controls prohibited manufacturers and other employers from raising wages enough to attract workers. when the war labor board declared that fringe benefits, such as sick leave and health insurance, did not count as wages for the purpose of wage controls, employers responded with significantly increased offers of fringe benefits, especially health care coverage, to attract workers. the tax deduction was later codified in the revenue act of 1954. president harry s. truman proposed a system of public health insurance in his november 19, 1945, address. he envisioned a national system that would be open to all americans, but would remain optional. participants would pay monthly fees into the plan, which would cover the cost of any and all medical expenses that arose in a time of need. the government would pay for the cost of services rendered by any doctor who chose to join the program. in addition, the insurance plan would give cash to the policy holder to replace wages lost because of illness or injury. the proposal was quite popular with the public, but it was fiercely opposed by the chamber of commerce, the american hospital association, and the ama, which denounced it as "socialism". foreseeing a long and costly political battle, many labor unions chose to campaign for employer-sponsored coverage, which they saw as a less desirable but more achievable goal, and as coverage expanded the national insurance system lost political momentum and ultimately failed to pass. using health care and other fringe benefits to attract the best employees, private sector, white-collar employers nationwide expanded the u.s. health care system. public sector employers followed suit in an effort to compete. between 1940 and 1960, the total number of people enrolled in health insurance plans grew seven-fold, from 20,662,000 to 142,334,000, and by 1958, 75% of americans had some form of health coverage. by 1976 85.9% of the employed population 17-64 years of age had hospital insurance while 84.2% had surgical insurance. kerr-mills act still, private insurance remained unaffordable or simply unavailable to many, including the poor, the unemployed, and the elderly. before 1965, only half of seniors had health care coverage, and they paid three times as much as younger adults, while having lower incomes. consequently, interest persisted in creating public health insurance for those left out of the private marketplace. the 1960 kerr-mills act provided matching funds to states assisting patients with their medical bills. in the early 1960s, congress rejected a plan to subsidize private coverage for people with social security as unworkable, and an amendment to the social security act creating a publicly run alternative was proposed. finally, president lyndon b. johnson signed the medicare and medicaid programs into law in 1965, creating publicly run insurance for the elderly and the poor. medicare was later expanded to cover people with disabilities, end-stage renal disease, and als. state risk pools prior to the patient protection and affordable care act, effective from 2014, about 34 states offered guaranteed-issuance risk pools, which enabled individuals who are medically uninsurable through private health insurance to purchase a state-sponsored health insurance plan, usually at higher cost, with high deductibles and possibly lifetime maximums. plans varied greatly from state to state, both in their costs and benefits to consumers and in their methods of funding and operations. the first such plan was implemented in 1976. efforts to pass a national pool were unsuccessful for many years. with the patient protection and affordable care act, it became easier for people with pre-existing conditions to afford regular insurance, since all insurers are fully prohibited from discriminating against or charging higher rates for any individuals based on pre-existing medical conditions. therefore, most of the state-based pools shut down. as of 2017, some remain due to statutes which have not been updated, but they also may cover people with gaps in coverage such as undocumented immigrants or medicare-eligible individuals under the age of 65. towards universal coverage persistent lack of insurance among many working americans continued to create pressure for a comprehensive national health insurance system. in the early 1970s, there was fierce debate between two alternative models for universal coverage. senator ted kennedy proposed a universal single-payer system, while president nixon countered with his own proposal based on mandates and incentives for employers to provide coverage while expanding publicly run coverage for low-wage workers and the unemployed. compromise was never reached, and nixon's resignation and a series of economic problems later in the decade diverted congress's attention away from health reform.the numbers of uninsured americans and the uninsured rate from 1987 to 2008.shortly after his inauguration, president clinton offered a new proposal for a universal health insurance system. like nixon's plan, clinton's relied on mandates, both for individuals and for insurers, along with subsidies for people who could not afford insurance. the bill would have also created "health-purchasing alliances" to pool risk among multiple businesses and large groups of individuals. the plan was staunchly opposed by the insurance industry and employers' groups and received only mild support from liberal groups, particularly unions, which preferred a single payer system. ultimately it failed after the republican takeover of congress in 1994. finally achieving universal health coverage remained a top priority among democrats, and passing a health reform bill was one of the obama administration's top priorities. the patient protection and affordable care act was similar to the nixon and clinton plans, mandating coverage, penalizing employers who failed to provide it, and creating mechanisms for people to pool risk and buy insurance collectively. earlier versions of the bill included a publicly run insurer that could compete to cover those without employer sponsored coverage (the so-called public option), but this was ultimately stripped to secure the support of moderates. the bill passed the senate in december 2009 with all democrats voting in favor and the house in march 2010 with the support of most democrats. not a single republican voted in favor of it either time. state and federal regulation historically, health insurance has been regulated by the states, consistent with the mccarran-ferguson act. details for what health insurance could be sold were up to the states, with a variety of laws and regulations. model acts and regulations promulgated by the national association of insurance commissioners (naic) provide some degree of uniformity state to state. these models do not have the force of law and have no effect unless they are adopted by a state. they are, however, used as guides by most states, and some states adopt them with little or no change. however, with the patient protection and affordable care act, effective since 2014, federal laws have created some uniformity in partnership with the existing state-based system. insurers are prohibited from discriminating against or charging higher rates for individuals based on pre-existing medical conditions and must offer a standard set of coverage. california in 2007, 87% of californians had some form of health insurance. services in california range from private offerings: hmos, ppos to public programs: medi-cal, medicare, and healthy families (schip). insurers can pay providers a capitation only in the case of hmos. california developed a solution to assist people across the state and is one of the few states to have an office devoted to giving people tips and resources to get the best care possible. california's office of the patient advocate was established july 2000 to publish a yearly health care quality report card on the top hmos, ppos, and medical groups and to create and distribute helpful tips and resources to give californians the tools needed to get the best care. additionally, california has a help center that assists californians when they have problems with their health insurance. the help center is run by the department of managed health care, the government department that oversees and regulates hmos and some ppos. massachusetts the state passed healthcare reform in 2006 in order to decrease the uninsured rate among its citizens. the federal patient protection and affordable care act (colloquially known as "obamacare") is largely based on massachusetts' health reform. due to that colloquialism, the massachusetts reform has been nicknamed as "romneycare" after then-governor mitt romney. public health care coverage public programs provide the primary source of coverage for most seniors and also low-income children and families who meet certain eligibility requirements. the primary public programs are medicare, a federal social insurance program for seniors (generally persons aged 65 and over) and certain disabled individuals; medicaid, funded jointly by the federal government and states but administered at the state level, which covers certain very low income children and their families; and chip, also a federal-state partnership that serves certain children and families who do not qualify for medicaid but who cannot afford private coverage. other public programs include military health benefits provided through tricare and the veterans health administration and benefits provided through the indian health service. some states have additional programs for low-income individuals. u.s. census bureau, "cps health insurance definitions" archived may 5, 2010, at the wayback machine</ref> in 2011, approximately 60 percent of stays were billed to medicare and medicaid—up from 52 percent in 1997. medicare main article: medicare (united states) in the united states, medicare is a federal social insurance program that provides health insurance to people over the age of 65, individuals who become totally and permanently disabled, end stage renal disease (esrd) patients, and people with als. recent research has found that the health trends of previously uninsured adults, especially those with chronic health problems, improves once they enter the medicare program. traditional medicare requires considerable cost-sharing, but ninety percent of medicare enrollees have some kind of supplemental insurance—either employer-sponsored or retiree coverage, medicaid, or a private medigap plan—that covers some or all of their cost-sharing. with supplemental insurance, medicare ensures that its enrollees have predictable, affordable health care costs regardless of unforeseen illness or injury. as the population covered by medicare grows, its costs are projected to rise from slightly over 3 percent of gdp to over 6 percent, contributing substantially to the federal budget deficit. in 2011, medicare was the primary payer for an estimated 15.3 million inpatient stays, representing 47.2 percent ($182.7 billion) of total aggregate inpatient hospital costs in the united states. the affordable care act took some steps to reduce medicare spending, and various other proposals are circulating to reduce it further. medicare advantage main article: medicare advantage medicare advantage plans expand the health insurance options for people with medicare. medicare advantage was created under the balanced budget act of 1997, with the intent to better control the rapid growth in medicare spending, as well as to provide medicare beneficiaries more choices. but on average, medicare advantage plans cost 12% more than traditional medicare. the aca took steps to align payments to medicare advantage plans with the cost of traditional medicare. there is some evidence that medicare advantage plans select patients with low risk of incurring major medical expenses to maximize profits at the expense of traditional medicare. medicare part d main article: medicare part d medicare part d provides a private insurance option to allow medicare beneficiaries to purchase subsidized coverage for the costs of prescription drugs. it was enacted as part of the medicare prescription drug, improvement, and modernization act of 2003 (mma) and went into effect on january 1, 2006. medicaid main article: medicaid medicaid was instituted for the very poor in 1965. since enrollees must pass a means test, medicaid is a social welfare or social protection program rather than a social insurance program. despite its establishment, the percentage of us residents who lack any form of health insurance has increased since 1994. it has been reported that the number of physicians accepting medicaid has decreased in recent years because of lower reimbursement rates. the affordable care act dramatically expanded medicaid. the program now covers everyone with incomes under 133% of the federal poverty level who does not qualify for medicare, provided this expansion of coverage has been accepted by the state where the person resides. meanwhile, medicaid benefits must be the same as the essential benefit in the newly created state exchanges. the federal government will fully fund the expansion of medicaid initially, with some of the financial responsibility (10% of medical costs) gradually devolving back to the states by 2020. children's health insurance program (chip)