The Passage of the Affordable Care Act

Essay #1 MIT Student 11.002/17.30 Making Public Policy 9/29/14 The Passage of the Affordable Care Act From Johnson to Nixon, from Clinton to Obama, American presidents have long wanted to reform the American healthcare system. As prices rose and the quality of care stagnated, the public repeatedly called for change. Despite public support, healthcare policy has barely evolved within the last century, save the additions of Medicare and Medicaid. Recently, President Barack Obama pushed the Patient Protection and Affordable Care Act (PPACA) through Congress, marking a new era for healthcare in America. Obamacare succeed where other healthcare reforms failed not because of superior content, but because of the political momentum liberals had at the time of proposal. In the 2008 elections, Democrats gained seats in both the House of Representatives and the Senate. This was the first time leading up to a healthcare proposal where one party not only controlled both Chambers of Congress and the presidency, but also gained seats in both chambers. With an electoral mandate, President Obama and leaders in Congress had a greater ability to force interest groups and wavering members of Congress to support the new healthcare bill. Capitalizing on favorable election results in 2008, newly elected President Obama worked quickly to make the most of the liberal climate that was American politics at the time. Critics often site Clinton’s drawn-out approach to healthcare reform as one of the primary reasons he was unable to pass legislation (Oberlander 1113). Clinton did not start championing healthcare until September 1993 when he had already been in office for close to a full year. The honeymoon period was over and conservatives were already beginning to prepare for the upcoming election cycle. They planned to rip Clinton apart (Skocpol 6-7). Obama did not make the same mistake. Even before he officially took office in January 2009, Obama worked with Max Baucus, the head of the Senate Finance Committee, and other legislatures, such as Ted Kennedy to form a blueprint for healthcare reform. They realized, “time was now the enemy. The longer it took to get reform through Congress, the less likely Congress would be to pass the legislation” (Cohn 17). With the beginning of a plan in place, Obama needed to work quickly. The 2008 elections gave Democrats 55 seats in the Senate, with two additional liberal Independents, up from 51 seats between the two groups in the 110th Congress. Similar gains emerged in the House of Representatives. This swing left represented a shift in the American political landscape. The Obama administration perceived the change in public opinion as an electoral mandate to carry out more liberal policies such as healthcare reform. By acting quickly, Obama made the most out of recent Democratic gains while the novelty of the election results still inspired congressmen and citizens alike. By early July 2009, senators caucusing with the Democrats totaled 60, enough to override a filibuster should more conservative senators choose to try and block a vote. Within the Senate, those opposed to a bill have the ability to filibuster, or draw out debate, unless a supermajority of sixty votes exists to override the filibuster and force a vote. This makes the 60th Senator an extremely influential individual. According to the theory of pivotal politics, the 60th Senator must feel that the proposed legislation is closer to his ideal position on any given issue than the status quo. If the 60th Senator does not feel that he will personally benefit, he has no reason to help override the filibuster (Krehbiel 25-26). In the case of Obamacare, the 60th Senator was likely Joe Lieberman, a Democrat turned Independent, or Ben Nelson, a Democrat from the conservative state of Nebraska. Even though both men were more conservative than many of their fellow congressmen, they still had ties and loyalties to the Democratic Party. When considering the political landscape, obtaining the support of both men did not seem like an impossible feat for Democrats. Therefore, numbers wise, the Democrats had the ability to pass healthcare reform without needing to convert any Republicans to there side, an important consequence of the sweeping victory in the most recent election cycle. Despite the huge number of Democrats in the Senate at the time, party leaders would need to convince and compromise with the most conservatives in their party to obtain the votes needed to override the filibuster. As previously mentioned, the pivot needs incentive to help stop a filibuster and call for a vote. Proponents of Obamacare removed the public option to please Lieberman and agreed to pay higher Medicaid expenses to Nebraska to sway Nelson (Cohn 24). Even with these personally tailored adjustments to the Affordable Care Act, it is unlikely that either Nelson or Lieberman would have voted like they did, if they were not already associated with the Democratic Party. For Nelson in particular, voting against your president and the rest of the party is difficult. In the future, he could have lost campaign support and money from the party base. Moreover, in the most recent election the majority of the country voted for Democrats and the liberal policies they supported. As a politician, one of your primary concerns is getting reelected. According to Arnold “legislators will do nothing to advance their other goals if such activities threaten their principal goal” (5). Additionally, legislators see their choices as paired alternatives where one will lead to a reelection (Arnold 6-7). For Nelson, who was in fact the last senator to sign on to healthcare reform, voting along party lines provided a clearer path to reelection. Such a choice may not have become clear if the vote was not completely partisan due to Democratic gains in the 2008 elections. In fact, even with Nelson’s vote, healthcare reform almost failed, because Democratic momentum slowed and even began moving in the opposite direction. In September 2009, Senator Ted Kennedy from Massachusetts passed away. His replacement, Paul Kirk voted with the Democrats in December to pass the Patient Protection and Affordable Care Act, but Massachusetts voters replaced him with Republican Scott Brown, before Congress completed reconciliation and Obama could sign the healthcare reform into law. With the loss of Kirk, Democrats no longer had a supermajority. Ultimately, a reconciliation loophole would be used to pass healthcare with only a simply majority. As exemplified above, even the smallest shift in Senate balance had the potential to kill Obamacare. Had voting occurred after the 2010 elections, it is unlikely that Democrats would have had the momentum or numbers to bring about reform. In addition to providing sufficient numbers to pass healthcare in both Chambers of Congress, the Democratic majority also helped garner support of interest groups. With power and money at their disposal, enemy interest groups can easily squash unfavorable legislation. Early on in the legislative process, Obama reached out to the Pharmaceutical Research and Manufactures of America (PhRMA). Together with PhRMA and other health industry interest groups, the Obama Administration worked to find money to fund healthcare reform. Obama agreed not to significantly decrease the price of pharmaceuticals to prevent the companies from launching a full-fledged media campaign against the new legislation (Oberlander 1115). For the interest groups, making a deal with the Obama administration was beneficial because it allowed them to be a part of the legislative process. While interest groups did have to make some concessions, they also had the opportunity to help shape policy that would bring in billions of dollars of new business each year. With such a large liberal hold on government, pharmaceutical groups and other health industry groups decided shaping policy was better than getting stuck with unfavorable legislation. Liberal leaders could have suggested and passed a plan that would actively hurt hospital and pharmaceutical companies. Thus, interest groups decided to join rather than opposed the liberal wave calling for reform. The 2008 election cycle won Democrats the presidency, extended margins in the House of Representatives and gave Democrats a supermajority in the Senate. As elected officials took office in early 2009, they had the energy and drive to create healthcare reform. Without strong numbers and the perceived will of the people, the Obama administration would never have garnered support of interest groups and wavering members of Congress. Healthcare reform would have failed. Thus, looking forward, it is important that conservatives perform better in elections. If we want to regain control of the country, the Club for Growth should commit to larger spending in congressional elections. If liberals continue to take control of Congress, they will have the power to extend healthcare, and at some point may offer a public option. With Republicans in office, we can slowly vote to scale back Obamacare and prevent other liberal agendas from passing in the future. Additionally, Club for Growth can support local leaders who speak out against the Patient Protection and Affordable Care Act. If governors and other state officials follow the example of Rick Perry and work to slow down implementation of exchanges, the public will turn on Obamacare and the liberal turn it represents. This opens a window for conservative politics in the future. Works Cited Arnold, R. Douglas. "Explaining Congressional Action." The Logic of Congressional Action. New Haven: Yale UP, 1990. 3-16. Print. Cohn, Johnathan. "How They Did It." New Republic 10 June 2010: 14-25. Print. Krehbiel, Keith. "A Theory." Pivotal Politics: A Theory of U.S. Lawmaking. Chicago: U of Chicago, 1998. 20-48. Print. Oberlander, J. "Long Time Coming: Why Health Reform Finally Passed." Health Affairs 29.6 (2010): 1112-116. Print. Skocpol, Theda. "A Pivotal Episode." Introduction. Boomerang: Clinton's Health Security Effort and the Turn against Government in U.S. Politics. New York: W.W. Norton, 1996. 1-19. Print.