How the idea became law.

1. How the idea became law
H.R.3590
Patient Protection and Affordable Care Act
Jared P. Wagner, MD

2. Feburary 2009
• In his first address to a full session of
congress, President Obama discusses
health care reform.
“health care reform cannot wait, it must not
wait, and it will not wait another year.” –
Obama February 24, 2009.

3. April 2009
• Senate Finance Committee Chairman Max Baucus,
D. Montana begins a series of roundtable
discussions.
• Initial debate centers around how to
finance the effort and how to best
expand coverage to the uninsured.
• Senator Arlen Spector leaves the Republican party
announcing that he will run for reelection in 2010 as
a Democrat.
• There are now 60 senate Democrats

4. Senate Mechanics
• Senate rules requires a supermajority of votes to end
debate legislation and advance to a final vote.
• Total of 60 votes out of 100 Senate members is needed.
• Controversial bills are unlikely to advance to a final vote unless 60
supporters can be found.
• Preventing a bill from coming to a vote for lack of 60 votes is referred
to as a filibuster.
• The one exception to this rule is a process called
reconciliation.
• Allows a bill automatically advance to a final vote. Only 50 votes are
needed.
• Strictly limited to mandatory spending programs or taxes.
• Must reduce the federal deficit over a 10 year period.
• Cannot include non budget related items
• Insurance regulations

5. March 2009
• American’s Health Insurance Plans (AHIP)
declares they are willing to cover preexisting
conditions if everyone is required to carry health
insurance.
• American’s Health Insurance Plans (AHIP) a
national association representing nearly 1300
member companies.
• AHIP support meant there would not be large scale
opposition from the insurance industry

6. June-July 2009
• Work on the Senate Finance committee shits to a small
group of six senators 3 Republicans and 3 Democrats.
Democrats Republicans
Max Baucus (MT) Olympia Snow (ME)
Kent Conrad (ND) Michael Enzi (WY)
Jeff Bingaman (NM) Charles Grassley (IA)
• These senators come to be called the gang of six.
• Obama and Congressional leaders the six to represent
the best chance for a bipartisan deal.
• Several controversial Democratic ideas are dropped.
Dropped Replaced With
Public Option Private but regulated exchanges
Income surtax on high earners Tax on high-end insurance plans

7. August 2009
• Congress adjourns for summer recess
– Senators and congressmen across the nation hold a
series of town hall meetings to explain the health
care legislation.
– These meeting are frequently disrupted by angry
protesters.
• Senator Ted Kennedy loses battle with cancer.
– Potential democratic votes (59)

8. Death Panel Scare
• Rumors that the health care law would establish
“death panels” to determine who deserved health care.
• In August, 2009 Sarah Palin wrote
• “The America I know and love is not one in which
my parents or my baby with Down Syndrome will
have to stand in front of Obama’s ‘death panel.”
• President Obama subsequently held a meeting where
he stressed that his plan would “not pull the plug on
grandma”.
• The source of the concerns the ability for a primary
care physician to obtain reimbursement for talking with
a patient about end of life care was quickly removed
from the legislation.

9. September 2009
• Senators Baucus bipartisan “Gang of Six” talks
collapse ending the possibility of broad
bipartisan consensus.
• Of the original three Republicans Only Olympia
Snow, R (MA) continues to support the bill.
• Senator Paul Kirk, D is sworn in as in interim
senator to fill Ted Kennedy’s seat until an
election is held in January 2010.
• Potential democratic votes (60)

10. October 2009
• The health care bill passes the Senate
Finance Committee on a vote of 14-9.
• Senate Majority Leader Harry Reid merges
the Finance Committee’s bill with the work
of another senate committee.
– The merged bill adds
a government run
public insurance option.
– Olympia Snow states
her opposition
to the
merged bill.

11. November 2009
• The House of Representatives passes its health
care reform bill by a vote of 220-115.
– House bill has a public option
– House bill pays for reform by increasing income tax
by 5.4% on wealthily Americans (income > $5,000)
• Reports emerge of Democratic opposition to the
bill in the senate.
– Mary Landreiu (LA) Opposed to public option
– Joe Lieberman (CT) Opposed to public option
– Ben Nelson (NE) Opposed to abortion funding

12. December 2009
• A number of compromises were done in the
senate to resolve opposition.
– Public option dropped from the senate bill.
– Deal is with senator Nelson allowing states to prohibit
abortion coverage for health insurance plans issues
on the new health care exchanges.
• As a result on December 24th the senate
overcomes a unified republican filibuster to pass
legislation 60-39.
– No Republicans vote for measure.
– One Republican hospitalized and unable to vote.

13. January 2010
• Efforts are made to combine the House and
Senate bills into a final common bill.
– Such a bill would have be passed by both the Senate
and the House again.
• January 15th House and Senate leaders say they
are close to a deal.
• Plans disrupted on January 19th when Scott
Brown, Republican wins the Massachusetts
special election.
– Potential senate democratic votes (59).
• House and Senate talks cease.
– Senate no longer has the needed votes.

14. Feburary 2010
• No major movement on health care legislation.
• Major news organizations announce that health
care reform may be dead.
– ABC News
• “Health care is effectively dead,” - ABC News’ senior political
correspondent Rick Klein
– Fox News
• “Prince Harry (Harry Reid) has to accept the fact that his
health care bill is dead.” – Sean Hannity
– Fox & Friends
– Weekly Standard
– Washington Post
– New York Post

15. March 2010
• Decision is made to attempt to pass the Senate bill
unchanged in the House of Representatives.
– Removes the need for another (60) vote in the Senate.
– Problem… Senate bill not popular in the more liberal House.
• To build sufficient support in the House the Senate
agreed to pass a series to tweaks to be passed through
reconciliation.
– Eliminating special deals given to some states (Nebraska).
– 3.8% tax on investment income for those > $250,000 annually.
– Funds from tax to close the medicare “donut hole” by 2020.
• March 21, 2010 Houses passes the senate’s version
219-212.
• March 25, 2010 Senate passes reconciliation “fixes” by a
vote of 56-43.
• March 31, 2010 Health care reform signed into law.

16. The First Year
• The health care bill included a number of
provision set to kick in over the first year.
• These were designed show the public an
immediate benefit from the legislation with the
hope of increasing public support.

17. Effective Immediately
• Young adults are now able to stay on their
parents’ insurance until their 26th birthday.
• Insurers not permitted to deny children coverage
based on preexisting conditions.
• Tax credit for small businesses (less then 25
employees) that offer health insurance.
– Credit for up to 35% of health care expenses.

18. Effective Within Three Months
Early 2010
• Individuals who can demonstrate inability to
obtain coverage due to pre-existing conditions
will be able to purchase it from special high-risk
insurance pools.
– Funded by government
– Temporary and active until 2014
– Replaced by insurance exchanges
• New plans will be required to implement an
appeals process for coverage determinations
and claims.

19. Effective Within Six Months
Mid-Late 2010
• New insurance policies must provide coverage
for preventive services without co-pays.
• Insurers can no longer cancel policies except in
cases of fraud.
• Insurers can no longer set lifetime coverage
caps on new policies.
• Medicare recipients who have fallen into the
coverage gap (“donut hole”) for Medicare
prescriptions will receive a $250 rebate.

20. Medicare and the Donut Hole
• Medicare patients pay for their prescription
needs until a deductible of around $300 is met.
– After the deductible is me Medicare covers 75% of
prescription costs until total cost reach approximatally
$2,800
• Once medication costs reach $2,800 the patient
pays 100% of drug cost until total costs
approach $6,200 when the costs are considered
to be catastrophic. (The Donut Hole)
• In 2010 seniors who fall into this payment range
will get a $250 rebate, the first in a series of
gradual closings of the gap phased in through
2020.

21. Thank You