the number of uninsured persons, roughly 35 mil-
lion in 1990, to about 45 million in the mid- to late
1990’s before declining to about 38.4 million, or
13.7 percent of the population, by 2000.
Major Efforts and Initiatives Bill Clinton incorpo-
rated health care reform into the 1992 presidential
campaign, dozens of health reform proposals were
introduced in Congress, and President George
H. W. Bush unveiled his plan. Market-oriented re-
forms sought incremental modifications of private
health insurance markets, single-payer tax-financed
plans covered all citizens such as that provided by
the Canadian government, and a hybrid to universal
coverage called “play or pay” plans mandated em-
ployers who did not provide health insurance cover-
age for their workers to contribute to a fund for un-
insured workers.
On January 25, 1993, President Clinton named
First Lady Hillary Rodham Clinton chair of the Presi-
dent’s Task Force on National Health Care Reform to
design a universal health care plan. In a nationally
televised address on September 22, President Clinton
outlined principles of his Health Security Plan meant
to provide health insurance to everyone while con-
taining costs. To achieve universal coverage, most em-
ployers would be required to fund health care for
their employees, with subsidies to small businesses.
The federal government would fund the purchase of
private health insurance policies for unemployed
persons or part-time workers. To contain costs, re-
gional health care alliances would be developed to
publicize competing health insurance policies so that
consumers could choose, and the government would
develop controls over prices charged by pharmaceu-
tical companies for drugs.
Questions about costs and complexity plagued
President Clinton’s 1,342-page reform initiative
from the start. Many feared they would pay more for
health insurance under the plan, and private insur-
ance companies augmented these fears by financing
a televised campaign featuring the fictitious middle-
class couple Harry and Louise voicing their con-
cerns. The proposed legislation languished in con-
gressional committees. Liberal Democrats such as
Minnesota senator Paul Wellstone and Washington
representative Jim McDermott favored a single-
payer plan similar to Canada’s. Others, like Tennes-
see Democratic representative Jim Cooper, railed
against cost-control provisions and the funding nec-
essary to obtain universal coverage. Conservatives of
both parties preferred to minimize the role of gov-
ernment involvement in health care, portraying the
Health Security Plan as a bureaucratic, big-govern-
ment scheme. By August, 1993, no reform plan com-
manded a majority of legislators.
Congressional elections in 1994 returned control
of Congress to the Republican Party, signaling a loss
of public confidence in government capacity. Bal-
ancing the budget, reliance on market-based mech-
anisms to address social problems, and shrinking the
scope of the federal government were evidenced in
the Republican’s Contract with America, released
on September 27, 1994, and promoted by Republi-
can representative Newt Gingrich, its main architect
who became House Speaker.
Impact After 1994, cost containment remained the
main impetus of incremental market-based health
care initiatives. The Health Insurance Portability
and Accountability Act of 1996 (HIPAA) included
portability provisions to prevent loss of health insur-
ance due to job changes, health insurance access
and renewability guarantees, and, on an experimen-
tal basis, medical savings accounts (MSA).
The Balanced Budget Act of 1997 expanded the
range of managed care options available to Medi-
care enrollees. Options included provider-sponsored
organizations (hospitals or physicians developed
plans) and preferred provider organizations (insur-
ance providers developed plans whose enrollees had
to obtain treatment from a roster of physicians and
hospitals that agreed to charge discounted fees and
to secure central approval for treatments). The act
also permitted states to implement mandatory
Medicaid managed care programs without a waiver
from federal authorities. The State Children’s
Health Insurance Program (SCHIP) was created as
Title XXI of the Social Security Act to help states in-
sure uninsured low-income children who were ineli-
gible for Medicaid.
Subsequent Events On December 8, 2003, Presi-
dent George W. Bush signed the Medicare Prescrip-
tion Drug, Improvement, and Modernization Act of
2003, adding prescription drug benefits to Medicare
on a voluntary basis. Health care expenditures rose
two to three times faster than GDP after 2000 before
tapering off but still exceeded GDP growth between
2004 and 2006. The number of uninsured persons
increased again after 2000, reaching a high of nearly412 Health care reform The Nineties in America