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Reveals the roots of America's failure to address the health care need of its citizens. In a comprehensive history of the failed efforts to enact universal insurance from the 1940s to the 1990s, the author shows how each attempt to enact national health insurance has met with fierce attacks by stakeholders

Rosenbaum discusses the implications of the Patient Protection and Affordable Care Act. The legislation will take years to implement, and its full meaning can only be conceptualized at this point. But January 2014 will arrive in the blink of an eye. In sum, the Affordable Care Act is transformational, and enormous implementation challenges lie ahead. But the opportunities for major advances in public health policy and practice are simply unparalleled. The Act represents a singular opportunity not only to transform coverage and care, but also to rethink the basic mission of public health in a nation with universal coverage.

Using data from the Survey of Income and Program Participation (SIPP), we study the health insurance and labor market implications of the recent Affordable Care Act (ACA) provision that allows dependents to remain on parental policies until age 26. Our comparison of outcomes for young adults aged 19-25 with those who are older and younger, before and after the law, shows a high take-up of parental coverage, resulting in substantial reductions in uninsurance and other forms of coverage. We also find preliminary evidence of increased labor market flexibility in the form of reduced work hours.

The Patient Protection and Affordable Care Act (ACA) of 2010 has been one of the most controversial laws in decades. The ACA relies extensively on the cooperation of states for its implementation, offering opportunities for both local adaptation and political roadblocks. Health insurance exchanges are one of the most important components of the for achieving its goal of near-universal coverage. Despite significant financial support from the federal government, many governors and legislatures have taken actions that have blocked or delayed significant progress in developing their exchanges. However, many state commissioners of insurance have played constructive roles in moving states forward in exchange planning through their expertise, leadership, and pragmatism, sometimes in spite of strong political opposition to the from governors and legislatures.

Context: This article chronicles the political history of efforts by the U.S. Congress to enact a law requiring \"parity\" for mental health and addiction benefits and medical/surgical benefits in private health insurance. The goal of the Paul Wellstone and Pete Domenici Mental Health Parity and Addiction Equity (MHPAE) Act of 2008 is to eliminate differences in insurance coverage for behavioral health. Mental health and addiction treatment advocates have long viewed parity as a means of increasing fairness in the insurance market, whereas employers and insurers have opposed it because of concerns about its cost. The passage of this law is viewed as a legislative success by both consumer and provider advocates and the employer and insurance groups that fought against it for decades. Methods: Twenty-nine structured interviews were conducted with key informants in the federal parity debate, including members of Congress and their staff; lobbyists for consumer, provider, employer, and insurance groups; and other key contacts. Historical documentation, academic research on the effects of parity regulations, and public comment letters submitted to the U.S. Departments of Labor, Health and Human Services, and Treasury before the release of federal guidance also were examined. Findings: Three factors were instrumental to the passage of this law: the emergence of new evidence regarding the costs of parity, personal experience with mental illness and addiction, and the political strategies adopted by congressional champions in the Senate and House of Representatives. Conclusions: Challenges to implementing the federal parity policy warrant further consideration. This law raises new questions about the future direction of federal policymaking on behavioral health.

Objective: To examine current disparities in mammography use, and changes in disparities over time by race, ethnicity, income, insurance, and combinations of these characteristics. Research Design: Comparison of cross-sectional surveys of mammography use using the 1993 and 2005 National Health Interview Survey. Subjects: Women aged 40-64 (1993, n = 4167; 2005, n = 7434). Measures: Mammogram within prior 2 years. Results: In 2005, uninsured women reported the lowest mammography use (38.3%). Though screening increased 6.9 percentage points among low-income, uninsured women, the overall disparity between insured and uninsured women did not change significantly between 1993 and 2005. Screening seems to have declined among middle- income, uninsured women, increasing the gap compared with middle-income, insured women. The lower mammography use in 1993 among American Indian/Alaska Native compared with white women was not present in 2005; however, lower use among Asian compared with white women emerged in 2005. We found no differences between African American and white women. Hispanic women were less likely than non-Hispanic women to report screening in 2005 (58.1% vs. 69.0%). Conclusions: Although mammography use increased for some groups between 1993 and 2005, low-income, uninsured women continued to have the lowest screening rates in 2005 and the disparity for this group was not reduced. The gap in screening use for middle-income, uninsured women increased, resulting from possible declines in mammography even for uninsured women not in poverty. Asian women became less likely to receive screening in 2005. Continuing efforts are needed to eliminate disparities. In- creased efforts are especially needed to address the large persistent disparity for uninsured women, including middle-income uninsured women.

Objective: Women who are immigrants or socioeconomically disadvantaged have been found to have significantly lower cervical cancer screening rates than their peers in Toronto, Ontario, Canada. The objective of this study was to examine rates of appropriate cervical cancer screening among women living in Ontario, Canada, using recent registration with Ontario's universal health insurance plan as an indicator of immigrant status. Methods: This retrospective cohort study included 2,273,995 screening-eligible women aged 25 to 69 years, who resided in Ontario's metropolitan areas during the calendar years 2003, 2004, and 2005. A validated algorithm was applied to the Ontario-wide physicians' claims database to determine which women had undergone cervical cancer screening with a Pap test during the 3-year period. Results: Appropriate cervical cancer screening occurred for 61.1% of women. Despite adjustment for physician contact and pregnancy rates, cervical cancer screening rates were especially low among: women aged 50 to 69 years; women living in low-income areas; and women who had registered with Ontario's universal health insurance plan within the preceding 10 years, a group consisting largely of recent immigrants. Women with all 3 of these characteristics had a screening rate of 31.0% compared with 70.5% among women with none of these characteristics. Conclusion: Within a system of universal health insurance, appropriate cervical cancer screening is significantly lower among women who are older, living in low-income areas, or recent immigrants. Efforts to reduce disparities in cervical cancer screening should focus on women with these characteristics.

An editorial discusses whether the Affordable Health Care Act is meeting the following three goals: (1) expanding coverage (and “reforming” the individual insurance market), (2) slowing health care spending and keeping it at a sustainable rate, and (3) improving clinical quality.

Health insurance plans that include coverage for out-of-network providers are common and have the potential to reduce health care costs and even improve quality. Yet, consumers may be exposed to significant unexpected and unreasonable out-of-pocket costs due to lack of accurate information on network participation, nontransparent out-of-pocket costs, inadequate provider networks, involuntary use of out-of-network emergency care, and use of out-of-network providers at in-network hospitals. Although the Affordable Care Act and some states provide some consumer protections, these may not be adequate.