US Elections

How a (Health Care Reform) Bill Becomes A Law (tl;dr)

By Luke Freedman in Sydney, Australia

20 February 2012

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If you haven’t already noticed, the topic of health care comes up a lot on the campaign trail. Like, all the time; seriously you’re going to be so tired of hearing about it by November. Since this issue isn’t going away anytime soon, it’s worth devoting a little time to understanding The Patient Protection and Affordable Care Act (PPACA) or “Obamacare.”

In the first of a two part series, I’m going to review the bill’s long and eventful journey in becoming law. In the second part, I’ll go into detail as to what health care reform actually does. As Otto Von Bismarck famously proclaimed, “If you like laws and sausages, you should never watch either one being made.” If you agree with Bismarck’s sentiment, it’s best to stop reading now.

Harry Truman was the first American president to formally propose a universal health care system and move the issue into the forefront of the American political debate. Although his plan gained little traction in 1945, Democrats have remained committed to comprehensive health care reform, and every Democratic president since Truman has expressed support for universal health care.

Both Barack Obama and Hilary Clinton made universal health care a key issue in their 2008 presidential primary campaigns. Unlike Clinton, Obama was opposed to requiring individuals to purchase insurance as a means of broadening the risk pool and decreasing health insurance premiums, “well, if things were that easy, I could mandate everybody to buy a house, and that would solve the problem of homelessness. It doesn't.” Ironically, the “individual mandate” ended up being the centre piece of the health care reform bill.

Upon taking office, Obama put health care reform at the top of his legislative agenda. The goal was to help curb the rising cost of health care, expand coverage to the uninsured, and prevent insurers from denying coverage to those with pre-existing conditions. Both Republicans and Democrats generally agreed that these issues eventually needed to be addressed, although there was wide disagreement over the best means of doing so.

With large majorities in both chambers of Congress and the support of President Obama, Democrats were optimistic that they could pass comprehensive health care reform. However, their plans hit an initial roadblock in February 2009 when former Senator Tom Daschle withdrew his nomination as secretary of health and human services amid revelations that he had not properly reported or paid his income taxes. Before the scandal, Daschle had been set to lead the Obama’s administration’s health care overhaul. 

Initially, Obama took a passive role in the health care reform process, outlining his broad goals but allowing Congress to try and work out the details of the plan. In May 2009, Speaker of the House Nancy Pelosi vowed to have the bill signed into law by August. However, things didn’t go exactly according to plan for the Democrats. At town hall meetings across the country citizens protested against the proposed bill, and Republican lawmakers warned of the dangers of “socialised medicine” and “rationing health care.”

Democrats also had trouble convincing the more moderate members of their coalition to sign onto the legislation. In the 2006 and 2008 elections, Democrats won a large number of seats in generally conservative congressional districts. While this was obviously good news for the party, many of these new members of Congress were very moderate. These “Blue Dog Democrats” were concerned about the costs of health care reform and were reluctant to endorse government rune insurance plans. Bills have to pass through relevant committees before they can proceed to the floor for a vote, and Democrats had to appease the demands of many House Blue Dogs in order to get the bill through committee. Democrats informed Obama that passage of the bill could take longer than anticipated.

There was also much controversy surrounding the issue of abortion. The 1976 Hyde amendment prohibits federal funds from being used to pay for abortions, but there was dispute over what this should mean in the context of publicly subsidized health care. Eventually, House Democrats agreed to adopt the Stupak amendment, a proposal by Michigan congressman Bart Stupak stipulating that no federal funds be used to cover any part of a health care plan that covered abortion. Many pro-choice Democrats were upset at the compromise, but the amendment ultimately secured the necessary votes for the bill’s passage.

On November 7 2009, the Affordable Health Care for America Act was passed by the House of Representatives by a narrow margin of 220-215. Only one Republican voted in favour of the bill and 39 Democrats voted against it. The bill included a government run insurance plan, or public option, that would compete against the plans offered by private insurers. The bill mandated that all citizens buy insurance or a pay fee, and provided government subsidies to those who could not afford insurance on their own. The bill would cost $1 trillion dollars and would extend health insurance coverage to 36 million Americans.

Progress in the Senate was also very extremely slow. Senate rules required 60 votes to prevent Republicans from “filibustering”, blocking the bill from proceeding to the Senate floor for a vote. This meant that Senate Majority leader Harry Reid needed to get all 60 members of the Senate Democratic caucus to sign onto the bill. In order to appease moderate Democrats, various versions of the House bill needed to be modified. On December 24, the bill was finally passed along a strict party lines vote (60-39). It would cost $871 billion over ten years, and, notably, did not include a public option. The language regarding abortion was different as well. People receiving federal subsidies could buy health plans that covered abortion, but they had to write a separate monthly cheque for abortion coverage.

The final task was to merge the two bills into one. While there was still work to be done, it seemed fairly inevitable that the Affordable Care Act would become law. Then, the unthinkable happened. On 29 January 2010, Republican Scott Brown won the Massachusetts Senate special election to fill the seat of the late liberal icon Ted Kennedy, who had died that past August. Democrats now lacked the 60 votes to override a filibuster, meaning they could not pass a modified version of the health care bill. Massachusetts had no Republican representatives in Congress, and hadn’t elected a Republican Senator since 1972. Ted Kennedy had called universal health care “the cause of his life,” but now reform appeared in jeopardy because Democrats couldn’t hold onto his seat in one of the most liberal states in the union. In the eyes of many, this was the end of the road for health care reform. Others Democrats wanted to abandon their ambition for sweeping reform, and instead try to pass much more moderate legislation.

However, key members of the party continued to explore other options for passing the bill. Obama also refused to back down on the issue, emphasizing that Democrats couldn’t give up now after coming so close to their goal.Eventually, Senate Democrats settled on a potential solution: “reconciliation.” Reconciliation is a process generally used to modify spending in bills for the purpose of deficit reduction, and requires a simple up or down vote instead of the 60 votes required to end a filibuster. The Senate couldn’t pass an entirely new bill through reconciliation, but they could make small budget related changes to the bill they had already passed in December.

In late February, Obama and Pelosi announced that they supported using reconciliation in order to get the bill through Congress. Democrats argued that they were justified in using the procedure because given that the bill was projected to reduce deficits, it could be considered a deficit reduction measure. They also pointed out that Republicans had previously used reconciliation to pass several major pieces of legislation. Republicans accused Democrats of using a loophole to get an unpopular piece of legislation through Congress.

Speaker Pelosi was clear that she did not have the votes to simply pass the Senate Bill in its exact current form, given that House members had concerns with some specific provisions. Most notable was a guarantee that Nebraska would not have to pay any of the costs associated with the health care bill’s expansion of Medicaid. Senate Majority Leader Harry Reid had offered this deal in order to convince Senator Ben Nelson from Nebraska to vote for the legislation. Senate Democrats agreed to amend these provisions through reconciliation.

Still, there was much work to be done. Speaker Pelosi had gotten House Democrats to already sign off on one bill; now she had to persuade them to pass a bill nearly identical to the one that the Senate had already approved. Many liberal Democrats were frustrated that the Senate bill was less comprehensive than the one they had passed, but they realized that at this point it was their only option. The real difficulty for Pelosi was winning over moderate, and especially, pro-life Democrats. The Stupak amendment had been essential in getting the support of around 40 members of Congress the first time around, but there could be no such provision in the final bill. The White House and House leadership worked with these pro-life Democrats to try and find an acceptable compromise.

Then, on the evening of 21 March, Congressman Stupak and a number of other pro-life Democrats announced they had reached an agreement with the Obama administration. Obama would issue an executive order reaffirming the government’s commitment to the Hyde Amendment and also address some of the Stupak coalition’s other minor concerns, such as clear abortion restrictions on government sponsored community health clinics.

Later that evening, the House of Representatives passed the Patient Protection and Affordable Care Act by a vote of 219-212. Every Republican and 34 Democrats voted against the bill. On 23 March, Obama signed the bill into law, proclaiming that health care reform reflects, “the core principle that everybody should have some basic security when it comes to their health care." Attorney General’s in 13 states immediately filed lawsuits claiming that the bill’s individual health care mandate was an unconstitutional violation of federal powers. Two days later, the Senate passed the reconciliation bill to amend the health care legislation in accordance with the stated wishes of the House. The reconciliation bill passed the Senate by a vote of 56 to 43. Senator Nelson was amongst three Democrats who voted against the bill. The process had been a long and often frustrating one, but Democrats had finally achieved the goal that had so long eluded them.

Tags: Barack Obama, Harry Reid, Health Care, Nancy Pelosi

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