Introduction
The year 2009 saw health care legislation at the apex of United States President Barack Obama's domestic agenda. At stake was landmark legislation reforming the United States' health care system. The ruling Democratic Party's plan focused on ameliorating health insurance, giving greater rights to patients, as well as an overhaul of the health care system itself, with an eye on improved access to patients for affordable care. Should such reform pass into law, it would be the most significant and sweeping domestic policy changes in the United States in decades.
Background
The general consensus was that the prospects for successful passage of health care reform would rise and fall on the willingness of both sides to compromise, or, the ability and desire of Democrats in Congress to pass health care reform legislation without the help of Republicans.
At issue for many politicians -- both Republican and centrist Democratic --was the cost of health care reform, with critics worrying about the astronomical costs, and the lack of economic benefit.
Republicans were also resistant to a public health care option (i.e. the concept of a government-backed health care exchange to compete with private insurers), which progressive Democrats demanded. Republicans were ideologically opposed to such a shift on the political landscape of the United States, and, as a result, railed against the notion of a public option, which would compete with private insurers in a bid to drive down skyrocketing costs. Republicans also believed that changes to the system would hurt the private insurance industry. In fact, leading Republicans argued that a competitive government-run health care program could be so effective as to put private insurers out of business.
The vociferous debate was not helped by the circulation of plainly false information about the proposed changes to health care, such as spurious claims by right-wing extremist voices claiming that "death panels" would be instituted for the elderly, that abortions would be federally funded, and that illegal immigrants would benefit from the new health care plan. Several congressional politicians were faced by angry attendees at town halls, making these claims, and tried to make clear the falsity of these assertions. Nevertheless, they were confronted by angry citizens who declared their opposition to the notion of government-run health care, which they declared to be "socialized medicine." They were seemingly unaware that the popular Medicare program for senior citizens was itself a government health care program existing under the aegis of the current health care regime.
On the other side of the equation, the left-wing base of the Democratic Party, angry about concessions being made to the Republicans in the hopes gaining support from them, pointed to the fact that several Republican politicians-- even the ones negotiating with Democrats in congressional committees -- seemed unwilling to support whatever compromise eventually might emerge. To that end, they pointed to an increasing number of Republicans who were suggesting that even the notion of cooperatives (as an alternative to the public health option) would be unacceptable to them. This reality meant that there was very little ground left upon which common ground with the Democrats could be forged.
Emboldened by the fact that Republicans appeared hard-pressed to actually make a deal with Democrats in committees, the left wing of the Democratic Party began to clamor for the public option, and placed pressure on both the president and moderates of both parties in congress. In this way, with the Senate trying to find a compromise proposal, and with the House moving fast toward a clenching embrace of the public option, the two chambers seemed to be on an ideological collision course with the president (and his agenda) in the middle of that path.
The President on Health Care Reform
President Obama's overall job approval numbers were on a downward slide in August 2009 due to anger from the left and right sides of the political spectrum. While there was an enduring and strong demand for health care reform of some sort, it was juxtaposed with decreasing support for President Obama's handling of the health care issue. Faced with criticism that it had lost control of the health care reform debate, and with fears rising that the endeavor to advance health reform would end in failure, the White House decided to take control of the policy agenda by scheduling a rare joint session of Congress for Sept. 9, 2009, to make clear President Obama's positions and expectations regarding health care reform in the United States.
On Sept. 9, 2009, President Barack Obama made the case for landmark health care reform in the United States of the type unseen in decades. President Obama expressly said he was ready to act, saying, "I am not the first president to take up this cause, but I am determined to be the last." President Obama noted that the United States was the only developed country that allowed millions of its people to experience "extraordinary hardship" -- either because fellow citizens simply live without health insurance and are therefore "just one accident or illness away from bankruptcy," or, because they are denied coverage even when insured due to the decisions made by insurance companies. Yet, as the president noted, despite these clear limits of the existing health care system, the United States actually spent more on health insurance than any other country.
Laying to rest speculation about whether he would address the matter of a "public option," President Obama said that such a choice would be made available to people, in order to force private insurance companies to operate in a competitive field, to the benefit of consumers. President Obama indicated openness to alternatives to the "public option" by mentioning co-operatives, but he drew a line in the sand on the government's role in health care. He asserted, "But I will not back down on the basic principle that, if Americans can't find affordable coverage, we will provide you with a choice."
On the issue of costs, President Obama said that a public insurance option would not be subsidized by the government. The president also warned that whatever final legislation came before him would only be signed if it were deficit neutral. That said, he reminded lawmakers that the current deficits faced by the country were made under the previous Bush administration for the Iraq war and tax cuts for the wealthy. The reference was an implicit nudge to members of Congress who had voted for those two extraordinarily expensive initiatives in recent years past, but were now balking at the cost of comprehensive health care reform today.
President Obama's address ended with citations from a letter from the late Senator Edward Kennedy, who had been known as the "liberal lion" of the Senate. President Obama used Kennedy's words to describe health care reform as "the great unfinished business" in the United States. Citing the letter, the president continued, "What we face is above all a moral issue; at stake are not just the details of policy but fundamental principles of social justice and the character of our country."
Health Care Legislation
Legislation on health care reform cleared multiple House committees and one Senate Committee by mid-summer 2009. Subsequently, in a final effort to offer up a bipartisan health care bill, the Senate Finance Committee released a draft of its proposal to overhaul the health care system. The bill was crafted under the supervision of the committee's chairman, centrist Democratic Senator Max Baucus of Montana, and brought a lengthy and difficult process to an end. In fact, in the fall of 2009, that bill cleared the important Finance Committee with the support of all Democrats, including those from conservative states, as well as limited bipartisan support from moderate Republican Senator Olympia Maine.
Central to Baucus' plan was a mandate requiring Americans purchase health insurance. To assist in the affordability of such a mandate, Baucus' plan would give tax credits to low- and middle-income people to help them to purchase health insurance. As well, a new fee would be imposed on insurance companies to help pay for coverage of uninsured individuals. Conspicuously absent from the bill was the creation of a government-run health insurance plan advocated by President Barack Obama. However, the draft made mention of new non-profit health insurance cooperatives to compete with private insurers. The plan also included health insurance reforms, such as making the exclusions of people with "pre-existing medical conditions" illegal. The cost of the plan was estimated to be just over $800 billion --significantly less than the other four other proposals in Congress. The costs would be offset by reductions in Medicare spending and by new revenue from an excise tax on health insurance companies and other industry entities.
This legislation by the Senate Finance Committee then entered a conference process with another bill already-passed bill in the upper chamber. That bill was crafted by Senator Chris Dodd and the late Senator Edward Kennedy in the Senate Health, Education, Labor and Pensions Committee.
On Sept. 23, 2009, Senate Majority Leader Harry Reid, a Democrat from Nevada, and and House Speaker Nancy Pelosi, Democrat of California, expressed support for the government-run "public option," which had been a volatile flash point in the health care debate. House Speaker Pelosi had already warned that whatever legislation ultimately emerged from the lower house of Congress would have to contain that public option, if it were to gain passage. Yet to be seen was whether or not the more conservative Senate would actually be able to do the same despite expressed support from Reid. Nevertheless, on Oct. 26, 2009, Senate Majority Leader Harry Reid presented the conference version of the legislation. He announced that the health care legislation headed to the Senate floor would include an option for government-run health insurance.
In a bid to satisfy centrist Democrats and those from conservative states, this public option would contain an "opt out" provision, which had been crafted by Democratic Senator Charles Schumer of New York. To this end, Majority Leader Reid, said: "As we've gone through this process, I've concluded, with the support of the White House and Senators Baucus and Dodd, that the best way forward is to include a public option with an "opt-out" provision for states." Accordingly, states would have one year to decide for themselves whether or not to "opt out" of the government-run health care program.
Addressing his decision to include the controversial public health option, Majority Leader Reid explained that polling data showed widespread and increasing support for the government's role in providing affordable health care to citizens, as advocated by President Obama and most Democrats in Congress. He noted that while the inclusion of this provision was no "silver bullet" in the health care reform effort, people nonetheless wanted the public option and it was key to providing competition.
Attention focused on the fact that while the bill included both the public option and co-operatives, the "trigger" option was conspicuously absent from the legislation. The "trigger" was an idea championed by Senator Snowe and would allow the public option to be go into effect only if there was insufficient competition at the systemic level without it. That was the only version of a public option that Senator Snowe favored, however, it was strongly resisted by several Democrats in both chambers who characterized it as ineffectual reform to the system. The inclusion of the "opt-out" provision vis a vis the "trigger" indicated that the Democrats were willing to fight for strong health care reform even if it alienated the few moderate Republicans. Still, Majority Leader Reid said he was "always looking for Republicans" to support legislation, although he could count these possible colleagues on "two fingers." He cautioned that even without them on board, Democrats would move forward on their own.
White House Spokesperson Robert Gibbs provided the following statement on behalf of the White House in response to Reid's announcement:
"The President congratulates Senator Reid and Chairmen Baucus and Dodd for their hard work on health insurance reform. Thanks to their efforts, we're closer than we've ever been to solving this decades-old problem. And while much work remains, the President is pleased that at the progress that Congress has made. He's also pleased that the Senate has decided to include a public option for health coverage, in this case with an allowance for states to opt out. As he said to Congress and the nation in September, he supports the public option because it has the potential to play an essential role in holding insurance companies accountable through choice and competition."
Going Forward
Senate Majority Leader Reid noted he was sending the legislation to the Congressional Budget Office for scoring. Ideally, he was hoping that the result would show that it was within the financial parameters set forth by the president to avoid adding to the deficit while saving the health care system money over the long haul.
After passage through the upper chamber, the conference legislation from the Senate would ultimately have to be reconciled with the bill ultimately emerging from the House of Representatives, which was expected to have strong public option. As aforementioned, House Speaker Pelosi had made clear that no legislation could pass through the Democratic-dominated lower chamber without inclusion of a strong government-run health insurance plan. These prospects were somewhat advanced by the fact that with the Senate version now contained a public option.
Final health care reform legislation was not expected to garner support from Republicans and could still run afoul with centrist Democrats in the Senate. Indeed, every Democratic vote in the Senate --including the two votes from the Independents that caucus with the Democrats -- would be needed to move the legislative process along by voting for cloture (closing off debate and moving toward the vote), even if they ultimately voted against the final bill. To that end, Independent Democrat Joe Lieberman was already signaling that he might not vote for cloture to advance the Senate bill, a move that could single-handedly derail health care reform. In this way, the final health care debate was likely to set up a massive and high stakes ideological battle.
Editor's Note:
It was yet to be seen if he had accomplished these goals. Would the president succeed in advancing his most significant domestic policy initiative? Or would health care reform bedevil President Obama as it did President Bill Clinton 16 years earlier? In the early 1990s, Clinton's health care reform plan ended in failure and Democrats lost control of the House of Representatives soon thereafter. In effect, the actual beneficiaries of the failure of health care reform efforts in the 1990s were the Republicans at the polls in congressional races. Could the Democrats again be headed to such a fate in 2010? Ultimately, if health care reform passed into law, it would be the most significant and sweeping domestic policy change in the United States in decades.