaks, adjustments, and possibly over time, major amendments. States too will continue to experiment on their own. Some insurers and health plans may resist change; others may find their economic self-interest and the health interests of the population they serve coincide.  And this assumes that announced efforts by some Republicans to repeal the law are unsuccessful.

In addition, the United States faces deep deficits for years to come. The health sector is unlikely to be off limits to a national debt-reduction strategy. Lawmakers pondered, and discarded, dozens of potential revenue raisers for health reform, ranging from taxes on sugary soft drinks to sweeping changes to the tax code.47 Expect to see many of these ideas resurface in a new context as the nation grapples with its deficit and debt.

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  • One of the most common errors reporters make is equating universal health care with government-run or socialized medicine. They aren't the same thing, even if some politicians claim they are. Socialized medicine means that hospitals are owned by the government, and most health providers are government employees. Universal health care simply means that everybody is covered: whether in a public system, a private system, or as is the case under U.S. health reform, a public-private hybrid.48
  • More health care does not always equal better health care. Get familiar with the basic ideas of the Dartmouth Atlas of Health Care ( In more than 30 years of work, the Dartmouth researchers have discovered huge differences in how people are cared for in different parts of the country. Regions that spend more on very sick people do not necessarily have better outcomes. In fact, lower-spending regions often show better results, partly because they tend to use more primary care and proportionately fewer specialists.49
  • Health policy as an academic field has grown tremendously since the early 1980s, in and outside of Washington. And nowadays it's all online, which makes the Washington think tanks more accessible to regional reporters. In addition, journalists can now tap into expertise in health or public policy departments at local universities. These academic experts can both help translate national policy and explain the impact of national proposals on a specific region or state.
  • Almost every story can be a health care story. Whether a reporter is covering a labor dispute, the local economy, personal bankruptcy, local politics or early childhood well-being, health care can nearly always be part of the picture.
  • More clinicians and provider groups have begun to encourage health care improvements on a local scale. Identify innovators in your community through organizations such as the Robert Wood Johnson Foundation, the Institute for Healthcare Improvement, and the American Academy of Family Physicians. Learn through your local hospitals and medical associations which providers are taking part in national pilot and demonstration programs, and which health plans may be backing innovation in the private sector too.
  • Find out what's unique about your state's health care system. Many states and governors are testing their own approaches to more affordable coverage and more integrated or evidence-based delivery of care.  The State Coverage Initiatives program, sponsored by the Robert Wood Johnson Foundation and administered by AcademyHealth in Washington, DC, keeps tabs on reforms at the state level ( The program offers policy and technical assistance to help states expand coverage and launch other reforms. The National Academy for State Health Policy is another useful resource (
  • The Association of Health Care Journalists ( has links to many resources, webcasts, and tip sheets of use to reporters covering reform.

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  • Does your community have a primary care shortage? How easy is it to get a primary care doctor? What is your state or community doing to encourage more doctors to go into primary care? Understand the role of primary care providers as care coordinators, not necessarily as HMO-style gatekeepers.
  • Much of our spending is - and will be - on the sickest patients near the end of life. But some of the money we spend in that period is on care that people do not really want, or care that we know will not improve their health or even prolong their life.  How is the new field of palliative medicine evolving, and can it save money while improving quality?  What kinds of hospitals (nonprofit, academic, for-profit, public?) offer palliative care and how easy is it to access?
  • "Medical homes" are appearing in numerous communities. A definition from the American Academy of Pediatrics: "Primary care that is accessible, continuous, comprehensive, family centered, coordinated, compassionate and culturally effective."50    Are there medical homes in your community? If so, what do they look like? How can patients access them? What is it like to be a patient in one of them? Is this a genuine innovation or new name for primary care?
  • Spend some time with local medical students. How much do they know about the health care system that they are entering?
  • Your local emergency room is a barometer for the health of your community’s medical system. Is it crowded? If so, it may be not only because of the growing numbers of uninsured. Explore how much of the overcrowding in your community is due to lack of insurance, how much is caused by the inability of the insured to access timely primary care (including nights and weekends). How much is due to internal management and patient flow problems within the hospital? If your ER isn't crowded, what are they doing right? How are people getting appropriate community-based care?
  • The Centers for Medicare and Medicaid Services, the federal government's Medicare agency, recently introduced "never event" payment rules, meaning they won't pay for certain avoidable conditions such as wrong-site surgery or certain hospital-acquired infections.51 Some states and private insurers are introducing similar policies. This isn't expected to radically change payments to hospitals in the early years, but it is designed to make hospitals take a hard look at how they can improve quality. How do hospitals in your community stack up? How have they  responded to the new policy? Is your state requiring hospitals to do more reporting on mistakes or hospital-acquired conditions including infections?
  • More employers are introducing workplace wellness and prevention programs. Are they working? Are they cost-effective? Do they discriminate against people who have chronic conditions?
  • Community health clinics have taken on an expanded role in covering the poor and the uninsured, and this will grow in the coming years. The new reform law includes major new funding for these clinics.  Quality varies; some clinics are actually de facto medical homes, which do a good job of providing primary care, coordinating chronic disease, and linking patients to needed social services in the community. How do your local clinics stack up?52



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Stuart Altman, Professor of National Health Policy, Brandeis University, 781/736-3804,

Stuart Butler, Vice President, The Heritage Foundation, 202/546-4400

Michael Cannon, Director of Health Policy Studies, Cato Institute, 202/789-5200,

Nancy Chockley, President, National Institute for Health Care Management, 202-296-4426,

Gary Claxton, Vice President/Director, Health Care Marketplace Project, Kaiser Family Foundation, 202/347-5270

David Colby, Vice President for Research and Evaluation, Robert Wood Johnson Foundation, 609/627-5754,

Sabrina Corlette, Director of Health Policy, National Partnership for Women and Families, 202/986-2600,

Peter Cunningham, Senior Fellow, Center for Studying Health System Change, 202/484-5261,

Richard Curtis, President, Institute for Health Policy Solutions, 202/789-1491,

Karen Davis, President, The Commonwealth Fund, 212/606-3800,

Stan Dorn, Senior Research Associate, Urban Institute, 202/833-7200

Michelle Doty, Associate Director of Research, The Commonwealth Fund, 212/606-3800,

Lynn Etheredge, Consultant, Health Insurance Reform Project, George Washington University, 301/654-4185

Pamela Farley Short, Professor and Director, Center for Health Care and Policy Research, Penn State University, 814/863-8786

Judy Feder, Professor, Public Policy Institute, Georgetown University, 202/687-8397

Steve Finan, Senior Director of Public Policy, American Cancer Society, 202/661-5700 

Paul Fronstin, Director, Health Research Program, Employee Benefit Research Institute, 202/775- 6352,

John Geyman, Professor Emeritus of Family Medicine, University of Washington, 360/ 378- 4814,

Paul Ginsburg, President, Center for Studying Health System Change, 202/484-5261,

Stuart Guterman, Assistant Vice President, Payment System Reform, The Commonwealth Fund, 202/292-6735,

Jocelyn Guyer, Senior Program Director, Center for Children and Families, Georgetown University, 202-784-4077

Edmund Haislmaier, Research Fellow, The Heritage Foundation, 202/546-4400

Antoinette Hays, Dean, Regis College School of Nursing and Health Professions, 781/768-7122,

Ida Hellander, Executive Director, Physicians for a National Health Program, 312/782-6006,

David Himmelstein, Associate Professor of Medicine, Harvard Medical School, 617/ 497- 1268,

John Holahan, Director of Health Policy Research, Urban Institute, 202/261-5666

Joy Johnson Wilson, Federal Affairs Counsel, National Conference of State Legislatures, 202/624-5400,

Judith Miller Jones, Director, National Health Policy Forum, 202/872-1469,

Risa Lavizzo-Mourey, President & CEO, Robert Wood Johnson Foundation, 888/631-9989,

Barbara Lyons, Deputy Director, Commission on Medicaid and the Uninsured, Kaiser Family Foundation, 202/347-5270,

Enrique Martinez-Vidal, Vice President, AcademyHealth, and Director, State Coverage Initiatives Program, 202/292-6700

Don McCanne, Senior Health Policy Fellow, Physicians for a National Health Program, 949/493-3714,

Catherine McLaughlin, Director of Health Research, Mathematica Policy Research, 734/794- 1122,

Tom Miller, Resident Fellow, American Enterprise Institute, 202/862-5886,

Robert Moffit, Director, Center for Health Policy Studies, The Heritage Foundation, 202/546-4400

Len Nichols, Professor and Director, Center for Health Policy Research and Ethics, George Mason University, 703/993-1978, 

Ron Pollack, Executive Director, Families USA, 202/628-3030, Communications Director: David Lemmon --

Karen Pollitz, Project Director, Health Policy Institute, Georgetown University, 202/687-3003

Uwe Reinhardt, James Madison Professor of Political Economy, Princeton University, 609/258- 4781

Sara Rosenbaum, Chair of Department of Health Policy, George Washington University, 202/530- 2343

Diane Rowland, Executive Vice President, Kaiser Family Foundation, 202/347-5270,

Matt Salo, Director, Health & Human Services Committee, National Governors Association, 202/624-5336,

Greg Scandlen, President and CEO, Consumers for Health Care Choices, 301/606-7364

Gordon Schiff, Associate Director of the Center for Patient Safety Research and Practice, Harvard Medical School, 617/ 732-4814,

Gail Shearer, Director, Health Policy Analysis, Consumers Union, 202/462-6262,

John Sheils, Vice President, The Lewin Group, 703/269-5610,

Judith Stein, Executive Director, Center for Medicare Advocacy, 860/456-7790,

James Tallon, President, United Hospital Fund, 212/494-0700,

Ken Thorpe , Professor and Chair, Rollins School of Public Health; Executive Director, Partnership to Fight Chronic Disease Advisory Board, Emory University, 404/727-3373

Grace-Marie Turner, President, Galen Institute, 703/299-8900

Alan Weil, Executive Director, National Academy for State Health Policy, 202/903-0101

Ellen-Marie Whelan, Associate Director of Health Policy, Center for American Progress, 202/481-8162,

Gail Wilensky, Senior Fellow, Project Hope, 301/656-7401,

Steffie Woolhandler, Associate Professor of Medicine, Harvard Medical School, 617/ 497- 1268,

Steve Zuckerman, Principal Research Associate, Urban Institute, 202/833-7200

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Marjorie Kanof, Managing Director, Health Care, Government Accountability Office, 202/512-7114

Charles Nelson, Assistant Division Chief, Income, Poverty and Health Statistics, US Census Bureau, 301/763-3183,

C. Stephen Redhead, Specialist in Health Policy, Congressional Research Service, 202/707-2261,

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David Abernethy, Senior Vice President, HIP Health Plans, 202/393-0660,

Alissa Fox, Senior Vice President, Office of Policy and Representation, Blue Cross Blue Shield Association, 202/626-8681,

Mary Grealy, President, Healthcare Leadership Council, 202/452-8700,,  (assistant)

Robert Graham, Professor, Robert and Myfanwy Smith Chair, Department of Family Medicine, University of Cincinnati College of Medicine, 513/558-5004

George Halvorson, Chairman and CEO, Kaiser Permanente, 510/271-5660

Angela Hunter, Director of Federal Affairs, Council for Affordable Health Insurance, 703/836- 6200 x387,

Charles Kahn, President, Federation of American Hospitals, 202/624-1500

Sister Carol Keehan, President, Catholic Health Association, 202/296-3993

Jeff Lemieux, Senior Vice President, Center for Policy and Research, America's Health Insurance Plans, 202/778-3200,

Robyn Martin, Senior Policy Analyst, Service Employees International Union, 202/7307359,

James Mongan, President and Chief Executive Officer, Partners Healthcare, 617/278-1004

Meg Murray, Chief Executive Officer, Association for Community Affiliated Plans, 202/204-7509,

Michael Rodgers, Vice President for Public Policy and Advocacy, Catholic Health Association, 202/296-3993,

Gerry Shea, Assistant to the President, AFL-CIO, 202/637-5237,

Laura Trueman, Executive Director, Coalition for Affordable Health Coverage, 202/626-8573

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Alliance for Health Reform

Alliance of Community Health Plans

America's Health Insurance Plans

Association of Health Care Journalists

Blue Cross Blue Shield Association

California HealthCare Foundation

Catholic Health Association

Center for Health Care and Policy Research, Penn State University
Center for Studying Health System Change

Coalition for Affordable Health Coverage
The Commonwealth Fund health reform site

Consumers for Health Care Choice

Consumers Union

Council for Affordable Health Insurance

Cover the Uninsured Week

Economic Research Initiative on the Uninsured

Employee Benefit Research Institute

Families USA

Federation of American Hospitals

Galen Institute

George Washington University Department of Health Policy

Georgetown University Center for Children and Families

Georgetown University Health Policy Institute

Government Accountability Office

Health Affairs Journal

Health Research and Educational Trust

Healthcare Leadership Council

Heritage Foundation

Institute for Health Policy Solutions

Kaiser Commission on Medicaid and the Uninsured
Kaiser Family Foundation health reform site

Kaiser Health News

Lewin Group

National Academy for State Health Policy

National Coalition on Health Care

National Conference of State Legislatures

National Governors Association

National Health Policy Forum

National Institute for Health Care Management

National Partnership for Women and Families

National Women's Law Center

New America Foundation  

Robert Wood Johnson Foundation

Rollins School of Public Health, Emory University

State Coverage Initiatives

United Hospital Fund

Urban Institute

U.S. Census Bureau


1 Congressional Budget Office (2010). “Cost Estimate for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation): Table 4.” Congressional Budget Office Analysis. ('sAmendmenttoReconciliationProposal.pdf).

2 Congressional Budget Office (2010). “Cost Estimate for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation): Table 4.” Congressional Budget Office Analysis. ('sAmendmenttoReconciliationProposal.pdf).

3 Congressional Budget Office (2010). “Health Care.” (

4 U.S. Census Bureau (2009). "Table HIA-1. Health Insurance Coverage Status and Type of Coverage by Sex, Race and Hispanic Origin: 1999 to 2008."(

5 Fronstin, Paul (2009). “Sources of Health Insurance and Characteristics of the Uninsured: Analysis of the March 2009 Current Population Survey.” EBRI Issue Brief no. 334. Washington, DC: Employee Benefit Research Institute. p. 15. ( ).

6 Authors’ calculations based on U.S. Census Bureau, Current Population Survey, 2009 Annual Social and Economic Supplement. “Table HI01. Health Insurance Coverage Status and Type of Coverage by Selected Characteristics: 2008.” (

7 Schoen, Cathy, S. R. Collins, J. L. Kriss, and M. M. Doty (2008). “How Many Are Underinsured? Trends Among U.S. Adults, 2003 and 2007.” Health Affairs. p. w298. (

8 Hartman, Micah, Anne Martin, Olivia Nuccio, Aaron Catlin and others (2010). “Health Spending Growth At A Historic Low In 2008.” January, Exhibit 1.  (

9 Truffer, Christopher J., Sean Keehan, Sheila Smith, Jonathan Cylus, Andrea Sisko, John A. Poisal, Joseph Lizonitz, and M. Kent Clemons. "Health Spending Projections Through 2019: The Recession’s Impact Continues." Health Affairs 29.3 (2010): 522-29. (

10 The Commonwealth Fund (2007). 2007 International Health Policy Survey in Seven Countries. Nov. 1. ( )..

11 Lawrence, D (2005). “Bridging the Quality Chasm,” in Building a Better Delivery System: A New Engineering/Health Care Partnership, Institute of Medicine. Washington D.C.: National Academies Press, 2005. 99-101. (

12 Office of the Press Secretary White House. “Remarks by the President and Vice President at Signing of the Health Insurance Reform Bill.” The White House, 23 Mar. 2010. Web. (

13 Schoen, Cathy et al. (2008). In Chronic Condition: Experiences of Patients with Complex Health Care Needs, in Eight Countries, 2008. The Commonwealth Fund, Nov. 13. (

14 Holahan, John, Bowen Garrett, Irene Headen, and Aaron Lucas. “Health Reform: The Cost of Failure.” The Robert Wood Johnson Foundation and The Urban Institute, 21 May 2009. ( and Carpenter, Elizabeth; Axeen, Sarah. “The Cost of Doing Nothing.” The New America Foundation, 13 Nov. 2008. (

15 Nichols, Len; Axeen, Sarah. “Employer Health Costs in a Global Economy: A Competitive Disadvantage for U.S. Firms” New America Foundation policy paper. May 2008. ( ). and CED Research and Policy Committee (2007). "Quality, Affordable Health Care for All: Moving Beyond the Employer-Based Health-Insurance System." Committee for Economic Development. (

16 Blendon, Robert J., and John M. Benson. "Public Opinion at the Time of the Vote on Health Care Reform." The New England Journal of Medicine (2010). Online. (

17 Congressional Budget Office (2010). “Cost Estimate for H.R. 4872, Reconciliation Act of 2010 (Final Health Care Legislation): Table 4.” Congressional Budget Office Analysis. ('sAmendmenttoReconciliationProposal.pdf).

18 Ibid.

19 Rovner, Julie. "Republicans Spurn Once-Favored Health Mandate." Morning Edition. NPR. 15 Feb. 2010. Radio. (

20 "H.R. 4872, The Health Care and Education Reconciliation Act." 111th Cong. (enacted). Sec. 2303. (

21 "H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 1311. (

22 The Commonwealth Fund (2010). “Timeline for Health Care Reform Implementation: Health Insurance Provisions.” April 1. (

23 "H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 2704 and Sec. 2711-2712. (

24 H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 2713 and Sec. 4104-4106. (

25 "H.R. 4872, The Health Care and Education Reconciliation Act." 111th Cong. (enacted). Sec. 1101. (

26 Bodenheimer, Thomas, Ellen Chen, and Heather D. Bennett. "Confronting The Growing Burden Of Chronic Disease: Can The U.S. Health Care Workforce Do The Job?" Health Affairs Vol. 28, No. 1 (2009): 64-74. (

27 Mechanic, Robert and Stuart Altman. "Medicare’s Opportunity to Encourage Innovation in Health Care Delivery." The New England Journal of Medicine (2010). Online. (

28 "H.R. 3590, The Patient Protection and Affordable Care Act." 111th Cong. (enacted). Sec. 6301. (

29 The Commonwealth Fund (2007). Mirror, Mirror on the Wall: An International Update on the Comparative Performance of American Health Care. May 15. 2007, (

30 Ibid.

31 The Commonwealth Fund (2008). In Chronic Condition: Experiences of Patients with Complex Health Care Needs in, in Eight Countries, 2008. ( ).

32 Kaiser Family Foundation (2008). See sections on “Cost Containment” and “Improving Quality /Health System Performance,” in “2008 Presidential Candidate Health Care Proposals: Side-by-Side Summary.” ( )..
33 Centers for Disease Control and Prevention. Chronic Disease Overview. ( ).

34 Thomas Bodenheimer, 2009.

35 Alliance for Health Reform/Commonwealth Fund briefing (2008) Primary Care Innovation: The Patient-Centered Medical Home.  (

36 Ebell, Mark (2008).  Future Salary and US Residency Fill Rate Revisited. JAMA; 300(10): 1131-1132. (

37 Hauer, Karen E.; Steven J. Durning; Walter N. Kernan; et al. (2008). "Factors Associated with Medical Students’ Career Choices Regarding Internal Medicine." Journal of the American Medical Association. Vol. 300, No. 10. p.1154-1164.

38 Ebell, Mark (2008). “Future Salary and US Residency Fill Rate Revisited.” JAMA; 300(10): 1131-1132. (

39 Johnson, Carla K. "Doctor Shortage? 28 States May Expand Nurses' Role." The Associated Press. Google, 14 Apr. 2010. Web. (

40 The Scan Foundation (2010). A Summary of the Patient Protection and Affordable Care Act (P.L. 111-148) and Modifications by the Health Care and Education Reconciliation Act of 2010 (H.R. 4872). (

41 DesRoches, Catherine; Campbell, Eric; Rao Sowmya et al. (2008).  Electronic health records in ambulatory care -- a national survey of physicians. New England Journal of Medicine; 359:50-60.  ( ).

42 Hogan, Sean O. and Stephanie M. Kissam (2010). “Measuring Meaningful Use.” Health Affairs 29,
No. 4 , p. 601-606. (

43 Orszag, Peter (2008). Evidence on the Costs and Benefits of Health Information Technology. Testimony before the Subcommittee on Health of the U.S. House Ways and Means Committee, July 24, p. 17. ( ).

44 Halamka, John D (2010). “Making The Most Of Federal Health Information Technology Regulations.” Health Affairs 29, No. 4, p. 596–600. (

45 Section 4302.  PPACA (

46 Section 4304.  PPACA (

47 United States. Cong. Senate. Senate Finance Committee. Financing Comprehensive Health Care Reform: Proposed Health System Savings and Revenue Options. S. Rept. 20 May 2009. (

48 Dorn, Stan; Holahan, John (2008). Are We Heading Toward Socialized Medicine? Urban Institute, April 16. (

49 Baicker, Katherine; Chandra, Amitabh (2004). Medicare Spending, the Physician Workforce, and Beneficiaries Quality of Care. Health Affairs, W4.184. (

50 See PowerPoint presentation by Melinda Abrams at the Sept. 22, 2008, briefing cosponsored by the Alliance for Health Reform and The Commonwealth Fund, Primary Care Innovation: The Patient-Centered Medical Home, and other downloadable resources on this subject ( ).

51 DoBias, Matthew (2009). CMS makes never event nonpayment rules official. Modern Healthcare, Jan. 15. ( ).

52 Alliance for Health Reform (2009) Community Health Centers: Their Post-Stimulus Role in Health Reform. (

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Graphics for This Chapter

The Individual Market and Tax Treatment of Health Insurance

Health Expenditures as a percent of gross domestic product, selected countries - 2007

Four Common Causes of Chronic Disease

Actual and Projected Health Spending, Selected Years, 1993-2019

Scores for U.S. on Dimensions of High Performance Health System, 2006 and 2008


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