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					CHART 1

    Health Care Reform: A Retrospective




          Health Care Reform: A Retrospective

                       Alan Schlobohm
                 Senior Program Administrator
                  Kaiser Family Foundation
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
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
CHART 4

Health Reform: Some key players in the Administration




                                              Nancy-Ann Min DeParle, Director        Melody Barnes, Director
           Kathleen Sebelius, HHS Secretary   White House Office for Health Reform   Domestic Policy Council




          Peter Orszag, Director
          White House Office of Management        Rahm Emanuel,                      Lawrence Summers, Director
          and Budget (to July 2010)               White House Chief of Staff         National Economic Council




                                                                                                   Return to Tutorials
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
CHART 6

House Committees with Jurisdiction over Health Reform


     House Committees

                        Energy & Commerce                       Jurisdiction:
                          Rep. Henry Waxman (D-CA)        Medicaid, CHIP, Medicare,
                          chairman                         federal health programs




                        Ways & Means                            Jurisdiction:
                          Rep. Charles Rangel (D-NY)    Tax subsidies for health care,
                          chairman                               Medicare




                        Education & Labor                      Jurisdiction:
                          Rep. George Miller (D-CA)      Pension/Employee Health
                          chairman                           benefits, ERISA




                                                                               Return to Tutorials
CHART 7

Senate Committees with Jurisdiction over Health Reform



     Senate Committees



                         Finance                                                Jurisdiction:
                           Sen. Max Baucus (D-MT)                         Tax Policy, Medicaid, CHIP
                           chairman




                         Health, Education, Labor & Pensions                    Jurisdiction:
                           Sen. Chris Dodd (D-CT) *                       Pensions, health/employee
                            * In the absence of Sen. Edward Kennedy            benefits, ERISA
                            (who passed away August 9, 2009), Sen. Dodd
                            led the HELP Committee deliberations




                                                                                               Return to Tutorials
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
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
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
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
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
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
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
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
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
CHART 17

Overview - Committees and Floor Debate (2009)

                    HOUSE                                                                       SENATE
   Energy &         Ways &          Education
  Commerce          Means
                                                      COMMITTEES                         Finance            HELP
                                     & Labor

    Passed           Passed          Passed                                           Passed                Passed
    July 31          July 16         July 17                                         October 13             July 16



           Three bills combined into one                                                 Two bills combined into one

                    October 29                                                                  November 18


                                                        FLOOR                       Motion to proceed to debate adopted
                                                     CONSIDERATION
                                                                                                November 21
           Limited floor debate – One day

           Two Amendments Considered;                                          Floor debate - 21 days         Nov. 30-Dec. 24
                 One Adopted

                    November 7                                                            Defeated 3 times
                                                                                           -- on 2 amendments
                                                                            Filibuster        and on the bill          Dec. 21-23
                                                                                          By Invoking Cloture
                                                                                           -- 60 votes required



                 HOUSE VOTE                       NEGOTIATIONS BETWEEN                        SENATE VOTE
                  Passed 220-215                HOUSE, SENATE & PRESIDENT                       Passed 60-39

                   November 7                                                                   December 24
CHART 18

Overview – Resolving Differences and Final Enactment (2010)

           House-passed bill                 Senate-passed bill
              H.R. 3962                          H.R. 3590

                                                                               March 23

                                               HOUSE VOTE                    Signed into law
                                              Passed 219-212                by the President

                                                 March 21                     Public Law
                                                                               111-148


                          The House made
                          changes to H.R.    Reconciliation bill
                          3590 which were        H.R. 4872
                          incorporated in…


                                               HOUSE VOTE
                                              Passed 220-211

                                                 March 21
                                                                   Kaiser‟s Health Reform Resource:
                            The Senate                                http://healthreform.kff.org/
                           agreed to the      SENATE VOTE
                           House bill, but
                            made small         Passed 56-43
                            changes…
                                                 March 25

                                                                               March 30
                            The House
                                               HOUSE VOTE                    Signed into law
                          passed the bill
                          as amended by       Passed 220-207                by the President
                            the Senate
                                                 March 25                     Public Law
                                                                               111-152

				
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