Wednesday, February 25, 2015

All or None: How the PPACA was finally passed

Change is never welcomed. Newton’s First law of motion explains why a body at rest remains at rest. Politics teaches us that this law is applicable to a group of people, especially to Congress. One of the reasons why PPACA is a historical landmark in American Legislature is because it defied the above stated law. Men from two parties do not work together, interests group do not come together, and more importantly presidents don’t neglect unfavorable polling results. With the benefit of hind sight, we can now study, in detail, what factors were responsible for the bill to become a reality.

Bill Clinton’s “Conservative means and liberal ends” experiment with healthcare reform was the founding stone of this legislation: the current president and his aides knew exactly what not to do if they wanted the bill to see the light of the day. President Obama knew early on that to see any progress in health reform, his team must work with everybody. Everybody here means interests groups, liberals and conservatives and various congressional committees. Max Baucus and Ted Kennedy were the unsung heroes that deserve equal credit for the success of such a strategy.1 (Jonathan Cohn)

The first perquisite for this bill was Democratic Coalescence. With three leading Democratic candidates proposing similar reform plans showed that intraparty agreement already existed even before President Obama’s election (Hacker, Page 40). The second important condition was provided by the forbidding economic reality of the day. During the 2008-09 economic recessions, several surveys made it clear that Americans craved security. That ensured some support for a bill that proposed coverage for previously uninsured, but were still not in support of an imposed mandate. The challenge for the Democratic Party was to bring the middle class, which already has insurance, on board to support the president in his crusade. The President himself had to change his stand on mandatory insurance purchases. Initially they were to be voluntary and President himself opposed Hillary Clinton on that issue, in his campaign ads (Feder, Page 414).

Later in the process, the President made sure that there was strong coordination between committees like Energy and Commerce, Ways and Means, and Education and Labor that, together, developed the bill. But it was also essential to work with Republicans who were likely to support the bill. Personal ambition can support and thrust a legislation; Max Baucus, who has a reputation of working on major legislative pieces, worked across party lines for the greater cause.  Similarly, the Workhorse group garnered the inside Washington momentum. On financial side Obama sought Ken Conrad’s support from the Congressional Budget Office and heeded to the demands of generating enough “scorable” savings to pay for expanding coverage of then projected $1 trillion  (Oberlander, Page 1113).

There was a much fiercer theme that propelled the supporters of the bill, to them the failure of PPACA would mean that USA is ungovernable and no major legislation can be passed in this country. The question that looms large is that with the extra insurance coverage to new Medicaid enrollees, who will pay for Medicaid as the years roll and Federal government pulls out its contribution to the states. . Are the cost cutting measures like electronic medical record requirements and Medicare savings incentives strong enough to surmount the ever increasing healthcare costs?  

1) Jonathan Cohn (2011), How they did it, New Republic Retrieved from:
2) Jacob S. Hacker (2011), Rethinking Conceptual Frameworks: Why Reform Happened, Journal of Health Politics, Policy and Law, Vol. 36, No. 3
3)  Judith Feder (2011), Reflections from Inside Too Big to Fail: The Enactment of Health Care Reform, Journal of Health Politics, Policy and Law, Vol. 36, No. 3
4) Jonathan Oberlander (2010) Long Time Coming: Why Health Reform Finally Passed, Health Affairs 29, NO. 6 (2010):

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