Senate
The Senate began work on its own proposals while the House was still working on the Affordable Health Care for America Act. Instead, the Senate took up H.R. 3590, a bill regarding housing tax breaks for service members.[89] As the United States Constitution requires all revenue-related bills to originate in the House,[90] the Senate took up this bill since it was first passed by the House as a revenue-related modification to the Internal Revenue Code. The bill was then used as the Senate's vehicle for their healthcare reform proposal, completely revising the content of the bill.[91] The bill as amended would ultimately incorporate elements of proposals that were reported favorably by the Senate Health and Finance committees. With the Republican minority in the Senate vowing to filibuster any bill they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the Senate.[92] At the start of the 111th Congress, Democrats had only 58 votes; the Senate seat in Minnesota ultimately won by Al Franken was still undergoing a recount, and Arlen Specter was still a Republican.
To reach 60 votes, negotiations were undertaken to satisfy the demands of moderate Democrats, and to try to bring several Republican senators aboard; particular attention was given to Bob Bennett, Mike Enzi, Chuck Grassley, and Olympia Snowe. Negotiations continued even after July 7 — when Franken was sworn into office, and by which time Specter had switched parties — due to disagreements over the substance of the bill, which was still being drafted in committee, and because moderate Democrats hoped to win bipartisan support. Then, on August 25, before the bill could come up for a vote, Ted Kennedy—a longtime healthcare reform advocate—died, depriving Democrats of their 60th vote. Before Kennedy's seat was filled, attention was drawn to Snowe because of her vote in favor of the draft bill in the Finance Committee on October 15, but she explicitly stated that this did not mean she would support the final bill.[75] Paul Kirk was appointed as Senator Kennedy's temporary replacement on September 24.
After the Finance Committee vote, negotiations turned to the demands of moderate Democrats, whose votes would be necessary to break the anticipated Republican filibuster. Majority leader Harry Reid focused on satisfying the Democratic caucus's centrist members until the holdouts came down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and Ben Nelson, a conservative Democrat, representing Nebraska. Lieberman, despite intense negotiations with Reid in search of a compromise, refused to support a public option, agreeing to vote for the bill only if the provision were not included,[75][93] although it had majority support in Congress. His demand was met.[94] There was debate among the bill's supporters over the importance of the public option,[95] although the vast majority of supporters concluded it was a minor part of the reform overall,[93] and Congressional Democrats' fight for it won various concessions, including conditional waivers allowing states to set up state-based public options such as Vermont's Green Mountain Care.[94][96]
Senate vote by state.
Democratic yes (58)
Independent yes (2)
Republican no (39)
Republican not voting (1)
With every other Democrat now in favor and every Republican now opposed, the White House and Reid moved on to addressing Nelson's concerns in order to win filibuster-proof support for the bill;[97] they had by this point concluded "it was a waste of time dealing with [Snowe]"[98] because, after her vote for the draft bill in the Finance Committee, she had come under intense pressure from the Republican Senate leadership.[99] After a final 13-hour negotiation, Nelson's support for the bill was won with two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges", which would require consumers to pay for the procedure out of pocket if the state so decided; and an amendment to offer a higher rate of Medicaid reimbursement for Nebraska.[70][100] The latter half of the compromise was derisively called the "Cornhusker Kickback"[101] and was repealed in the subsequent reconciliation amendment bill.
On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster. The bill then passed, also 60–39, on December 24, 2009, with all Democrats and two independents voting for it, and all Republicans against (except Jim Bunning, who did not vote).[102] The bill was endorsed by the AMA and AARP.[103]
Several weeks later, on January 19, 2010, Massachusetts Republican Scott Brown was elected to the Senate in a special election to replace the late Ted Kennedy, having campaigned on giving the Republican minority the 41st vote needed to sustain Republican filibusters.[70][104][105] The special election had become significant to the reform debate because of its effects on the legislative process. The first was psychological: the symbolic importance of losing Kennedy's traditionally Democratic Massachusetts seat made many Congressional Democrats concerned about the political cost of passing a bill.[106][107] The second effect was more practical: the loss of the Democratic supermajority complicated reform proponents' legislative strategy.[107]
House
House vote by congressional district.
Democratic yea (219)
Democratic nay (34)
Republican nay (178)
No representative seated (4)
Brown's election meant Democrats could no longer break a filibuster in the Senate. In response, White House Chief of Staff Rahm Emanuel argued that Democrats should scale back to a less ambitious bill; House Speaker Nancy Pelosi pushed back, dismissing Emanuel's scaled-down approach as "Kiddie Care."[108][109] Obama also remained insistent on comprehensive reform, and the news that Anthem Blue Cross in California intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous Democrats after Scott Brown's win.[108][109] On February 22, President Obama laid out a "Senate-leaning" proposal to consolidate the bills.[110] He held a meeting with both parties' leaders on February 25. With Democrats having lost a filibuster-proof supermajority in the Senate but having already passed the Senate bill with 60 votes on December 24, comprehensive reform proponents' most workable option was for the House to abandon its bill, the Affordable Health Care for America Act, and pass the Senate's bill, the Patient Protection and Affordable Care Act, instead.
Various health policy experts encouraged the House to pass the Senate version,[111] but House Democrats were not happy with it and had expected to be able to negotiate changes in a House-Senate conference before passing a final bill.[107] With that option off the table, since any bill that emerged from conference that differed from the Senate bill would have to be passed in the Senate despite another Republican filibuster, most House Democrats agreed to pass the Senate bill on condition that it be amended by a subsequent bill.[107] They drafted the Health Care and Education Reconciliation Act, which could be passed by the reconciliation process.[108][112][113]
Unlike rules under regular order, as per the Congressional Budget Act of 1974, reconciliation cannot be subject to a filibuster. But reconciliation is limited to budget changes, which is why the procedure was not used to pass the ACA in the first place; the bill had inherently non-budgetary regulations.[114][115] Still, although the already passed Senate bill could not have been passed by reconciliation, most of House Democrats' demands were budgetary: "these changes—higher subsidy levels, different kinds of taxes to pay for them, nixing the Nebraska Medicaid deal—mainly involve taxes and spending. In other words, they're exactly the kinds of policies that are well-suited for reconciliation."[112]
The remaining obstacle was a pivotal group of pro-life Democrats led by Bart Stupak who were initially reluctant to support the bill. The group found the possibility of federal funding for abortion significant enough to warrant opposition. The Senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill as it would be non-budgetary and thus outside the process's domain. Instead, Obama issued Executive Order 13535, reaffirming the principles in the Hyde Amendment.[116] This won the support of Stupak and members of his group and assured the bill's passage.[113][117] The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.[118] The next day, Republicans introduced legislation to repeal the bill.[119] Obama signed the ACA into law on March 23, 2010.[120] The amendment bill, The Health Care and Education Reconciliation Act, was also passed by the House on March 21; the Senate passed it by reconciliation on March 25, and Obama signed it on March 30.
I did not realize that I wrote this in the Gruber thread.
