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386 21 Organizing for Health Care Reform National and State-Level Efforts and Perspectives JACQUIE ANDERSON MICHAEL MILLER ANDREW MCGUIRE This chapter begins with an overview of how constituencies were built and mobilized and how “systems of advocacy” developed that helped make possible the passage of the Patient Protection and Affordable Care Act of 2010, despite an increasingly hostile political environment and widespread disinformation campaign. Lessons learned from state-level health care reform efforts, as well as from the failed national health care reform initiative under President Bill Clinton, will then be discussed. The impact on movement building of key setbacks along the way (e.g., loss of the public option critical to many more liberal supporters, and efforts of a well-orchestrated opposition movement to decrease public support during the crucial summer months before the final vote) also will be highlighted. The chapter then will examine an effort to establish “Medicare for All,” or single payer coverage, in the state of California and its organizing- and coalition-building strategies.1 On March 23, 2010, President Barack Obama made history when he signed the Patient Protection and Affordable Care Act (ACA) into law. The ACA holds the promise of providing affordable access to health care for more than 30 million Americans who now lack coverage and of improving coverage for tens of millions more. The ACA also has the potential to promote greater racial and economic equity, since the majority of the Americans who will be receiving coverage will be low-income families and communities of color (Henry J. Kaiser Family Foundation 2010). Key among its provisions were increased coverage through an expansion of Medicaid and by providing premium subsidies to low- and middle-income people (in the form of income-based tax credits) available through new, regulated insurance marketplaces, called exchanges, that were expected to reach about two-thirds of the uninsured population in the United States. The ACA also included a major overhaul of health insurance law, prohibiting carriers from imposing preexisting-condition exclusions, setting arbitrary dollar caps on coverage , or charging differential rates based on health status. The reformed health law ORGANIZING FOR HEALTH CARE REFORM 387 further would require carriers to offer coverage to all comers, offer at least a minimum-benefit package, and spend at least a minimum percentage of premium dollars on paying for the health care of their subscribers. The ACA purported to control costs while offering quality improvements. It further made significant new investments in public health, by requiring new private health insurance plans to fully cover the costs of a number of recommended preventive services. This means patients pay no deductibles or copayments or otherwise share costs of these services such as mammograms and colonoscopies. In addition, the law also requires coverage for a new annual wellness visit under Medicare and eliminates cost sharing for recommended preventive services covered by that federal program. The ACA also imposes a responsibility on most individuals and many employers to contribute to the cost of coverage. It thus required that all Americans carry a minimum-level insurance by 2014. Equally significant, however, is what the ACA does not contain. Efforts to expand coverage for all based on Medicare were never able to gain serious political traction in Congress and the question of how coverage for immigrants would be addressed quickly became a lightning rod during the debate (with certain immigrants excluded from coverage altogether). Elements of the original proposal that had broad popular backing but were opposed by various health care industry groups, such as creating a public insurance plan (the “public option”) to compete with private insurers, fell by the wayside during the debate (Halpin 2010, 1120). Compromises on components of the bill separate from the public option attracted less public attention but are perhaps equally important. Some have already contributed to the difficult implementation period that followed immediately upon passage—such as the four-year delay in the main expansion of coverage and the failure to provide sufficient federal financial assistance to state governments during the transition period to full ACA implementation. The impact of others—such as inadequate subsidies for some low-wage workers—may not be apparent until after the law goes into effect. Indeed, the Center for Medicare and Medicaid Services (Foster 2009; Truffer et. al. 2010) has estimated that in 2019, when health care reform is fully implemented, there will still be over 20 million uninsured Americans, and the cost of care will still be rising faster than inflation...


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