Health Care Reform: A Retrospective

1. CHART 1 Health Care Reform: A Retrospective Health Care Reform: A Retrospective Alan Schlobohm Senior Program Administrator Kaiser Family Foundation

2. CHART 2 The Process of Health Reform Legislation Health reform on the agenda Health reform: some key players in the Administration The Congressional budget and health reform House and Senate Committees with health jurisdiction Committee procedures House floor procedures Senate floor procedures Resolving differences between House and Senate legislation Signed into Law by the President Return to Tutorials

3. CHART 3 Health Reform and the national agenda President Obama at the White House Forum on Health Care Reform, March 5, 2009 Health reform was at or near the top of the national agenda from the early days of the Obama presidency Return to Tutorials

4. CHART 4 Health Reform: Some key players in the Administration Nancy-Ann Min DeParle, Director White House Office for Health Reform Melody Barnes, Director Domestic Policy Council Kathleen Sebelius, HHS Secretary Peter Orszag, Director White House Office of Management and Budget (to July 2010) Rahm Emanuel, White House Chief of Staff Lawrence Summers, Director National Economic Council Return to Tutorials

5. CHART 5 The Congressional Budget and Health Reform • The Congressional Budget • Adopted by Congress in April 2009 • Provided a ‘reserve fund’ for health reform legislation • Required health reform legislation to be budget neutral • Allowed health reform legislation to be protected from Senate filibuster through the use of ‘budget reconciliation’ procedure Return to Tutorials

6. Energy & Commerce Rep. Henry Waxman (D-CA) chairman Ways & Means Rep. Charles Rangel (D-NY) chairman Education & Labor Rep. George Miller (D-CA) chairman CHART 6 House Committees with Jurisdiction over Health Reform House Committees Jurisdiction: Medicaid, CHIP, Medicare, federal health programs Jurisdiction: Tax subsidies for health care, Medicare Jurisdiction: Pension/Employee Health benefits, ERISA Return to Tutorials

7. CHART 7 Senate Committees with Jurisdiction over Health Reform Senate Committees Finance Jurisdiction: Tax Policy, Medicaid, CHIP Sen. Max Baucus (D-MT) chairman Health, Education, Labor & Pensions Jurisdiction: Pensions, health/employee benefits, ERISA Sen. Chris Dodd (D-CT) * * In the absence of Sen. Edward Kennedy (who passed away August 9, 2009), Sen. Dodd led the HELP Committee deliberations Return to Tutorials

8. CHART 8 Hearings • Public hearings • Forum for raising important issues • Comments from policy experts and stakeholders • Allowed committee members to voice their opinions • Range of public and private interest groups • Patients rights advocates • Medical community • Insurance companies • Pharmaceutical companies • Employers • Labor unions • “Walk-throughs” -- explain and debate specific proposals Return to Tutorials

9. CHART 9 Drafting Legislation • Each committee worked on specific legislative language • House - committees presented a combined “tri-committee” bill • Senate - two committees worked on separate areas of the bill • HELP Committee - public health and insurance market reform sections • Finance Committee - revenue provisions, Medicare, Medicaid Return to Tutorials

10. CHART 10 Congressional Budget Office Analysis • Review by Congressional Budget Office (CBO), a nonpartisan agency that works for Congress • Estimates the costs and effect on federal budget • Considers legislation as a whole and each component separately • Committee’s staff consults CBO regarding budgetary effect of specific provisions • 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 Return to Tutorials

11. CHART 11 Mark-Ups • Mark-Ups – public meetings to vote on bill • Bill debated by committee members and amendments are offered and voted upon • Each of the five committees 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 Return to Tutorials

12. CHART 12 House Floor Procedures • Three House committee bills 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 • Debate bill • Bill passed on November 7, 2009: 220-215 Return to Tutorials

13. CHART 13 Senate Floor Procedures – Regular Order • 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 Return to Tutorials

14. CHART 14 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 • H.R. 3590 was passed on December 24, 2009 – by a vote of 60-39 Return to Tutorials

15. CHART 15 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 • The second bill is then sent to the President Return to Tutorials

16. CHART 16 Legislation Signed Into Law • Health Reform in 2010 – President Obama Signed two bills into law • H.R. 3590 – Public Law 111-148 • 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. 4872 – Public Law 111-152 • Passed under budget reconciliation procedures by House and Senate; made some changes to P.L. 111-148 • President Obama signed budget reconciliation bill on March 30, 2010 Return to Tutorials

17. December 24 November 7 Floor debate - 21 days Nov. 30-Dec. 24 CHART 17 Overview - Committees and Floor Debate (2009) HOUSE SENATE Energy & Commerce Ways & Means Education & Labor Finance HELP COMMITTEES Passed July 31 Passed July 16 Passed July 17 Passed October 13 Passed July 16 Three bills combined into one Two bills combined into one October 29 November 18 FLOOR CONSIDERATION Motion to proceed to debate adopted November 21 Limited floor debate – One day Two Amendments Considered; One Adopted Defeated 3 times -- on 2 amendments and on the bill Filibuster Dec. 21-23 By Invoking Cloture -- 60 votes required HOUSE VOTE NEGOTIATIONS BETWEEN SENATE VOTE Passed 220-215 Passed 60-39 HOUSE, SENATE & PRESIDENT November 7

18. March 23 HOUSE VOTE Passed 220-211 March 21 CHART 18 Overview – Resolving Differences and Final Enactment (2010) House-passed bill Senate-passed bill H.R. 3962 H.R. 3590 HOUSE VOTE Signed into law Signed into law by the President by the President Passed 219-212 Public Law 111-152 Public Law 111-148 March 21 The House made changes to H.R. 3590 which were incorporated in… Reconciliation bill H.R. 4872 Kaiser’s Health Reform Resource: http://healthreform.kff.org/ The Senate agreed to the House bill, but made small changes… SENATE VOTE Passed 56-43 March 25 March 30 The House passed the bill as amended by the Senate HOUSE VOTE Passed 220-207 March 25