On March 23rd, President Obama signed into law The Patient Protection and Affordable Care Act, more commonly known as the ACA, or colloquially as Obamacare. Obama, and his staffers, had feared failure on multiple occasions (Obama, 2020), and when it comes to promoting their legislative agenda, the question has always been whether a president can get lawmakers to accept something they would not originally pass (Beckmann, 2008. pg. 407). Despite this, the Obama administration and Congressional Democrats defied the odds and ushered in a new era in American health politics (Oberlander, 2010. pg. 1112).
The strategic problem for all presidents is that their power is inherently limited. It always has and will be limited, because the fragmentation of the institutions of government severely restricts their ability to determine the passage of legislation and the implementation of policy. The ‘genetic code’ of the constitution cannot be escaped (Bowels, 1987. pg. 2). Obama, a President who had promised to end the gridlock within the halls of Congress, ran headfirst into this ‘genetic code’.
Attempts at reforming the US health system have an established record of losing, and in 2009 there were plenty of reasons to believe they would fail again. In 2009, Obama inherited a polarised political environment, soaring budget deficits, an economy on the verge of a second great depression, along with a myriad of smaller challenges, all of which stood in the way of reform (Oberlander, 2010. pg.1112). The state of the nation and the world, the expectations of the public, and partisan control of government are among the many environmental factors that help define parameters for policy-making and that shape presidential-congressional relations (Shull, 1997. pg. 6).
Obama embarked on an ambitious legislative push to reform the American healthcare system. Both the politics and the substance of health care are complicated. Yet, Obama was determined to change the injustices of the American Healthcare system. Spurred on by his mentor, Teddy Kennedy, a Democratic Senator who had been diagnosed with a malignant brain tumor, Obama and his team began to map out their legislative strategy, beginning with a headcount (Obama, 2020).
Despite the fact that Obama had come into office with large Democratic majorities in Congress, these were nothing like the majorities that Presidents Roosevelt and Johnson enjoyed when Congress passed Social Security and Medicare. The 111th US Congress closely resembled the 103rd Congress or the one that killed President Clinton’s efforts to reform health care in 1993-1994. Obama’s greatest challenge would be ensuring the passage of ambitious healthcare legislation, similar in size and scope to the Great Society and New Deal programs, without the advantage of the large congressional majorities of those eras (Oberlander, 2010. pg. 1112-1113).
Richard Neustadt realized the limitations of presidential influence, and asserts convincingly that the essence of the president’s political leadership over Congress is his ability to persuade; “All presidents wish they could make Congress serve them as a rubber-stamp, converting their agendas into prompt enactments, and most presidents will try to bring that miracle about, whenever and as best they can” (Neustadt, 1973. pg. 136).
However, the democratic head count was incredibly flimsy, especially in the Senate, with ailing Senators, such as Ted Kennedy and Robert Byrd, along with several conservative Democrats, such as Ben Nelson and Joe Liberman. These routes all provided a manner in which the crucial sixtieth, and filibuster-proof, the vote could be lost (Obama, 2020).
Obama and his team knew that passing something as controversial as health-care reform, via solely partisan votes, would make the law vulnerable down the line. Therefore, the President and his legislative advisers attempted to fashion their scheme in a way that had a chance of garnering some Republican votes (Obama, 2020).
These attempts to reach out across the aisle, whilst initially promising, were ultimately fruitless, as Republicans gradually abandoned all pretense of wanting to negotiate. This darkened the mood at the White House, which was further darkened by a series of increasingly dire poll numbers (Obama, 2020).
Obama decided he would spend the first two weeks of August 2009 holding various town halls in states such as Montana and Colorado, where support for health reform was weakest (Obama, 2020). The country was now in the middle of what was daubed as the “Tea Party Summer”, which was an organized effort to espouse many people’s fears regarding healthcare reform, with a right-wing political agenda. Heading to and from every town hall, Obama was greeted by dozens of angry protesters. One thing was certain; a large portion of the American people did not trust the words of Obama, or of Democratic lawmakers (Obama, 2020).
The majority of presidential legislative proposals face problems, sometimes insurmountable ones. As aforementioned, presidential power always has, and always will be, limited due to the fragmentation of the different branches of government. According to Neustadt, however, the impact of the president on legislation depends on; “The measure of the man. His strength or weakness, then, turns on his personal capacity to influence the conduct of the men who make up the government” (Neustadt, 1960. pg.4).
Knowing that they had to try something substantial to reset and re-energize the contentious healthcare debate, David Axelrod, a senior adviser to the president, suggested that Obama deliver an address before a special joint session of Congress, a high-stakes roll of the dice, that had only been used twice in the past sixteen years (Obama, 2020). On the 9th of September, Obama delivered this address, and according to polling data, it increased the public’s support for the healthcare bill. Even more important for the President’s agenda, it seemed to stiffen wavering congressional Democrats (Obama, 2020).
From the very start of the health-care debate, those on the left had pushed for a modification of the Massachusetts model, first coined by the Republican governor of Massachusetts, Mitt Romney. This was the so-called “Public-option”, and it was hoped that it would lay the groundwork for a single-payer system. It was an intelligent idea and had garnered enough signatories that Nancy Pelosi included it in the House Bill (Obama, 2020).
Speaker Pelosi engineered the quick passage of the House bill in the face of huge opposition from the Republicans. If the Senate could pass a similar version before Christmas, January could then be used to negotiate the differences and work out the fine detail (Obama, 2020).
However, in the Senate, there were nowhere near sixty votes for the public option. Obama and his team thought of a possible compromise – by offering the public option in the parts of the country where the entry of a public insurer system could help drive down the overall price of insurance (Obama, 2020).
However, this was still too much for the more conservative elements of the Democratic Senate caucus to endure. Various Senators, such as Joe Liberman, announced they would not vote for a package containing a public option, under any circumstances. The Nebraskan Senator, Ben Nelson, was also wavering (Obama, 2020). The Democrats could not afford to lose a single vote in the Senate. The vote of every Democratic Senator would be pivotal to the eventual outcome. Nelson wanted to ensure that the final version of the law prohibited the use of public funds for abortions (Nelson, 2009).
These crucial votes were only won after the public option was excluded from the Senate’s bill, and after the motion was changed to allow states to opt-out of insurance exchange plans to provide abortion coverage. In December 2009, after twenty-four days of debate, the Senate passed the Patient Protection and Affordable Care Act – Obamacare – with exactly sixty votes (Obama, 2020). The Senate bill would now head to the House for reconciliation.
However, the Democrat’s plans were scuppered by the special election in Massachusetts, where the Republicans won the traditionally Democratic Senate seat. This victory was significant because of its effect on the Democrats in Congress. The Republican victory was a humiliation for the Democrats, and humiliation made many Democrats in Congress concerned about the political cost of healthcare reform. Moreover, the election meant that Democrats could no longer break a Republican filibuster in the Senate.
The original Democratic plan was to negotiate changes during a conference committee in January 2010, before passing a final bill (Obama, 2020). However, since any change would now have to pass over a Republican filibuster in the Senate, House Democrats would now have to pass the Senate’s bill. As most of the House Democrats’ concerns were budgetary, and thus, these concerns were addressed via the reconciliation process (Chait, 2010).
The last hurdle for Obamacare was a critical group of pro-life House Democrats, led by Bart Stupak. Their concerns could not be addressed via the reconciliation process, like the majority of other members, as the group’s concerns regarding the possibility of federal funding for abortion, are not a budgetary issue. To resolve this sticking point, Obama issued Executive Order 13535, which re-affirmed the principles of the Hyde Amendment, winning over the wavering Democrats and assuring the bill’s passage (Chait, 2010). The House duly passed the Senate’s Bill on the 21st March 2010, with a vote of 219-212. A mere two days later, Obama signed the ACA into law.
The Congressional Democrats defied the odds, and the enactment of the ACA marked a new chapter in American health politics. Moreover, this was a victory for Obama, it cemented his legacy and was one of the crowning achievements of his presidency. The final bill may not have been what Obama had wanted, but like Presidents before him, he had exhausted every locker in the presidential armory to get the ACA over the line. Neustadt states that the impact of the president on legislation “depends on the measure of the man…” (Neustadt, 1960. pg. 4). Obama’s measure was tested during the bitter battle over health care, and the result was a historic piece of legislation that, given the constraints imposed by both the U.S. political and health systems, is probably as good as it gets (Oberlander, 2010).
- Beckmann, M., (2008), The President’s Playbook: White House strategies for lobbying Congress. In; The Journal of Politics, Vol 70, pp. 407-419. [Online] Accessed on 26102020. Available from: https:www.jstor.orgstablepdf10.1017s0022381608080390.pdfrefreqid=excelsior:20cbf84e8c97e56b2d1e43254c0b80c7.