said he would veto any health insurance reform, and kennedy returned to sponsoring his original universal national health insurance bill. in april 1975, with one third of its sponsors gone after the november 1974 election, the ama replaced its "medicredit" plan with an employer mandate proposal similar to nixon's 1974 plan. in january 1976, ford proposed adding catastrophic coverage to medicare, offset by increased cost sharing. in april 1976, democratic presidential candidate jimmy carter proposed health care reform that included key features of kennedy's universal national health insurance bill. in december 1977, president carter told kennedy his bill must be changed to preserve a large role for private insurance companies, minimize federal spending (precluding payroll tax financing), and be phased-in so not to interfere with balancing the federal budget. kennedy and organized labor compromised and made the requested changes, but broke with carter in july 1978 when he would not commit to pursuing a single bill with a fixed schedule for phasing-in comprehensive coverage. in may 1979, kennedy proposed a new bipartisan universal national health insurance bill—choice of competing federally-regulated private health insurance plans with no cost sharing financed by income-based premiums via an employer mandate and individual mandate, replacement of medicaid by government payment of premiums to private insurers, and enhancement of medicare by adding prescription drug coverage and eliminating premiums and cost sharing. in june 1979, carter proposed more limited health insurance reform—an employer mandate to provide catastrophic private health insurance plus coverage without cost sharing for pregnant women and infants, federalization of medicaid with extension to the very poor without dependent minor children, and enhancement of medicare by adding catastrophic coverage. in november 1979, long led a bipartisan conservative majority of his senate finance committee to support an employer mandate to provide catastrophic-only private health insurance and enhancement of medicare by adding catastrophic coverage, but abandoned efforts in may 1980 due to budget constraints in the face of a deteriorating economy. 1980s the consolidated omnibus budget reconciliation act of 1985 (cobra) amended the employee retirement income security act of 1974 (erisa) to give some employees the ability to continue health insurance coverage after leaving employment. clinton initiative health care reform was a major concern of the bill clinton administration headed up by first lady hillary clinton. the 1993 clinton health care plan included mandatory enrollment in a health insurance plan, subsidies to guarantee affordability across all income ranges, and the establishment of health alliances in each state. every citizen or permanent resident would thus be guaranteed medical care. the bill faced withering criticism by republicans, led by william kristol, who communicated his concern that a democratic health care bill would "revive the reputation of... democrats as the generous protector of middle-class interests. and it will at the same time strike a punishing blow against republican claims to defend the middle class by restraining government." the bill was not enacted into law. the "health security express," a cross-country tour by multiple buses carrying supporters of president clinton's national health care reform, started at the end of july 1994. during each stop, the bus riders would talk about their personal experiences, health care disasters and why they felt it was important for all americans to have health insurance. 2000-2008: bush era debates in 2000 the health insurance association of america (hiaa) partnered with families usa and the american hospital association (aha) on a "strange bedfellows" proposal intended to seek common ground in expanding coverage for the uninsured. in 2001, a patients' bill of rights was debated in congress, which would have provided patients with an explicit list of rights concerning their health care. this initiative was essentially taking some of ideas found in the consumers' bill of rights and applying it to the field of health care. it was undertaken in an effort to ensure the quality of care of all patients by preserving the integrity of the processes that occur in the health care industry. standardizing the nature of health care institutions in this manner proved rather provocative. in fact, many interest groups, including the american medical association (ama) and the pharmaceutical industry came out vehemently against the congressional bill. basically, providing emergency medical care to anyone, regardless of health insurance status, as well as the right of a patient to hold their health plan accountable for any and all harm done proved to be the biggest stumbling blocks for this bill. as a result of this intense opposition, the patients' bill of rights initiative eventually failed to pass congress in 2002. as president, bush signed into law the medicare prescription drug, improvement, and modernization act which included a prescription drug plan for elderly and disabled americans. during the 2004 presidential election, both the george bush and john kerry campaigns offered health care proposals. bush's proposals for expanding health care coverage were more modest than those advanced by senator kerry. several estimates were made comparing the cost and impact of the bush and kerry proposals. while the estimates varied, they all indicated that the increase in coverage and the funding requirements of the bush plan would both be lower than those of the more comprehensive kerry plan. in 2006 the hiaa's successor organization, america's health insurance plans (ahip), issued another set of reform proposals. in january 2007 rep. john conyers, jr. (d-mi) has introduced the united states national health care act (hr 676) in the house of representatives. as of october 2008, hr 676 has 93 co-sponsors. also in january 2007, senator ron wyden introduced the healthy americans act (s. 334) in the senate. as of october 2008, s. 334 had 17 cosponsors. also in 2007, ahip issued a proposal for guaranteeing access to coverage in the individual health insurance market and a proposal for improving the quality and safety of the u.s. health care system. "economic survey of the united states 2008: health care reform" by the organisation for economic co-operation and development, published in december 2008, said that: tax benefits of employer-based insurances should be abolished. the resulting tax revenues should be used to subsidize the purchase of insurance by individuals. these subsidies, "which could take many forms, such as direct subsidies or refundable tax credits, would improve the current situation in at least two ways: they would reach those who do not now receive the benefit of the tax exclusion; and they would encourage more cost-conscious purchase of health insurance plans and health care services as, in contrast to the uncapped tax exclusion, such subsidies would reduce the incentive to purchase health plans with little cost sharing." in december 2008, the institute for america's future, together with the chairman of the ways and means health subcommittee, pete stark, launched a proposal from jacob hacker, co-director of the u.c. berkeley school of law center on health, that in essence said that the government should offer a public health insurance plan to compete on a level playing field with private insurance plans. this was said to be the basis of the obama/biden plan. the argument is based on three basic points. firstly, public plans success at managing cost control (medicare medical spending rose 4.6% p.a. compared 7.3% for private health insurance on a like-for-like basis in the 10 years from 1997 to 2006). secondly, public insurance has better payment and quality-improvement methods because of its large databases, new payment approaches, and care-coordination strategies. thirdly, it can set a standard against which private plans must compete, which would help unite the public around the principle of broadly shared risk while building greater confidence in government in the long term. also in december 2008, america's health insurance plans (ahip) announced a set of proposals which included setting a national goal to reduce the projected growth in health care spending by 30%. ahip said that if this goal were achieved, it would result in cumulative five-year savings of $500 billion. among the proposals was the establishment of an independent comparative effectiveness entity that compares and evaluates the benefits, risks, and incremental costs of new drugs, devices, and biologics. an earlier "technical memo" published by ahip in june 2008 had estimated that a package of reforms involving comparative effectiveness research, health information technology (hit), medical liability reform, "pay-for-performance" and disease management and prevention could reduce u.s. national health expenditures "by as much as 9 percent by the year 2025, compared with current baseline trends." debate in the 2008 presidential election although both candidates had a health care system that revolved around private insurance markets with help from public insurance programs, both had different opinions on how this system should operate when put in place. senator john mccain proposed a plan that focused on making health care more affordable. the senator proposed to replace special tax breaks for persons with employer-based health care coverage with a universal system of tax credits. these credits, $2,500 for an individual and $5,000 for a family would be available to americans regardless of income, employment or tax liability. in his plan, senator mccain proposed the guaranteed access plan which would provide federal assistance to the states to secure health insurance coverage through high-risk areas. senator mccain also proposed the idea of an open-market competition system. this would give families the opportunity to go across state lines and buy health plans, expanding personal options for affordable coverage and force the health insurance companies to compete over the consumers’ money on an unprecedented scale. barack obama called for universal health care. his health care plan called for the creation of a national health insurance exchange that would include both private insurance plans and a medicare-like government run option. coverage would be guaranteed regardless of health status, and premiums would not vary based on health status either. it would have required parents to cover their children, but did not require adults to buy insurance. the philadelphia inquirer reported that the two plans had different philosophical focuses. they described the purpose of the mccain plan as to "make insurance more affordable," while the purpose of the obama plan was for "more people to have health insurance." the des moines register characterized the plans similarly. a poll released in early november, 2008, found that voters supporting obama listed health care as their second priority; voters supporting mccain listed it as fourth, tied with the war in iraq. affordability was the primary health care priority among both sets of voters. obama voters were more likely than mccain voters to believe government can do much about health care costs. 2009 reform debate main article: health care reform debate in the united states in march 2009 ahip proposed a set of reforms intended to address waste and unsustainable growth in the current health care market. these reforms included: an individual insurance mandate with a financial penalty as a quid pro quo for guaranteed issue updates to the medicare physician fee schedule; setting standards and expectations for safety and quality of diagnostics; promoting care coordination and patient-centered care by designating a "medical home" that would replace fragmented care with a coordinated approach to care. physicians would receive a periodic payment for a set of defined services, such as care coordination that integrates all treatment received by a patient throughout an illness or an acute event. this would promote ongoing comprehensive care management, optimizes patients’ health status and assist patients in navigating the health care system linking payment to quality, adherence to guidelines, achieving better clinical outcomes, giving better patient experience and lowering the total cost of care. bundled payments (instead of individual billing) for the management of chronic conditions in which providers would have shared accountability and responsibility for the management of chronic conditions such as coronary artery disease, diabetes, chronic obstructive pulmonary disease and asthma, and similarly a fixed rate all-inclusive average payment for acute care episodes which tend to follow a pattern (even though some acute care episodes may cost more or less than this). on may 5, 2009, us senate finance committee held hearings on health care reform. on the panel of the "invited stakeholder", no supporter of the single-payer health care system was invited. the panel featured republican senators and industry panelists who argued against any kind of expanded health care coverage. the preclusion of the single payer option from the discussion caused significant protest by doctors in the