American Presidents and Health Reform: A Chronolgy

Franklin D. Roosevelt (1933-1945)
1934
The Committee on Economic Security, an advisory committee of President Roosevelt, appoints its own advisory panel to assist on hospital-related issues. Robert Jolly, in his role as president of AHA (an elected position in the 1930s), is asked to serve on the committee.
1935
On Aug. 14, the Social Security Act is signed by Roosevelt. Over the course of the next seven decades, it will become one of the most influential, far-reaching health-related acts of Congress in the history of the United States, eventually serving as the legislative launching pad for both Medicare and Medicaid. Shortly after the act becomes law, FDR appoints the Interdepartmental Committee to Coordinate Health and Welfare Activities to assess the health care needs of the American people.
1938
Three years after its inception, the Interdepartmental Committee to Coordinate Health and Welfare Activities presents its findings to FDR, along with a recommendation outlining a national health program. The National Health Conference, held in late July, provides the forum for sharing the report with the medical, public health and allied professions—and the general public.
1938
Roosevelt signs the Food, Drug and Cosmetic Act of 1938 into law. The act greatly expands the control and power of the Food and Drug Administration and specifically charges the agency with initiating a new system of drug regulation that requires manufacturers to prove a drug’s safety before it can be brought to market. The act is a response to more than 100 people dying in 1937 after ingesting a new sulfa-based drug marketed as Elixer Sulfanilamide.
1939
Sen. Robert F. Wagner (D-NY) introduces a national health bill that incorporates the recommendations of the National Health Conference. The bill dies in committee.
1940
Roosevelt sends a message to Congress in January 1940 singling out construction of hospitals in a modest legislative proposal—50 hospitals, at a total cost of less than $10 million. The subsequent Hospital Construction Act of 1940 dies in Congress.
1941
The Lanham Act provides federal assistance for infrastructure needs of communities impacted by the growing defense industry, including health facilities. The act establishes a precedent for government aid to private not-for-profit hospitals.
1942
Rep. Thomas Eliot introduces a bill that heralds formal renewal of interest in federally subsidized hospitals construction, independent of the Lanham program.
1943
President Franklin D. Roosevelt, in his State of the Union message, for the first time calls for a social insurance system that would extend “from the cradle to the grave.”
1943
The Wagner-Murray-Dingell bill is introduced in Congress. It calls for comprehensive health insurance under Social Security. No action is taken on it.
1943
The Emergency Maternal and Infant Care Act is adopted by Congress to protect the dependents of the four lowest ranks of servicemen. It is administered by the Children’s Bureau.
1944
The Social Security Board in its annual report recommends compulsory national health insurance.
1944
The Public Health Service Act gives the National Institutes of Health authority to award grants for nonfederal research.

Harry S. Truman (1945-1953)
1945
President Truman calls for national health insurance in a message to Congress in November. A revised Wagner-Murray-Dingell bill, asking for national health insurance, is introduced.
1946
On July 3, Truman signs the National Mental Health Act of 1946, which provides for the first time in U.S. history a significant amount of funding for research into the causes, prevention and treatment of mental illness and leads to the establishment in 1949 of the National Institute of Mental Health. 
1946
The Hospital Survey and Construction Act, introduced by Sens. Lister Hill and Harold H. Burton, is passed on Aug. 13, authorizing the Hill-Burton program. The Hill-Burton Act and subsequent amendments distribute $4 billion to 6,900 hospitals and other health facilities over a 30-year span. It provides federal aid to the states for hospital facilities. To be granted funds, states must survey existing facilities and assess the need for new construction. Designed to reduce inequities in access to hospital care, the law ensures that the poorer states, with greater deficiencies in hospitals, receive a larger portion of federal aid. The Community Service Assurance provision of the act requires facilities receiving Hill-Burton funds to make their services available to people residing in the facility’s service area without discrimination on the basis of race, color, national origin, creed or any other ground unrelated to the individual’s need for the service or the availability of the needed service in the facility.
1946
The Taft-Smith-Ball bill to provide grants to states for medical aid to the poor is introduced in Congress. No action is taken.
1947
The Taft-Hartley labor law is passed with a clause removing hospitals from the jurisdiction of the National Labor Relations Board.
1947
The Wagner-Murray-Dingell bill is re-introduced.
1948
In the first federal action to protect water resources in the United States, the Water Pollution Law provides funds for sewage treatment system and pollution research and empowers the Justice Department to file suit against polluters.
1949
President Truman again sends a message to Congress calling for national health insurance.
1949
Republicans introduce a bill in Congress, the Flanders-Ives bill, or the Flanders-Ives-Nixon bill, calling for a federal subsidy to make it possible for low-income people to buy adequate hospital insurance. The federal government’s proportion of the premium would depend on the individual’s income. The states would operate the plan and would be required to share in the cost of the subsidy, depending on the average income in the state. The federal government’s share would range from one-third to three-quarters. Hearings are held, but nothing else happens.
1950
The Social Security Act is amended to provide direct payment to doctors, hospitals and other providers of care by the states, with matching federal aid.
1952
Murray-Humphry-Dingell-Celler bills were introduced in the House and Senate calling for health insurance for Social Security beneficiaries.
1952
The President’s Commission on Health Needs of the Nation reports in favor of health insurance for Social Security beneficiaries.

Dwight D. Eisenhower (1953-1961)
1954
The Eisenhower administration supports a reinsurance bill under which the federal government would subsidize partial payment of premiums for low-income individuals.
1956
The “Military Medicare” program is enacted, giving health care service to military dependents.
1956
The Social Security Act is amended to give monthly benefits to permanently and totally disabled workers between the ages of 50 and 64.
1957
The Forand bill, providing for health insurance for Social Security beneficiaries, is introduced into Congress with the support of the AFL-CIO.
1959
The Forand bill is reintroduced in Congress. The House Ways and Means Committee in executive session votes 17 to 8 against it. A stripped-down bill (less surgery benefits) is defeated 16 to 9 in committee.
1959
A Senate subcommittee holds hearings on the problems of the aged (primarily their health problems
1959
Congress enacts the Federal Employees Health Benefits Act and the first FEP open enrollment period is held a year later.
1960
The presidential Task Force on Health and Social Security for the American People is appointed by President-elect John F. Kennedy.
1960
A Kennedy-Anderson bill is introduced, calling for wider benefits than the Forand bill. It is unable to pass.
1960
The Kerr-Mills bill is passed. It provides federal-state aid for the medically indigent.
1961
The presidential Task Force on Health and Social Security for the American People recommends health insurance for the elderly under Social Security.

John F. Kennedy (1961-1963)
1961
Newly inaugurated President Kennedy sends a special message to Congress on health.
1961
The King-Anderson bill, an early version of Medicare, is introduced in Congress. It does not progress beyond hearings in the Ways and Means Committee.
1962
An attempt is made to attach a health insurance amendment (the Anderson-Javits amendment) to a welfare bill in the Senate. The amendment is tabled.
1963
President Kennedy sends a special message to Congress on the problems of the aged.
1963
The King-Anderson bill (Medicare) is again introduced in Congress.

Lyndon B. Johnson (1963-1969)
1964
President Johnson sends a special message to Congress on the health of the nation; in it he advocates Medicare.
1964
The Ways and Means Committee postpones action on the King-Anderson bill.
1964
An amendment to the Social Security Act is reported out by the Ways and Means Committee in July. The proposed amendment includes an increase in cash benefits but no health care items. The House passes the amendment in July. Senate hearings are held in August. The bill is reported out without health provision late in the month. A Medicare measure as a floor amendment to HR 11864 passes the Senate in September. Conference committee members are unable to reconcile differences between House and Senate versions in October.
1964
The Hill-Burton program, which provides funding for the construction and modernization of hospitals, is extended through 1969. One of the 1964 amendments provides funding to outmoded hospitals.
1965
The King-Anderson bill is reintroduced.
1965
Mills’ Medicare proposal is substituted for King-Anderson by the Ways and Means Committee in March. The Mills bill passes the House by a wide margin in April. The Senate holds hearings and executive sessions from late April to late June and passes the bill by a wide margin in July. The House-Senate conference committee reconciles the differences between the House and Senate versions of the Mills bill.
1965
The House and Senate passes the conference committee report. Medicare and Medicaid become part of the Social Security Amendments of 1965 after President Lyndon B. Johnson flies to Independence, Mo., on July 30 to sign the bill into law in the presence of former President Truman, thus ending a stage in the process that had begun several decades before.
July 1, 1966:
Medicare coverage begins. All individuals ages 65 and over are automatically covered under Part A. Coverage begins for seniors who sign up for the voluntary medical insurance program (Part B). More than 19 million individuals ages 65 and older enroll in Medicare.
1966
Comprehensive health-planning agencies, set up under legislation of 1966 (PL 89-49), provide federal funding to states for statewide planning, for the establishment of areawide or metropolitan health-planning agencies at the local level, and for training a new type of profession in health-care planning.

Richard Nixon (1969-1974)
1970
In the face of economic pressures from the Vietnam war and stagflation, the Economic Stabilization Act of 1970 is passed, inaugurating a policy of wage and price controls. Government efforts to control costs would be an issue for hospitals throughout the decade.
1970
The Occupational Safety and Health Act (OSHA) places certain duties on employers and employees to ensure safe and healthful working conditions.
1971
The Nixon Administration proposes a National Health Insurance Standard Act that consists of two major parts. One part is a government-prescribed minimum amount of private medical and hospital insurance coverage financed by mandatory employer and employee payment of premiums, with a government subsidy of premium payments in specific situations. The other part is a sliding scale of government-paid benefits for families with earnings less than $5,000 per year.
1971
A Health Security Act is introduced in the Senate by Sen. Edward Kennedy and in the House by Rep. Martha Griffiths that would provide federal payment of nearly all health costs for every U.S. citizen.
1971
The president signs the Comprehensive Health Manpower Training Act of 1971 to provide increased manpower in the health professions, and the Nurse Training Act of 1971 to provide training for increased numbers of nurses.
1972
President Nixon signs the Social Security Amendments of 1972, the first major adjustment to Medicare since its enactment. Medicare eligibility is extended to individuals under age 65 with long-term disabilities (who were receiving SSDI payments for two years) and to individuals with end-stage renal disease. The amendments also establish professional standards review organizations to review patient care, encourage the use of health maintenance organizations and give Medicare the authority to conduct demonstration programs.
1972
Medicare benefits are expanded to include some chiropractic services, speech therapy and physical therapy.
1973
Medicare coverage begins for individuals receiving Social Security Disability Insurance cash payments for two or more years. Nearly 2 million people under age 65 with long-term disabilities or end-stage renal disease are covered.
1973
The HMO Act of 1973 lays the groundwork for managed care. While prepaid group health plans had begun in the early 1900s, this Nixon administration legislation provides federal support to promote their expansion. Nevertheless, HMOs grow more slowly than anticipated during the 1970s. 

Gerald Ford (1974-1977)
1974
An amendment to the National Labor Relations Act extends protected status to hospital employees engaged in collective bargaining. As a result, unions focus on hospitals and make significant gains. About a quarter of all hospitals have collective bargaining agreements, and a third of the hospital workforce is unionized by 1978, when the growth in collective bargaining contracts slows to a rate similar to that in other industries.
1974
New health system agencies (HSAs), set up under PL 93-641 to replace the comprehensive health-planning agencies, are required to develop plans for health-resource and health-status needs for the population residing within each of 205 designated health-service areas, based on specified national goals. The legislation prompts wide-scale development of state certificate-of-need programs.
1976
The Ford administration proposes capping Medicare payments to hospitals. The AHA averts the effort by organizing a voluntary effort to successfully reduce the rate of increase for community hospital expenses during 1978-1979.

Jimmy Carter (1977-1981)
1977
President Carter backs national health insurance when elected to the White House, but other issues soon supersede. AHA delegates endorse universal health insurance in principle, but note that “no single way of organizing medical and health care services can be developed for application to all communities, and the system should build on the strengths of its diversity and adaptability.”
1977
Joe Califano, secretary of the Department of Health, Education and Welfare, creates the Health Care Financing Administration to administer both the Medicare and Medicaid programs. About 1,500 employees are transferred to HCFA from the Social Security Administration.
1980
The Omnibus Reconciliation Act of 1980 expands home health services by eliminating the limit on the number of home health visits, the prior hospitalization requirement, and the deductible for any Part B benefits. It also requires the HEW secretary to develop a list of surgical procedures that could be done on an outpatient basis in an ambulatory surgical center and would be reimbursed on a prospective payment system. The Baucus Amendments bring Medicare supplemental insurance, also called "Medigap," under federal oversight and establish a voluntary certification program for Medigap policies.

Ronald Reagan (1981-1989)
1981
Freedom of choice waivers (1915b) and home and community-based care waivers (1915c) are established in Medicaid; states are required to provide additional payments to hospitals treating a disproportionate share of low-income patients (i.e., DSH hospitals).
1981
The Omnibus Budget Reconciliation Act of 1981 includes provisions to slow the growth in Medicare spending, including a change that results in an increase in the inpatient hospital deductible.
1982
The Tax Equity and Fiscal Responsibility Act increases the Part B premium to cover 25 percent of program costs as part of policies designed to slow the growth of Medicare spending. Hospice services for the terminally ill are added to Medicare's covered benefits. TEFRA facilitates HMOs' participation in the Medicare program and establishes a risk-based prospective payment system for these plans. The act also expands HCFA's quality oversight efforts by replacing Professional Standards Review Organizations (PSROs) with Peer Review Organizations (PROs). TEFRA imposes a ceiling on the amount Medicare would pay for a hospital discharge and requires HHS to submit a plan for prospective payments to hospitals and nursing homes. TEFRA required federal employees to begin paying the HI payroll tax.
1983
In an effort to control Medicare costs and promote efficiency, the inpatient acute hospital prospective payment system is enacted by the federal government. It introduces preset payment rates for treatment of Medicare patients, moving away from reimbursement based on hospital costs. Diagnosis-related groups are developed for payment rate-setting. As the DRG system evolves toward an Oct. 1 implementation, the Health Care Financing Administration agrees with the AHA that DRG payment rates would not be a flat rate per discharge. Rather, the system would be case mix adjusted. Direct and indirect medical education costs, capital costs and outliers were among many issues still being reviewed at the time.
1983
The Orphan Drug Act makes changes in the law to encourage development and marketing of drugs for rare diseases or conditions which are not economically feasible for private industry to develop and market.
1984
The Deficit Reduction Act of 1984 freezes physician fees, establishes the Participating Physicians' Program, and establishes fee schedules for laboratory services, all of which are intended to slow the growth of Medicare's spending and constrain the federal deficit.
1985
The Consolidated Omnibus Budget Reconciliation Act of 1985 makes Medicare coverage mandatory for newly hired state and local government employees.
1985
The Emergency Extension Act of 1985 freezes PPS payment rates for inpatient hospital care and continues physician payment freezes to slow the growth of Medicare spending.
1985
The Emergency Medical Treatment and Labor Act is enacted. The law requires any hospital participating in Medicare to provide medical screening and stabilizing treatment to any patient who comes to its emergency room, regardless of ability to pay.
1986
The Omnibus Budget Reconciliation Act of 1986 revises several of the payment procedures for various Medicare services in order to help slow the growth in Medicare spending.
1987
The Omnibus Budget Reconciliation Act of 1987 imposes quality standards for Medicare- and Medicaid-certified nursing homes in response to well-documented quality problems facing seniors in nursing homes. OBRA 87 also modifies payments to providers under Medicare as part of the deficit reduction legislation.
1987
The Health Care Financing Administration proposes regulations for Medicare payment rates for hospital outpatient surgeries, raising concern among hospital leaders about the financial impact and competition with freestanding ambulatory surgery centers. ASCs had increased from 41 to 690 over the previous four years.
1987
The Medicare and Medicaid Patient and Program Protection Act of 1987 is enacted to improve antifraud efforts and strengthen beneficiary protection programs.
1987
The Balanced Budget and Emergency Deficit Control Reaffirmation Act of 1987 freezes Medicare payment rates in an attempt to slow Medicare spending.
1988
The Medicare Catastrophic Coverage Act of 1988, the largest expansion of the program since the enactment of Medicare, includes an outpatient prescription drug benefit and a cap on beneficiaries' out-of-pocket expenses, and expands hospital and skilled nursing facility benefits. Medicaid begins coverage of Medicare premiums and cost-sharing for Medicare beneficiaries with incomes below 100 percent of the federal poverty level, known as Qualified Medicare Beneficiaries. The U.S. Bipartisan Commission on Comprehensive Health Care (which became known as Pepper Commission after the late Congressman Claude Pepper of Florida) is established to assess the feasibility of a long-term care benefit under Medicare.
1988
The Clinical Laboratory Improvement Amendments strengthens quality performance requirements for clinical laboratories to ensure accurate and reliable laboratory tests and procedures.

George Bush (1989-1993)
1989
The Medicare Catastrophic Coverage Act of 1988 is repealed after higher-income senior citizens protest new premiums. A new Medicare fee schedule for physician and other professional services, a resource-based relative value scale, replaces charge-based payments. Limits are placed on physician balance billing above the new fee schedule. Physicians are prohibited from referring Medicare patients to clinical laboratories in which their physicians, or physicians' family members, have a financial interest.
1989
The Medicare Catastrophic Coverage Repeal Act of 1989 retracts the major provisions of the 1988 Medicare Catastrophic Coverage Act, including both the outpatient drug benefit and the out-of-pocket limit. QMB benefits are retained.
1989
The Omnibus Budget Reconciliation Act of 1989 establishes the Resource-Based Relative Value Scale for physicians, replacing charge-based payments. Limits are placed on physician balance billing. OBRA 1989 includes a number of other provisions designed to slow the growth in Medicare spending.

The Omnibus Budget Reconciliation Act of 1989 includes a statute on physician self-referral, commonly referred to as the Stark I law, after its author Rep. Pete Stark. Under the Stark law, physicians in the Medicare program are banned from referring patients to clinical laboratory services in which physicians or their family members have a financial interest. A Stark II law is passed by Congress in 1993, extending the ban to additional clinical services and to the Medicaid program.
1990
The Omnibus Budget Reconciliation Act of 1990 (OBRA 1990) establishes the Specified Low-Income Medicare Beneficiary eligibility group requiring state Medicaid programs to cover premiums for beneficiaries with incomes between 100 percent and 120 percent of the federal poverty level. Medicare is expanded to cover screening mammography and partial hospitalization services in community mental health centers. Federal standards are established for Medigap policies, including standardized benefit packages and minimum loss ratios, replacing the voluntary certification system.
1990
Safe Medical Devices Act of 1990 amends the Federal Food, Drug, and Cosmetic Act to require medical device user facilities to report to the Secretary of Health and Human Services, the manufacturer, or both whenever they believe there is a probability that a medical device has caused or contributed to a death, illness or injury.
1990
The Ryan White Comprehensive AIDS Resources Emergency Act is the single largest federal program designed specifically for people with HIV/AIDS. First enacted in 1990, and reauthorized in 1996 and 2000, the CARE Act provides care and support services to individuals and families affected by HIV/AIDS, functioning as the “payer of last resort”; that is, it fills the gaps in care for those who have no other source of coverage or face coverage limits. Federal CARE Act funding is provided to cities, states and directly to providers and other organizations.
1991
Medicaid Disproportionate Share Hospital (DSH) spending controls are established, and provider-specific taxes and donations to states are capped.

Bill Clinton (1993-2001)
1993
The Clinton administration launches an ill-fated attempt at sweeping health care reform. A legislative proposal, delivered to Congress six months after it was promised, is torn apart by lawmakers unwilling to compromise.
1995
The Paperwork Reduction Act of 1995 amends the U.S. Code to reduce by 5 percent the federal paperwork burdens imposed on individuals, small businesses, state and local governments, education and nonprofit institutions and federal contractors. It also establishes in statute the NIH Office of Information Resources Management.
1996
The Aid to Families with Dependent Children entitlement program is replaced by the Temporary Assistance for Needy Families block grant; the welfare link to Medicaid is severed; a new mandatory low-income group not linked to welfare is added; and enrollment/termination of Medicaid is no longer automatic with receipt/loss of welfare cash assistance.
1996
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) has several important provisions. First, it amends the Public Health Service Act, the Employee Retirement Income Security Act of 1974 (ERISA), and the Internal Revenue Code of 1986 to provide for new federal rules improving continuity or "portability" of coverage in the large group, small group and individual health insurance markets. CMS implements HIPAA provisions affecting the small group and individual markets. Second, it creates the Medicare Integrity Program that dedicated funding to program integrity activities and allows CMS to competitively contract for program integrity work. Third, it creates national administrative simplification standards for electronic health care transactions. Fourth, it requires HHS to issue privacy regulations if Congress fails to enact substantive privacy legislation.
1997
Under the Balanced Budget Act of 1997 (BBA), the State Children's Health Insurance Program (SCHIP) is created, limits on Medicaid payments to disproportionate share hospitals are revised; new Medicaid managed care options and requirements for states are established. Medicare changes include:

1. Establishing an array of new Medicare managed care and other private health plan choices for beneficiaries, offered through a coordinated open enrollment process.
2. Expanding education and information to help beneficiaries make informed choices about their health care.
3. Requiring CMS to develop and implement five new prospective payment systems for Medicare services (for inpatient rehabilitation hospital or unit services, skilled nursing facility services, home health services, hospital outpatient department services, and outpatient rehabilitation services).
4. Slowing the rate of growth in Medicare spending and extending the life of the trust fund for 10 years.
5. Providing a broad range of beneficiary protections.
6. Expanding preventive benefits.
7. Testing other innovative approaches to payment and service delivery through research and demonstrations.

1999
Healthcare Research and Quality Act reauthorizes and renames the Agency for Health Care Policy and Research as the Agency for Healthcare Research and Quality (AHRQ). Provisions require the AHRQ director, in order to promote innovation in evidence-based clinical practice and health care technologies, to consult with the NIH director and work with the National Library of Medicine to develop an electronic clearinghouse of currently available assessments and those in progress. The NIH director will serve on the AHRQ Advisory Council as an ex officio member.
1999
The Balanced Budget Refinement Act of 1999 increases payments for some Medicare providers and increases the amount of Medicaid DSH funds available to hospitals in certain states and the District of Columbia. Other related legislation improves Medicaid coverage of certain women's health services.
2000
The Needlestick Safety and Prevention Act requires changes in the blood-borne pathogens standards in effect under the Occupational Safety and Health Act of 1970 to protect workers whose occupations expose them to pathogens such as HIV. Employers are required to use needles and other medical devices that have built-in safety mechanisms to reduce accidental punctures and to keep a log of needlestick injuries that protect confidentiality of injured employees.
2000
The Medicare, Medicaid and SCHIP Benefits Improvement and Protection Act of 2000 provide relief from the dramatic payment cuts in the Balanced Budget Act of 1997. BIPA includes across-the-board payment increases in Medicare and Medicaid that affect most hospitals, as well as improvements for specific hospital categories and programs.
2000
The Benefits Improvement and Protection Act (BIPA) further increases Medicare payments to providers and managed health care organizations, reduces certain Medicare beneficiary co-payments, and improves Medicare's coverage of preventive services. BIPA creates a new Medicaid prospective payment system for Federally Qualified Health Centers and Rural Health Clinics and modifies the amount of Medicaid DSH funds available to hospitals, while providing a one-year extension on the sunset of transitional medical assistance provided to families eligible for welfare.
2000
Authorized by the BBA, the Health Care Financing Administration implements an outpatient prospective payment system that significantly changes how hospitals are reimbursed for outpatient services under Medicare.

George W. Bush (2001-2009)
2003
The MedicarePrescription Drug, Improvement, and Modernization Act makes the most significant changes to Medicare since the program began. MMA creates a prescription drug discount card until 2006, allows for competition among health plans to foster innovation and flexibility in coverage, covers new preventive benefits and makes numerous other changes. In 2006, the new voluntary Part D outpatient prescription drug benefit will be available to beneficiaries from private drug plans as well as Medicare Advantage plans. Employers who provide retiree drug coverage comparable to Medicare’s will be eligible for a federal subsidy.

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