Passing Health Care Reform The Affordable Care Act of 2010

The Process of Reform

Health Reform and the National Agenda

Key Administration Players

The Congressional Budget and Health Reform

House Committees With Jurisdiction over Health Reform

Senate Committees with Jurisdiction over Health care

Starting the Process--Hearings

Drafting Legislation The Committees in both Chambers went to work on their part of the larger bill. The House had three committees at work and they produced a combined “tri-committee” bill. In the Senate the two committees with jurisdiction went to work and produced one combined bill.

Congressional Budget Office Analysis The bills or sections of bills being considered by each chamber were submitted for review to the CBO. The Congressional Budget Office (CBO), a nonpartisan agency that works for Congress –Estimated the costs and effect on federal budget –Considered legislation as a whole and each component separately President Obama set maximum total cost for reform bill of $1 trillion –Bill was to be fully paid for (i.e. not increase the deficit) –Committee leaders and staff worked to keep everything at or under this target

Mark-Ups After CBO estimates, Mark-Ups meetings were held – public meetings to vote on bill –Bill debated by all the various committee members in each chamber and amendments are offered and voted upon Each of the five committees in the two chambers approved health reform legislation –Votes in each committee along party lines, except the Senate Finance Committee After committee approval, bill forwarded for consideration by full House or Senate

House Floor Procedures The Three House committee bills were combined into single piece of legislation (HR 3962) ‘Whip Count’ ­Final vote tally for bill House Rules Committee ­Defines rules for terms of debate on House floor The bill was debated and passed on November 7, 2009:

Senate Floor Procedures – Different in Senate Debate ­Senators who have the floor may speak as long as they want Amendments ­May offer as many amendments as they desire Filibuster ­Tactic used to delay legislation Cloture ­Motion for ending filibuster ­Requires three-fifths vote Passage ­After cloture, passage requires simple majority ­The Senate passed the House reform bill on December 24, 2009 by a vote of

Senate Floor Procedures – Budget Reconciliation Option Two types of bills not subject to filibuster in the Senate ­Budget Resolutions ­Budget Reconciliation Budget Resolution -Provides broad outline of spending and revenue Budget Reconciliation ­Optional ­Requires simple majority ­Limited debate time ­No limit on the amount of amendments that can be offered ­Byrd Rule - Legislation and any amendments must be budget related

Reconciling Differences The House and Senate versions of the legislation were different in many respects. One important problem was while both chambers worried about cost containment, the House members believed that the Senate bill was particularly weak at controlling costs and raising revenue.

Resolving Differences Between House and Senate Legislation Option 1 – House Senate Conference Committee ­Negotiations ­Conference Report ­Full House, Senate approve revised legislation and send to President Option 2 ­One chamber accepts the other chamber’s bill without making any changes, sending the legislation on to the President Option 3 ­After the bill is enacted (option 2), Congress passes a second bill which makes changes to the new law. This is the Sidecar bill. ­The second bill is then sent to the President

Time Out: The Republican “Takeover” The special election that almost derailed reform. Overcoming the Republicans “Majority”

Passing Reform—Overcoming the “Republican Majority” Since both chambers had passed the ACA in 2009, the Democrats intended to follow the usual procedure of working out differences between the two versions of the bill by appointing a conference committee. This strategy was suddenly in doubt when in the fall of 2009 Scott Brown, a Republican Tea Party favorite, won the Massachusetts Senate seat that became open when Ted Kennedy died.

The Need for a New Strategy Because the Senate Republicans filibuster almost all Democrat legislation, bills cannot pass in the Senate without a super-majority of 60 votes. Brown’s win gave the Republicans 41 seats. The Village Voice ran a headline that said: “Scott Brown wins in Mass. Race, Giving, GOP Majority in the Senate.”

Obama Rallies Support Brown’s victory threw the Democratic Party into disarray. In the House and Senate, Democrats debated passing a watered down bill that addressed only a few problems. Obama rejected that option. He said he was not elected president to design school uniforms. Obama held a summit on reform, asking the Republicans for input.

The President’s Summit Obama offered a new version of reform based on key provisions that had been agreed to by Democrats in both chambers. The Summit demonstrated the President’s continuing support for reform and reenergized the Democrats. The President’s plan was endorsed by the AARP, the AMA, the major labor unions, and many of the major insurance companies (as long there was no public option and there was an individual mandate).

The Two-Step Strategy The Democrats rallied and began to develop a new strategy. The Democratic leadership in both chambers agreed to a two-part strategy to get around the 41 vote Republican filibuster bloc in the Senate. The House would pass the 2009 Christmas Eve Senate bill, along with a second bill (a sidecar bill) that would enact various changes in taxes and spending agreed upon in advance with Senate Democrats.

Sidecar The Sidecar bill would then be passed by simple majority in the Senate, using the established procedure know as “reconciliation,” by which fiscal bills can avoid filibusters. The Sidecar (or reconciliation) bill would make the House Democrats happy. (Republicans had repeatedly used this approach to pass tax cuts for wealthy Americans. Therefore, it was hard for them to challenge the strategy.)

The Plan This plan allowed Congress to build on all that had been accomplished in One problem was that it required the House Democrats to trust Senate Democrats to carry through with the sidecar vote. The House Democrats were afraid that the Senate would bog down (as usual) and the sidecar would not be passed.

A More Radical Plan The Senate Majority Leader, Reid, made public a letter signed by more than 50 Senate Democrats promising to vote for the sidecar bill. They kept this promise. One result was the passage of the Senate version which was bolder, more liberal, and less weighted down with special side deals than the House version.

The More Radical Plan With only 51 votes needed, special deals worked out with Democrats for their support were scrapped. The “Cadillac tax” (opposed by Labor) was reduced and delayed, but remained in the bill. The Sidecar placed higher taxes on health- care industries, wealthy Medicare beneficiaries, Wall Street, medical services providers, and certain financial investments. In turn, the House accepted a cost-monitoring commission for Medicare.

The CBO Estimates and Projections The CBO projected long-term savings and documented that the Senate bill plus the sidecar would not only pay for health reform but cut the federal budget over a ten year period. Both the Democrats and Republicans generally trust the CBO, but the CBO estimates in this case made the Republicans unhappy.

Legislation Signed Into Law Health Reform in 2010 – President Obama Signed two bills into law H.R – Public Law ­Health reform bill passed by the Senate in December 2009, passed by the House March 2010, and signed into law on March 23, 2010 H.R – Public Law Passed under budget reconciliation procedures by House and Senate; made some changes to P.L President Obama signed budget reconciliation bill on March 30, 2010

Overview - Committees and Floor Debate (2009) COMMITTEES FLOOR CONSIDERATION HOUSE Energy & Commerce Ways & Means Education & Labor Passed July 31 Passed July 16 Passed July 17 SENATE Two bills combined into one Motion to proceed to debate adopted FinanceHELP Passed July 16 Passed October 13 Three bills combined into one October 29 HOUSE VOTE Passed Limited floor debate – One day Two Amendments Considered; One Adopted November 7 November 18 November 21 Floor debate - 21 days Nov. 30-Dec. 24 November 7 Filibuster Defeated 3 times -- on 2 amendments and on the bill By Invoking Cloture votes required Dec December 24 SENATE VOTE Passed NEGOTIATIONS BETWEEN HOUSE, SENATE & PRESIDENT

Overview – Resolving Differences and Final Enactment (2010) House-passed bill H.R The House made changes to H.R which were incorporated in… Reconciliation bill H.R HOUSE VOTE Passed March 21 Senate-passed bill H.R HOUSE VOTE Passed March 21 SENATE VOTE Passed March 25 The Senate agreed to the House bill, but made small changes… HOUSE VOTE Passed March 25 March 30 Signed into law by the President March 23 Public Law Signed into law by the President The House passed the bill as amended by the Senate Public Law

The Design of Health Care Reform There are a lot of nations with universal health care and therefore a lot of “models” for health care reform. The ACA was not the result of copying best practices from developed nations. It is a uniquely American version, based on a lot of consultation and research, but it is not the result of simply seeking the best possible options.

Instead, it reflects a series of major compromises with power players. It is, in other words, not a model of textbook Rational Decision making.

The Design of Health Care Reform Doctors, Hospitals, Insurance Companies, Drug Companies, Medical services and supply companies, Unions, and the Business Community all had to play a role and feel like they were either going to be advantaged by change or not as badly hurt as they would be by other options. The Individual mandate and no public option were critical for the Insurance industry. Doctors and hospitals wanted more patients, reasonable fees, less paperwork, more efficient health care.

The Design of Health Care Reform The Drug Companies wanted to make sure that they would have a larger market and more consumers with insurance. Unions wanted more workers covered and protection for their “Cadillac” plans. Business wanted a more efficient, less costly system and better tax breaks for health care costs.

The Design of Health Care Reform The result is a huge compromise—the result of dealing with a collection of well-financed groups with a lot of expertise in getting what they want from government. It was a battle of Titans rather than consumers. This is often the case with public policies. In the end, compromises of this type leave a lot of people unhappy, including those who supported the bills and voted for them.