Health Care Reform: A Retrospective

1. Health Care Reform: A Retrospective Alan Schlobohm Senior Program Administrator Kaiser Family Foundation Hello, I am Alan Schlobohm with the Kaiser Family Foundation. In this tutorial, I will review how the Patient Protection and Affordable Care Act, the health reform law enacted in March 2010 made its way, step-by-step, through the legislative process. Hello, I am Alan Schlobohm with the Kaiser Family Foundation. In this tutorial, I will review how the Patient Protection and Affordable Care Act, the health reform law enacted in March 2010 made its way, step-by-step, through the legislative process.

2. We will look at the early role of the President in setting the agenda, and will highlight people in the administration who played a leading role in passing health reform.We�ll look at the key Congressional committees where consideration of health reform began, and then we�ll move through how health reform was considered on the House and Senate floors. Finally, we�ll sort through the somewhat complex manner in which the House and Senate resolved their differences in order for President Obama to sign health reform into law. We will look at the early role of the President in setting the agenda, and will highlight people in the administration who played a leading role in passing health reform.We�ll look at the key Congressional committees where consideration of health reform began, and then we�ll move through how health reform was considered on the House and Senate floors. Finally, we�ll sort through the somewhat complex manner in which the House and Senate resolved their differences in order for President Obama to sign health reform into law.

3. While health reform has long been a major national concern, it received serious consideration in Congress only four times in the last 50 years � under Presidents Harry Truman, Richard Nixon, Bill Clinton, and Barack Obama. President Obama made health reform one of his top priorities � both as a candidate and again in the earliest days of his presidency. The president held a high-profile forum on health reform at the White House in March 2009. In the spring, the President�s budget proposal to Congress included a special reserve fund of $630 billion over ten years, which would cover about half the cost associated with enacting comprehensive health reform legislation. While health reform has long been a major national concern, it received serious consideration in Congress only four times in the last 50 years � under Presidents Harry Truman, Richard Nixon, Bill Clinton, and Barack Obama. President Obama made health reform one of his top priorities � both as a candidate and again in the earliest days of his presidency. The president held a high-profile forum on health reform at the White House in March 2009. In the spring, the President�s budget proposal to Congress included a special reserve fund of $630 billion over ten years, which would cover about half the cost associated with enacting comprehensive health reform legislation.

4. The president assembled a team of cabinet officials and White House staff to provide leadership and organization for the executive branch�s work on health reform. The Department of Health and Human Services (HHS) administers existing federal health programs including Medicare and Medicaid. HHS Secretary Kathleen Sebelius along with policy experts from HHS and its various divisions, including the Centers for Medicare and Medicaid Services (CMS), helped develop the details of health reform for the administration. In addition, to those working in federal agencies, many White House staff were directly involved, including Nancy-Ann DeParle, director of the White House Office for Health Reform; Peter Orszag director of the White House Office of Management and Budget (OMB); Rahm Emanuel, White House Chief of Staff; Melody Barnes, director of the White House Domestic Policy Council; and Lawrence Summers, director of the National Economic Council.The president assembled a team of cabinet officials and White House staff to provide leadership and organization for the executive branch�s work on health reform. The Department of Health and Human Services (HHS) administers existing federal health programs including Medicare and Medicaid. HHS Secretary Kathleen Sebelius along with policy experts from HHS and its various divisions, including the Centers for Medicare and Medicaid Services (CMS), helped develop the details of health reform for the administration. In addition, to those working in federal agencies, many White House staff were directly involved, including Nancy-Ann DeParle, director of the White House Office for Health Reform; Peter Orszag director of the White House Office of Management and Budget (OMB); Rahm Emanuel, White House Chief of Staff; Melody Barnes, director of the White House Domestic Policy Council; and Lawrence Summers, director of the National Economic Council.

5. In general, President Obama�s early strategy was to put health reform on the national agenda, set out certain parameters of his vision for health reform, and then to work with Congress through the legislative process. The first step in the legislative process was passage of Congress� annual budget resolution. The resolution set aside funds in the budget for passage of reform. It required that health reform not increase the deficit. And it authorized the Congress to use the budget reconciliation process, if necessary, to streamline passage. In general, President Obama�s early strategy was to put health reform on the national agenda, set out certain parameters of his vision for health reform, and then to work with Congress through the legislative process. The first step in the legislative process was passage of Congress� annual budget resolution. The resolution set aside funds in the budget for passage of reform. It required that health reform not increase the deficit. And it authorized the Congress to use the budget reconciliation process, if necessary, to streamline passage.

6. In Congress, jurisdiction over health issues, including health reform, is spread between five different committees in the House and Senate. Health jurisdiction is somewhat overlapping in the House. �The Energy and Commerce committee has the broadest jurisdiction over health issues in the House of Representatives. It oversees Medicaid, the Children�s Health Insurance Program (CHIP), and most federal public health programs. The committee shares jurisdiction over Medicare with the Ways and Means Committee. The House Ways and Means Committee has primary oversight over tax policy, and in terms of health care, looks after programs that are supported by payroll deductions � specifically, Medicare � and has jurisdiction over federal tax subsidies for health insurance. The House Education and Labor Committee has primary oversight over pension, health, and other employee benefits, including the Employee Retirement Security Act (ERISA), which is a federal rule that sets minimum standards for many private plans. �In Congress, jurisdiction over health issues, including health reform, is spread between five different committees in the House and Senate. Health jurisdiction is somewhat overlapping in the House. �The Energy and Commerce committee has the broadest jurisdiction over health issues in the House of Representatives. It oversees Medicaid, the Children�s Health Insurance Program (CHIP), and most federal public health programs. The committee shares jurisdiction over Medicare with the Ways and Means Committee. The House Ways and Means Committee has primary oversight over tax policy, and in terms of health care, looks after programs that are supported by payroll deductions � specifically, Medicare � and has jurisdiction over federal tax subsidies for health insurance. The House Education and Labor Committee has primary oversight over pension, health, and other employee benefits, including the Employee Retirement Security Act (ERISA), which is a federal rule that sets minimum standards for many private plans. �

7. Health jurisdiction is more clearly divided between two Senate panels. The Finance Committee has primary oversight over tax policy in general (including federal tax subsidies for health insurance), as well as federal health programs financed by a specific tax or trust fund (such as Medicare), and other programs like Medicaid and the Children�s Health Insurance Program. The Committee on Health, Education, Labor and Pensions � as its name suggests � has oversight over pension, health and other employee benefits, including ERISA, and other federal public health programs and agencies. In addition to the specific issues that each Committee covers, Committee chairs play a large role in driving the work and timetable of a Committee. In particular, the HELP Committee was a center of attention during health reform because it was the home base for Senator Edward Kennedy, Democrat of Massachusetts, long the leading Democratic advocate for health reform in Congress. �Health jurisdiction is more clearly divided between two Senate panels. The Finance Committee has primary oversight over tax policy in general (including federal tax subsidies for health insurance), as well as federal health programs financed by a specific tax or trust fund (such as Medicare), and other programs like Medicaid and the Children�s Health Insurance Program. The Committee on Health, Education, Labor and Pensions � as its name suggests � has oversight over pension, health and other employee benefits, including ERISA, and other federal public health programs and agencies. In addition to the specific issues that each Committee covers, Committee chairs play a large role in driving the work and timetable of a Committee. In particular, the HELP Committee was a center of attention during health reform because it was the home base for Senator Edward Kennedy, Democrat of Massachusetts, long the leading Democratic advocate for health reform in Congress. �

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 House and Senate committees considered health reform in a series of stages. �Initially, committees held formal public hearings on specific aspects of health reform, receiving testimony from both government and public witnesses. These hearings provided a forum for important issues to be raised, to hear comments from policy experts and stakeholders and allow committee members to ask questions and air their views. Given the substantial impact of health reform on the private and public sector, many different interest groups took positions and voiced their opinions both publicly and privately with legislators. Groups included patients� rights advocates, the medical community, insurance companies, pharmaceutical companies, small and large employers, and labor unions just to name a few. �Committees may also conduct less formal meetings called �walk-throughs�, which are more focused on explanation of and debate over specific proposals. �Combined, the three House committees held 19 hearings, and the two Senate panels held 17. House and Senate committees considered health reform in a series of stages. �Initially, committees held formal public hearings on specific aspects of health reform, receiving testimony from both government and public witnesses. These hearings provided a forum for important issues to be raised, to hear comments from policy experts and stakeholders and allow committee members to ask questions and air their views. Given the substantial impact of health reform on the private and public sector, many different interest groups took positions and voiced their opinions both publicly and privately with legislators. Groups included patients� rights advocates, the medical community, insurance companies, pharmaceutical companies, small and large employers, and labor unions just to name a few. �Committees may also conduct less formal meetings called �walk-throughs�, which are more focused on explanation of and debate over specific proposals. �Combined, the three House committees held 19 hearings, and the two Senate panels held 17.

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 Eventually, each committee began work on specific legislative language, initially informally, generally in private, and later in formal public meetings. At the direction of the chairman, committee staff worked to turn policy ideas and proposals into actual legislative language. �Given the somewhat overlapping nature of health jurisdiction in the House, the three House committee chairmen and their staffs coordinated their work on drafting the legislation. The combined draft was referred to as the �tri-committee� bill. �The leadership and staff of the two Senate committees took more separate tracks, with the HELP Committee concentrating its work on the public health and insurance market reform sections, while the Finance Committee handled the revenue provisions, and sections related to Medicare and Medicaid. Eventually, each committee began work on specific legislative language, initially informally, generally in private, and later in formal public meetings. At the direction of the chairman, committee staff worked to turn policy ideas and proposals into actual legislative language. �Given the somewhat overlapping nature of health jurisdiction in the House, the three House committee chairmen and their staffs coordinated their work on drafting the legislation. The combined draft was referred to as the �tri-committee� bill. �The leadership and staff of the two Senate committees took more separate tracks, with the HELP Committee concentrating its work on the public health and insurance market reform sections, while the Finance Committee handled the revenue provisions, and sections related to Medicare and Medicaid.

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 Every piece of legislation is subject to analysis by the Congressional Budget Office (CBO), a nonpartisan agency that works for the U.S. Congress. CBO estimates the federal costs of a proposal and its effect on the federal budget. CBO considers legislation as a whole, as well as each component part. At the drafting stage, committee staff will consult with CBO almost continuously, obtaining estimates on specific provisions. Often the provisions will be revised multiple times based on CBO estimates of their cost. �President Obama set a target for the total cost of health reform at not more than $1 trillion over ten years, and also that the bill be fully paid for � that is not increase the deficit. This gave an added importance to CBO�s estimates, as committee leaders and staff worked to keep everything at or under the target. �CBO also provides cost estimates of amendments that committee members may seek to offer. When the chairman is ready, and CBO has completed its formal cost estimate of the chairman�s bill, then the committee will schedule public committee meetings to vote on the bill. Every piece of legislation is subject to analysis by the Congressional Budget Office (CBO), a nonpartisan agency that works for the U.S. Congress. CBO estimates the federal costs of a proposal and its effect on the federal budget. CBO considers legislation as a whole, as well as each component part. At the drafting stage, committee staff will consult with CBO almost continuously, obtaining estimates on specific provisions. Often the provisions will be revised multiple times based on CBO estimates of their cost. �President Obama set a target for the total cost of health reform at not more than $1 trillion over ten years, and also that the bill be fully paid for � that is not increase the deficit. This gave an added importance to CBO�s estimates, as committee leaders and staff worked to keep everything at or under the target. �CBO also provides cost estimates of amendments that committee members may seek to offer. When the chairman is ready, and CBO has completed its formal cost estimate of the chairman�s bill, then the committee will schedule public committee meetings to vote on the bill.

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 At these meetings � known as mark-ups � the bill is explained by staff, debated by committee members, amendments are offered, adopted or rejected, and eventually, the bill is either approved or defeated. There is no limitation on the number of amendments that committee members can offer, but the amendments must be within the jurisdiction of the committee. After weeks of debate, each of the five committees eventually approved health reform legislation. Votes on passage were strictly party-line in four of the five panels, with the exception being the Senate Finance Committee. When a committee approves a bill, the legislation is forwarded for consideration by the full House or Senate, along with a committee report, which among other things provides an explanation of each of the bill�s provisions. At these meetings � known as mark-ups � the bill is explained by staff, debated by committee members, amendments are offered, adopted or rejected, and eventually, the bill is either approved or defeated. There is no limitation on the number of amendments that committee members can offer, but the amendments must be within the jurisdiction of the committee. After weeks of debate, each of the five committees eventually approved health reform legislation. Votes on passage were strictly party-line in four of the five panels, with the exception being the Senate Finance Committee. When a committee approves a bill, the legislation is forwarded for consideration by the full House or Senate, along with a committee report, which among other things provides an explanation of each of the bill�s provisions.

12. House and Senate floor procedures are quite different. Let�s consider the House first. �After the three House health committees each adopted health reform legislation, and before legislation was considered on the House floor, a couple of interim steps were taken. �First, under the direction of House leaders, the bills approved by the three health committees were compiled together into a single piece of legislation (HR 3962). �In part, this is a technical process of stitching separate components together, like the Medicaid provisions out of the Energy and Commerce Committee, the revenue provisions from Ways and Means, and ERISA changes from Education and Labor. �Also, this stage is the point where the leadership made a final count of support for the bill (known as a �whip count�). Both individual legislators and groups of legislators � sometimes referred to as caucuses � will ask for and in many cases secure specific changes to the bill, in exchange for promising to vote in favor of final passage. For example, some pro-life Democrats agreed to support the bill after the House leadership agreed to allow them to offer an abortion-related amendment during floor consideration. �Once the House Democratic leadership was reasonably confident they had enough votes for passage, the legislation was sent to the House Rules Committee, which then prepared a rule to set the terms for debate on the House floor. The rule provided for four hours of general debate, plus about another hour and a half for consideration of two amendments and one parliamentary motion by the minority party. �The full House then voted on whether to adopt the rule � which requires only a simple majority to pass. After the rule was adopted, then debate on the bill itself began. �During debate, the House adopted one amendment. Finally, the House voted to pass the bill. The vote was 220-215 on November 7, 2009. House and Senate floor procedures are quite different. Let�s consider the House first. �After the three House health committees each adopted health reform legislation, and before legislation was considered on the House floor, a couple of interim steps were taken. �First, under the direction of House leaders, the bills approved by the three health committees were compiled together into a single piece of legislation (HR 3962). �In part, this is a technical process of stitching separate components together, like the Medicaid provisions out of the Energy and Commerce Committee, the revenue provisions from Ways and Means, and ERISA changes from Education and Labor. �Also, this stage is the point where the leadership made a final count of support for the bill (known as a �whip count�). Both individual legislators and groups of legislators � sometimes referred to as caucuses � will ask for and in many cases secure specific changes to the bill, in exchange for promising to vote in favor of final passage. For example, some pro-life Democrats agreed to support the bill after the House leadership agreed to allow them to offer an abortion-related amendment during floor consideration. �Once the House Democratic leadership was reasonably confident they had enough votes for passage, the legislation was sent to the House Rules Committee, which then prepared a rule to set the terms for debate on the House floor. The rule provided for four hours of general debate, plus about another hour and a half for consideration of two amendments and one parliamentary motion by the minority party. �The full House then voted on whether to adopt the rule � which requires only a simple majority to pass. After the rule was adopted, then debate on the bill itself began. �During debate, the House adopted one amendment. Finally, the House voted to pass the bill. The vote was 220-215 on November 7, 2009.

13. � Now let�s consider the Senate. �Senate rules place few limits on the rights of senators during floor debate. A senator who seeks recognition normally has a right to the floor if no other senator is speaking, and then may speak for as long as he or she wishes. With few exceptions, senators may offer as many amendments as they wish to legislation considered on the floor, and the amendments need not be germane, that is, relevant, to the subject of the bill. Senators may offer and debate a wide array of procedural motions as well. �These are all elements utilized during a Senate filibuster � the act of blocking legislation by preventing it from coming to a vote. During the health reform debate, there was great concern that the Republicans in the Senate would filibuster the bill and delay or prevent its passage. �The Senate can end a filibuster only by passing what is known as a cloture motion. The votes of three-fifths of senators duly chosen and sworn are required to approve cloture. In the current senate, with 100 members, cloture requires 60 votes. Once cloture is invoked, total time for consideration is limited to 30 hours. Only germane amendments submitted in writing before cloture was invoked are allowed. Once the 30 hours are concluded, passage of a bill under the regular order requires only a simple majority. � Now let�s consider the Senate. �Senate rules place few limits on the rights of senators during floor debate. A senator who seeks recognition normally has a right to the floor if no other senator is speaking, and then may speak for as long as he or she wishes. With few exceptions, senators may offer as many amendments as they wish to legislation considered on the floor, and the amendments need not be germane, that is, relevant, to the subject of the bill. Senators may offer and debate a wide array of procedural motions as well. �These are all elements utilized during a Senate filibuster � the act of blocking legislation by preventing it from coming to a vote. During the health reform debate, there was great concern that the Republicans in the Senate would filibuster the bill and delay or prevent its passage. �The Senate can end a filibuster only by passing what is known as a cloture motion. The votes of three-fifths of senators duly chosen and sworn are required to approve cloture. In the current senate, with 100 members, cloture requires 60 votes. Once cloture is invoked, total time for consideration is limited to 30 hours. Only germane amendments submitted in writing before cloture was invoked are allowed. Once the 30 hours are concluded, passage of a bill under the regular order requires only a simple majority.

14. Obtaining enough votes for cloture is often very difficult, but Senate rules do provide an alternative. �In the Senate, there are two types of bills that are not subject to a filibuster, and thus only require a simple majority for passage. These are: (1) budget resolutions; and (2) budget reconciliation. �Congress annually adopts a budget resolution, which provides a broad outline of how much Congress plans to spend on programs and how much revenue it expects to collect during the next fiscal year (and several years beyond). �The budget resolution can also include special instructions for Congress to make changes in tax policy, or to make changes to spending on certain federal programs known as entitlements, like Medicare or Medicaid. The legislative procedure for enacting such changes is known as budget reconciliation, which is exempt from filibuster. Floor consideration is limited to 20 hours, including time for debating all amendments and motions. A simple majority is required for passage. �In the budget resolution adopted by Congress in April 2009, Congress authorized the potential use of budget reconciliation for health reform. �The advantage of budget reconciliation is its exemption from the filibuster; its limitation is that Senate rules restrict the scope of what can be included in the bill. For example, under a rule named for the late Senator Robert Byrd, senators can object to any provision that does not change spending or tax revenues, or to any provision which has a budget impact that is merely incidental to the policy changes it would make. �High profile provisions in the Democrats� health reform legislation � such as the elimination of pre-existing conditions, or the requirement that all individuals have health insurance coverage � would have been subject to a Byrd rule challenge if included in a reconciliation bill. 60 votes are required to overturn a Byrd rule challenge � the same number of votes needed to overcome a filibuster on a bill considered under the regular order. �In 2009, Congressional leaders decided to proceed under the regular order, leaving reconciliation as a back-stop. �In the Senate, the Finance and HELP committee bills were merged together into one bill -- HR 3590. The legislation was debated on the Senate floor for 21 days in November and December 2009. In the process, the Senate considered 130 amendments, 100 of which were adopted, with the remainder defeated, withdrawn or ruled out of order. The Senate voted to defeat four separate filibusters. Finally, on December 24, 2009, the Senate approved its bill by a vote of 60-39. Obtaining enough votes for cloture is often very difficult, but Senate rules do provide an alternative. �In the Senate, there are two types of bills that are not subject to a filibuster, and thus only require a simple majority for passage. These are: (1) budget resolutions; and (2) budget reconciliation. �Congress annually adopts a budget resolution, which provides a broad outline of how much Congress plans to spend on programs and how much revenue it expects to collect during the next fiscal year (and several years beyond). �The budget resolution can also include special instructions for Congress to make changes in tax policy, or to make changes to spending on certain federal programs known as entitlements, like Medicare or Medicaid. The legislative procedure for enacting such changes is known as budget reconciliation, which is exempt from filibuster. Floor consideration is limited to 20 hours, including time for debating all amendments and motions. A simple majority is required for passage. �In the budget resolution adopted by Congress in April 2009, Congress authorized the potential use of budget reconciliation for health reform. �The advantage of budget reconciliation is its exemption from the filibuster; its limitation is that Senate rules restrict the scope of what can be included in the bill. For example, under a rule named for the late Senator Robert Byrd, senators can object to any provision that does not change spending or tax revenues, or to any provision which has a budget impact that is merely incidental to the policy changes it would make. �High profile provisions in the Democrats� health reform legislation � such as the elimination of pre-existing conditions, or the requirement that all individuals have health insurance coverage � would have been subject to a Byrd rule challenge if included in a reconciliation bill. 60 votes are required to overturn a Byrd rule challenge � the same number of votes needed to overcome a filibuster on a bill considered under the regular order. �In 2009, Congressional leaders decided to proceed under the regular order, leaving reconciliation as a back-stop. �In the Senate, the Finance and HELP committee bills were merged together into one bill -- HR 3590. The legislation was debated on the Senate floor for 21 days in November and December 2009. In the process, the Senate considered 130 amendments, 100 of which were adopted, with the remainder defeated, withdrawn or ruled out of order. The Senate voted to defeat four separate filibusters. Finally, on December 24, 2009, the Senate approved its bill by a vote of 60-39.

15. The next stage in the legislative process is to resolve the differences between the House and Senate bills. For health reform, this got under way in January 2010.The most common way Congress works to resolve differences between House and Senate legislation is through the �conference� process, shown as Option 1 on this chart. �In brief, each chamber appoints a few members to represent them at a conference committee. Negotiations are conducted; an agreement is reached; a formal committee meeting is held to ratify the agreement; a conference report explaining the legislation is prepared; and then each chamber votes to approve the compromise. If both chambers approve, then the bill goes to the president for veto or signature into law. Only conference reports on reconciliation bills are exempt from a Senate filibuster. �Since the House and Senate health reform bills were passed under the regular order, not through budget reconciliation, the pending conference agreement, once completed, could still be filibustered. In fact, by the time the conference was to begin, there were 41 Senate Republicans � enough to sustain a filibuster. So Democrats considered their parliamentary alternatives, and came up with the following solution, which is shown on this chart as Options 2 and 3. First, House Democrats agreed to accept the Senate health reform bill without change. With no further action required by the Senate, the Senate bill was sent directly to the President, who signed it into law on March 23. � Second, House and Senate Democrats reached agreement on changes to some budget-related provisions in the Senate bill, which were incorporated into a budget reconciliation bill. Both the Senate and House passed the reconciliation bill on March 25. President Obama signed this second bill into law on March 30. The next stage in the legislative process is to resolve the differences between the House and Senate bills. For health reform, this got under way in January 2010.The most common way Congress works to resolve differences between House and Senate legislation is through the �conference� process, shown as Option 1 on this chart. �In brief, each chamber appoints a few members to represent them at a conference committee. Negotiations are conducted; an agreement is reached; a formal committee meeting is held to ratify the agreement; a conference report explaining the legislation is prepared; and then each chamber votes to approve the compromise. If both chambers approve, then the bill goes to the president for veto or signature into law. Only conference reports on reconciliation bills are exempt from a Senate filibuster. �Since the House and Senate health reform bills were passed under the regular order, not through budget reconciliation, the pending conference agreement, once completed, could still be filibustered. In fact, by the time the conference was to begin, there were 41 Senate Republicans � enough to sustain a filibuster. So Democrats considered their parliamentary alternatives, and came up with the following solution, which is shown on this chart as Options 2 and 3. First, House Democrats agreed to accept the Senate health reform bill without change. With no further action required by the Senate, the Senate bill was sent directly to the President, who signed it into law on March 23. � Second, House and Senate Democrats reached agreement on changes to some budget-related provisions in the Senate bill, which were incorporated into a budget reconciliation bill. Both the Senate and House passed the reconciliation bill on March 25. President Obama signed this second bill into law on March 30.

16. This chart summarizes the final steps just discussed. ��On March 21, 2010, the House took up, and passed HR 3590, the comprehensive health reform bill approved by the Senate in December 2009. The final House vote was 219-212. The legislation was signed into law by President Obama on March 23. Also on March 21, the House approved HR 4872, a budget reconciliation bill, which made changes to some of the budget-related provisions of the comprehensive health reform bill. The House vote was 220-211. On March 25, the Senate approved the bill by a vote of 56-43. Because a couple provisions were ruled out of order in the Senate under the Byrd Rule, the House had to vote on the bill one more time, which it did later that same day. The final vote was 220-207. President Obama signed the budget reconciliation bill into law on March 30, 2010. This chart summarizes the final steps just discussed. ��On March 21, 2010, the House took up, and passed HR 3590, the comprehensive health reform bill approved by the Senate in December 2009. The final House vote was 219-212. The legislation was signed into law by President Obama on March 23. Also on March 21, the House approved HR 4872, a budget reconciliation bill, which made changes to some of the budget-related provisions of the comprehensive health reform bill. The House vote was 220-211. On March 25, the Senate approved the bill by a vote of 56-43. Because a couple provisions were ruled out of order in the Senate under the Byrd Rule, the House had to vote on the bill one more time, which it did later that same day. The final vote was 220-207. President Obama signed the budget reconciliation bill into law on March 30, 2010.

17. Our last two charts provide a quick overview of the process of passing health reform. �This first chart covers 2009 � from the committees, to the House and Senate floor, and the onset of House-Senate negotiations over a final bill. Our last two charts provide a quick overview of the process of passing health reform. �This first chart covers 2009 � from the committees, to the House and Senate floor, and the onset of House-Senate negotiations over a final bill.

18. Our last chart covers the final stages in early 2010. �The House passed the Senate�s health reform bill, which was signed into law by the President on March 23, 2010. �Certain changes to the new law were incorporated in a second bill, HR 3590, which was considered under the budget reconciliation process. This legislation was sent to the president, who signed it into law on March 30, 2010. As you can see, it was a long and windy road to the passage of health reform legislation in 2010. If you want to learn more about specific aspects of health reform, you can check out the resources on the Kaiser Family Foundation�s website. Thank you.Our last chart covers the final stages in early 2010. �The House passed the Senate�s health reform bill, which was signed into law by the President on March 23, 2010. �Certain changes to the new law were incorporated in a second bill, HR 3590, which was considered under the budget reconciliation process. This legislation was sent to the president, who signed it into law on March 30, 2010. As you can see, it was a long and windy road to the passage of health reform legislation in 2010. If you want to learn more about specific aspects of health reform, you can check out the resources on the Kaiser Family Foundation�s website. Thank you.