Government and Politics


Health care reform in the United States

President Obama’s healthcare reforms tell us a great deal about how Congress works. Kay Moxon uses the reform of healthcare as a case study of the legislative process in Congress.

On 23 March 2010, Barack Obama signed into law America’s biggest social reform package in 45 years, following what he referred to as ‘a year of debate and a century of trying’. Obama campaigned for the presidency in 2008 promising fundamental reform of a system that left 45 million Americans uninsured in spite of costing $2.2 trillion in 2007 — twice the OECD average per head. ‘Obamacare’ should extend healthcare to an additional 32 million Americans (see Boxes 1 and 2 for details).

This is viewed by liberals as a historic advance in social justice while conservatives are not only sceptical about the projected cost savings but see it as an unjustified government intrusion into the private choices of Americans. The ferocity of opposition to the passage of the bill — the old colonial era slogan ‘Don’t tread on me’ has been resurrected — could represent the opening up of a new chapter in the American culture wars.

The legislative process

The reform of healthcare not only represents a landmark for US society and a major achievement for Barack Obama as president, but its tortuous passage provides numerous lessons for the student of American government and politics. Most obviously, since it came close to failing at virtually every legislative hurdle (see Box 3), it provides an excellent case study of the legislative process in Congress.

Box 1 US healthcare: pre-reform

  • Most individuals obtained health insurance coverage through their employers via salary deduction; others signed up for private insurance schemes.

  • Medicare provided government funded healthcare for the over-65s.

  • Medicaid provided government funded healthcare for those on very low incomes.

  • The State Children’s Health Insurance Programme provided coverage for children whose parents did not qualify for Medicaid.

  • The uninsured were treated in emergency rooms only.


Box 2 US healthcare: post reform (to take effect 2010–14)

  • An individual mandate: individuals must get health insurance or face a fine.

  • Subsidies provided for the less well off.

  • State-based insurance exchanges for those who do not have insurance provided by employers.

  • Tougher regulation of insurers: they cannot deny coverage to those with pre-existing conditions and they cannot put lifetime caps on coverage.

  • Scope of Medicaid extended.

  • Prescription drug coverage gap within Medicare closed.

  • Paid for by cutting waste in Medicare programme plus a tax on the most expensive, or ‘Cadillac’, insurance plans.


The bill illustrates the roles of both the speaker within the House of Representatives and the senate Majority Leader. Speaker Nancy Pelosi was instrumental in forging a majority to support it in the House, as was majority leader Harry Reid in the Senate. The crucial role of committees within Congress was also evident. Obama largely left it to congressional committees to frame the legislation — the role of Senator Max Baucus as chair of the Senate Finance Committee is par-ticularly noteworthy.

As much as any bill in history it showed the significance of the checks and balances within the US system of government which in this case almost led to paralysis. The need for compromise — often involving the trading of ‘pork’ — and the importance of the president’s powers of persuasion in order to achieve worthwhile reform were clearly highlighted. Perhaps of most significance was the impact of the filibuster within the Senate. This, together with the loss of their 60-seat supermajority in the Senate in January 2010, forced the Democrats to use rather obscure (and according to many Republicans, underhand) budgetary procedures to get the legislation passed.

An executive order guaranteeing that state funds would never be spent on abortions other than in cases of rape, incest, or where the mother’s life is in danger was needed to persuade socially conservative Democrat Representative Bart Stupak and others to support the Senate bill. The bill was eventually passed through the House without ever going to a conference committee — clearly showing the powers of the president to circumvent constitutional checks and balances. The healthcare bill also highlighted the increased role of parties within Congress over recent years — and the increased polarisation of those parties.

However, parties are not the only significant political players to exert influence within American politics, and interest group lobbying played a crucial role here. If the attorneys general in such states as Virginia, South Carolina and Florida succeed in challenging the constitutionality of forcing individuals to buy health insurance, the healthcare bill might even provide a useful example of the workings of the Supreme Court.


Previous advance in healthcare reform — Medicare and Medic- aid in 1965 — were passed by cross-party coalitions. Although Obama campaigned in 2008 with a promise of bipartisan politics, it quickly became clear that any kind of bipartisan bill was not going to be possible here.

Box 3 Timeline: key events in the passage of the bill


7 November - House of Representatives passes its healthcare bill by 220–215; 39 Democrats join all Republicans except one (Anh Cao of Louisiana) in opposing the bill.

24 December - Senate passes its healthcare bill on an entirely partisan vote: 60–39 (60 being the minimum necessary to overcome a Republican filibuster). Discussions begin on reconciling the different bills from each chamber.


19 January - Republican Scott Brown wins a special election to the late Senator Ted Kennedy’s seat in Massachusetts, erasing the Democrats’ supermajority in the Senate and their ability to break a Republican filibuster on the final passage of a compromise bill emerging from a conference committee.

25 February - President Obama and congressional leaders from both parties hold a televised summit.

21 March - House of Representatives passes the Health Care Bill 219–212 votes. (This is largely the bill passed by the Senate in December: a procedural manoeuvre meaning that the bill would not have to return to the Senate for final approval). All House Republicans and 34 Democrats oppose the bill. A ‘budget reconciliation bill’ which includes better benefits for seniors and low income families is also passed. Budget related provisions can pass through the Senate with just a simple majority.

23 March - President Barack Obama signs the Patient Protection and Affordable Care Act into law.

25 March - Senate votes 56–43 in favour of the reconciliation bill. Democrat senators Blanche Lincoln and Mark Pryor of Arkansas plus Ben Nelson of Nebraska join all the Republicans in opposing the bill.

25 March - House of Representatives gives its final approval to the reconciliation bill, 220–207.

29 March - Obama signs the reconciliation bill into law.


Republican congressman Anh Cao of Louisiana supported the initial House bill and Republican senator Olympia Snowe of Maine voted with the Democrats within the Senate Finance Committee, but this was as close as any Republicans came to supporting this reform. Such extreme party discipline enhances the power of the filibuster and the potential for a minority to hamper the plans of the majority.

The Democrats were not quite so disciplined and with smaller majorities in each chamber they might not have got the measure passed. Several wavering Democrats in the Senate needed to be bought off with ‘pork’. In the House, many fiscally conservative ‘Blue Dog’ Democrats refused to back the bill and many social conservatives — led by Bart Stupak — required reassurance regarding abortion funding.

For more liberal Democrats, the Senate bill was too much of a compromise and, particularly given the absence of a ‘public option’ (a state-run insurer to compete with the private sector) was worse than no bill at all. Representative Dennis Kucinich of Ohio was an influential liberal in this camp whom the White House successfully lobbied to reverse his opposition at the last minute. Overall, it was notable that those first-term representatives defending slim majorities in erstwhile Republican districts were the most likely to be reluctant to support the bill.


According to Mike Lillis of the Washington Independent (‘Health Care Reform’, Earmark Edition, 29 March 2010): ‘It’s the first rule of congressional lawmaking: never miss an opportunity to grab everything you can for your constituents, even if it comes at the expense of everyone else.’ Given the closeness of the votes in Congress and the importance of the bill to the administration, there was plenty of potential for such ‘pork barrel politics’ here. The list of senators who managed to add ‘earmarks’ to the bill is long. Most blatantly, making a joke of his earlier claim that his vote was ‘not for sale’, Democrat Ben Nelson of Nebraska managed to withhold his support for the bill long enough to force Senate majority leader Harry Reid to promise that Nebraska would not have to bear any of the cost of future expansion of Medicaid.

The Vermont independent senator Bernie Sanders (who was counted in the 60 votes the Democrats needed in the Senate) had threatened to oppose the bill if it failed to contain a strong ‘public option’; however he changed his mind when his request for $10 billion extra for community health spending was granted, together with extra funding for Vermont to pay for Medicaid. And Max Baucus, who as chairman of the Senate Finance Committee was largely responsible for writing the bill, managed to include a provision to expand Medicare coverage to those living near an asbestos mine in his own state of Montana — a cause for which he had long campaigned.


Arguably the biggest winner from healthcare reform was not those who gained access to health insurance for the first time, or even Barack Obama, but the lobbying industry. The watchdog Center for Public Integrity reported that lobbyists were paid at least $1.2 billion to work on health issues including healthcare reform in 2009; this represents more than a third of all lobbying spending that year. Lawmakers were outnumbered 6 to 1 in Washington by registered healthcare lobbyists, mostly working on behalf of drug and insurance companies. In addition to direct lobbying, billions more were spent by interested parties on television advertising as well as contributions to candidates’ re-election coffers. This bill has almost certainly had more money spent on it by various interest groups than any bill in US history.

Two of the biggest spenders on lobbying were the Pharmaceutical Research and Manufacturers of America (PhRMA) and the American Medical Association (AMA). Individual drug companies such as GlaxoSmithKline, Pfizer and Johnson and Johnson also spent heavily. They were joined by companies such as Blue Cross and Blue Shield Association (BCBSA), a federation of health insurers. Virtually all members of Congress — as well as President Obama, who received $1.2 million for his presidential campaign — have received money at some time from the healthcare sector. However, probably most notable is the $1.5 million that Senator Baucus accepted for his political funds during 2009. Working alongside Baucus, drafting much of the wording for the reform, was Liz Fowler, a Senate committee counsel whose previous job was vice-president of Wellpoint, the country’s largest health insurer.

There can be no doubt that many interested parties were attempting to buy influence over the healthcare bill, and on the face of it many of them seem to have been successful. The US drug industry managed to fend off price curbs as well as receive 12 years of protection against cheaper generic drugs. Proposals to allow competition from low-cost imported drugs were also quashed. And of course the health insurance industries — while having to accept tougher regulation — now have a pool of new customers who will have to buy their product or face a fine; and thanks largely to their lobbying efforts, they face no competition from a ‘public option’.

Kay Moxon teaches at Tonbridge School and is Assistant Editor of POLITICS REVIEW.

Reproduced by permission of Philip Allan Updates