Feature: Print Advertising in the Health Care Reform Debate

President Barack Obama made health care reform a central priority of his administration from the outset, second only to the immediate need to foster an economic recovery. In his Feb. 24, 2009 address to a joint session of Congress, Obama declared, “Health care reform cannot wait, it must not wait, and it will not wait another year.” A Health Care Summit at the White House on March 5 marked the formal start of an historic debate which was to take many twists and turns over the next year.

According to the Centers for Medicare and Medicaid Services, U.S. health care spending in 2009 totaled about $2.5 trillion, accounting for 17.3% of the GDP. This is a significantly higher share than in other industrialized countries, and health care spending is growing at a more rapid rate than the economy as a whole, potentially jeopardizing long term financial stability. At the same time about 16 percent of Americans or between 40 and 45 million are uninsured. These two strands—how to control costs and how to increase access—defined the debate of 2009-10. 

Debates over health care have been going on for the better part of a century. In 1912 Theodore Roosevelt ran for president on a Progressive Party platform which called for “a single national health service.” On July 30, 1965 President Lyndon Johnson signed the legislation creating Medicare and Medicaid.  In 1993 the Clinton administration sought to achieve reform as President Clinton designated First Lady Hillary Rodham Clinton to lead the Task Force on National Health Care Reform. The failure of that effort contributed to Democrats’ loss of a majority in the House for the first time since 1954. States have been experimenting with solutions as well. In 2006 Massachusetts under Republican Gov. Mitt Romney adopted health care reform legislation requiring most residents to have health insurance. 

The issue of health care cuts directly to the question of the proper role of the federal government, and vast ideological differences were much on display as the debate unfolded in 2009-10. Progressives argued that health care is a right and advocated for a single payer system. This idea did not find favor among legislators, but the possibility of a public option to compete with insurers did have considerable support. By contrast, conservatives said that America’s health care system is the best in the world and that free market solutions can fix problems the system may have. Critics warned of a government take-over of health care as a step towards socialism, foresaw rationing, and said that in any case the federal government could not afford to take on the cost of “Obamacare.” In addition to such questions as whether to include a public option and how to pay for reforms without adding to the deficit, other contentious issues emerged most notably over language on abortion and coverage for illegal immigrants. 

Perhaps mindful of the failure of the Clinton effort, President Obama let Congress take the lead on health care reform. Legislation worked its way through three House committees and two Senate committees. During the summer of 2009 many members held health care town hall meetings, at times contentious. Former Gov. Sarah Palin and others even warned of “death panels.” After the heated summer, President Obama refocused the debate with his address to a joint session of Congress on September 9.

Throughout the process, Democrats proved unable to attract much if any Republican support for their proposals. The most sustained effort was made by Senate Finance Committee Chairman Max Baucus (D-MT), but he eventually gave up. Also in the Senate, Sen. Ron Wyden (D-OR) worked for a time with Sen. Robert Bennett (R-UT) on a proposal. In the House, Rep. Roy Blunt (R-MO) headed up the Health Care Solutions Group, and the conservative Republican Study Committee presented a proposal in July. As noted by PolitiFact, by late September 2009 more than 35 Republican health care reform bills had been introduced advancing such ideas as tort reform and allowing consumers to shop across state lines for health insurance.

On October 29, House Democrats introduced their bill, H.R. 3962, the Affordable Health Care for America Act, at a rally on the west side of the Capitol. The House voted on the legislation on Saturday, November 7. The margin looked close; President Obama visited Capitol Hill to make a final pitch to undecided House Democrats. After a full day of debate, at 11:14 p.m. the House voted 220-215 to approve H.R. 3962. A late amendment providing restrictions on federal funding for abortion was key to passage. Just one Republican, Rep. Anh Cao (LA) supported the bill, while 39 Democrats opposed it.

The Senate process was criticized for a lack of transparency, and the final legislation did not include the public option favored by progressives, but did include a number of controversial deals such as the “Cornhusker Kickback” and the “Louisiana Purchase.” The Senate stayed in session until December 24, before passing its version of health care reform by a 60-39 party line vote.

All looked set for a conference committee early in 2010 until Republican state Sen. Scott Brown’s upset win in the January 19 U.S. Senate special election in Massachusetts cost Democrats their supermajority. For a time Democrats were completely flummoxed, some advocated going to a more modest piecemeal approach. Many observers pronounced health care reform dead. Republicans pressed to “start over.” 

On February 25 President Obama convened a televised bipartisan meeting on health care reform with congressional leaders at Blair House, setting the end game in motion. A few days earlier Obama had finally introduced his own proposal, modeled fairly closely on the Senate bill. After the bipartisan meeting Obama pointed to some areas of agreement with Republicans, but made clear his intention to proceed with broader reform. Obama’s rhetoric in this period was sharply critical of the health insurance industry.

Congressional Democrats considered whether to attempt a controversial “deem and pass” procedure, but decided against it. A vote was set for Sunday March 21. The future of Obama’s presidency seemed very much at stake. CBS News reported that from March 2009 through the Friday before the vote Obama had delivered a total of 54 speeches and statements on health care. On March 20 Obama made another trip to Capitol Hill, where he made a final pitch to the House Democratic Caucus. The magic number was 216. By the morning of the vote it was still too close to call. Abortion remained an issue with the potential to defeat the measure, and the White House issued a statement saying Obama would sign an executive order clarifying the abortion language. As House Members debated, hundreds of tea-partiers gathered outside urging them to “kill the bill.” That night, however, the House passed the Patient Protection and Affordable Care Act (H.R. 3590) and the accompanying reconciliation measure, the Health Care and Education Reconciliation Act of 2010 (H.R. 4872), by a margin of 219-212 with all Republicans and 34 Democrats voting against.

President Obama signed the legislation on March 23, and the Senate promptly took up the reconciliation bill, operating under budget rules which limited debate to twenty hours. Senate Republicans managed to find a couple of rules violations forcing the reconciliation package back to the House for another vote, but the Senate approved the measure by a vote of 56-43, all Republicans and three Democrats voting against, and the House followed that evening with a 220-207 vote.

Even as Obama signed the bill challenges were already in progress. Attorneys general in a number of states moved to challenge the constitutionality of the measure, particularly the individual mandate requiring citizens to buy health insurance. On Capitol Hill some Republican members vowed to repeal the law.

The result of this sausage making is a far-reaching health insurance reform measure which the Congressional Budget Office says will extend health insurance to 32 million Americans. Balancing the individual mandate are provisions to address much criticized practices of the insurance industry. Although some provisions take effect immediately, major portions such as the state health insurance exchanges and the requirement that insurance companies cover those with pre-existing conditions are not set to start until 2014; the excise tax on “Cadillac” plans was even put off until 2018.

CBO estimates that taxes and fees and spending cuts will bring in $1.1 trillion over ten years to cover the costs of the reform, including limits on the growth of Medicare payments and higher Medicare taxes on high income households. CBO puts the cost over ten years at $985 billion, primarily to expand Medicaid and provide subsidies for private insurance.

Whether the reforms will do enough to control costs remains to be seen; major pillars of the current system such as insurance through employers and fee for service remain intact. Even if the reforms survive the challenges, two thousand-plus pages of law are bound to entail unintended consequences and to require adjustments far into the future.

Passage of the historic health insurance reform legislation did have immediate political consequences. On the one-year anniversary of his administration, President Obama had been seen as floundering and not living up to expectations. Comparisons were drawn to Jimmy Carter. New York (12/07/2009) asked “Whatever Happened to Barack Obama?” American Interest (1/2010) had Obama “Flirting with Failure,” and Newsweek (02/01/2010) described an “Inspiration Gap.” Just two months later Obama and the Democrats’ win on health care put an emphatic stop to those stories.

Timeline

March 25 - Senate approves the reconciliation package by a vote of 56-43, all Republicans and three Democrats voting against, and the House follows that evening with a 220-207 vote.

March 23 - President Obama signs the health insurance reform bill in the East Room.

March 21 - White House statement saying Obama will sign executive order on abortion language.  House concurs on Senate amendments to H.R. 3590, the Patient Protection and Affordable Care Act, and passes H.R. 4872, the Reconciliation Act of 2010, by a vote of 219-212.

March 20 - President Obama makes a last pitch to the House Democratic Caucus in the Capitol Visitor Center.

Feb. 25 - Televised Bipartisan Meeting on Health Care Reform at Blair House.

Jan. 19, 2010 - State Sen. Scott Brown (R) wins the U.S. Senate special election in Massachusetts, costing the Democrats their supermajority in the Senate.

Dec. 24, 2009 - Senate passes H.R. 3590, Patient Protection and Affordable Care Act as amended, by a party line vote of 60-39.

Nov. 7 - House passes the Affordable Health Care for America Act, H.R. 3962, by a vote of 220-215, only one Republican voting for.

Oct. 29 - House Democrats introduce their bill, the Affordable Health Care for America Act, H.R. 3962, melded together from the three committees’ legislation, at a rally on the West side of the Capitol.

Oct. 13 - Senate Finance Committee approves bill.

Sept. 16 - After unsuccessful efforts to gain bipartisan support with Sens. Grassley, Enzi and Snowe, Senate Finance Chair Max Baucus releases the chairman’s mark.

Sept. 9 - President Obama delivers a speech on health care to a Joint Session of Congress.

July 31 - House Energy and Commerce Committee approves bill.

[July 30 Republican Study Committee chair Tom Price (GA) introduces the Empowering Patients First Act].

July 17 - House Ways and Means Committee and House Education and Labor Committee approve bills.

July 14 - House Democrats announce America’s Affordable Health Choices Act.

[May 20 Sens. Coburn (OK) and Burr (NC) And Reps. Ryan (WI) and Nunes (CA) introduce a Republican bill].

March 5 - Health Care Summit in the East Room of the White House.

March 2 - President Obama nominates Gov. Kathleen Sebelius (D-KS) as his Secretary of HHS

Feb. 3 - President Obama’s initial pick for Secretary of HHS, former Sen. Majority Leader Tom Daschle, withdraws.