7: CASE STUDY—THE AFFORDABLE CARE ACT

On the evening of March 21, 2010, Rep. David R. Obey of Wisconsin, a man who had served nearly half a century in public office and who was first elected to the House of Representatives in 1969, rose to preside over the House chamber. The hour was late, and the House was preparing for a momentous vote on what was arguably one of the most important yet controversial bills of the last forty years. Within minutes, House members would decide the fate of a health-care reform bill that was the centerpiece of President Obama’s domestic agenda, and that its supporters believed would be a landmark law that advanced the cause of justice in America.

To the bill’s opponents, the stakes could hardly have been higher. The fight over comprehensive health-care reform had been brutal and seemingly never-ending. Republicans in Congress mounted a spirited and unified attack against the bill that, on more than one occasion, appeared on the verge of defeating it permanently. Many congressional Democrats—and some advisors in President Obama’s inner circle—were urging that the administration and its allies abandon its efforts, fearing a catastrophic legislative failure from which the new president would never recover.

Moreover, the Democrats lacked the united front with which Republicans opposed the Affordable Care Act. Indeed, the bill threatened to splinter the Democratic coalition that had come to power with huge majorities following the 2008 election. The “Blue Dog” Democrats—a coalition of conservative Democrats that was frequently at odds with the party’s more progressive leadership—had serious reservations about passing a major health-care overhaul. In a separate but not entirely unrelated conflict, a coalition of socially conservative Democrats who opposed abortion rights threatened to scuttle the bill unless concessions were made regarding insurance coverage for abortion services.

On March 21, 2010, when Obey brought the vote to a close and declared that the legislation had passed, the House of Representatives had indeed made history. For more than sixty years, presidents had tried and failed to enact comprehensive health-care reform at the federal level. Yet the legislative history of the Affordable Care Act can be traced to the weeks leading up to President Obama’s inauguration on a frigid winter day in 2009. The story of the health-care reform effort in many ways began in the hospital room of an ailing elder statesman of the Democratic Party—one who would not live to see its enactment. The following case study is intended to illuminate the legislative process that culminated in the enactment of the historic health-care law, the merits of which continue to be contentiously debated as of this writing. Out of necessity, the case study details legislative maneuverings concerning the Senate’s consideration of the bill. Given that this book is devoted to enhancing the layman’s understanding of the House of Representatives, however, it is admittedly written from a House-centric perspective.

PROLOGUE: LAYING THE GROUND WORK

In October of 2008, then-Sen. Barack Obama of Illinois appeared poised for a historic victory in the presidential election over Sen. John McCain (R-AZ). Democrats, already in control of the House and Senate following a Democratic wave in the 2006 midterm elections, appeared highly likely to increase their majorities in both chambers. For Sen. Edward M. “Ted” Kennedy, the prospect of Obama’s election signaled his last and best hope to help craft legislation providing for the enactment of universal health-care coverage, which Kennedy called “the cause of my life.” Kennedy, after all, had been an early and critical supporter of Obama during the presidential primaries, and the young Illinois senator was often compared to Kennedy’s late brother, President John F. Kennedy. Having seen the Clinton administration’s health-care reform effort collapse in 1993, Kennedy had hoped to move quickly. Even before Obama’s election, Kennedy conducted meetings with lobbyists and members of both parties from his hospital bed.1 As chairman of the powerful Health, Education, Labor and Pensions (HELP) Committee in the Senate, Kennedy was in a position to exert considerable influence over health-care reform legislation.

Despite his efforts, Kennedy’s declining health sidelined him during the debate for which he had waited his entire political life. Moreover, the absence of the “liberal lion” (as he was known) created a political void in the Senate—a void which would be filled by Sen. Max Baucus (D-MT), a far more conservative Democrat whose commitment to health-care reform seemed difficult to gauge. In a clear demonstration of his intention to assert his political clout during the Senate’s consideration of health reform, Baucus published a “white paper”2 laying out a blueprint for health-care reform just eight days after Obama’s election as president. Baucus’s plan mirrored much of what Obama had called for in campaigning on universal health care, as it:

1. created an exchange in which plans would compete with one another, and through which the uninsured would receive subsidies to purchase insurance;

2. expanded existing government health insurance programs to further reduce the number of uninsured; and

3. overhauled the health insurance market by instituting new regulations (such as prohibiting insurers from denying coverage to those with pre-existing medical conditions).

Much of the media’s attention in the early days of the health-care reform effort focused on Baucus’s intentions and on the U.S. Senate generally. This is no surprise, as senators—who represent entire states—receive more press coverage than House members. Yet in retrospect, it seems clear that Baucus’s outsized influence over the process of crafting health-care legislation put the Democratic Party’s liberal wing at a disadvantage. Baucus had flatly rejected a single-payer approach (the health-care system favored by many European countries), and did not insist on a new government-run insurance plan that would compete with private insurers. While single-payer was seen as a pipe dream from the very beginning, the government-run plan—known as the “public option”—was seen by progressives as not only achievable, but a critical element of meaningful reform.

NAVIGATING HEALTH-CARE REFORM THROUGH COMMITTEES

In the House, the chairmen of the three committees with legislative jurisdiction over the bill joined together in an effort to avoid the intraparty splintering that had brought down legislative efforts in the past, including President Clinton’s health-care initiative in 1993. Those chairmen were:

• Rep. George Miller (D-CA), the chairman of the Education and Labor Committee, a tough-minded liberal who was first elected to the House in 1974, and was a close ally of then-Speaker Nancy Pelosi;

• Rep. Henry Waxman (D-CA), the chairman of the Energy and Commerce Committee, another liberal veteran of the House; and

• Rep. Charlie Rangel (D-NY), the chairman of the Ways and Means Committee, who has represented a Harlem-based congressional district since 1970.

In March, April, and May of 2009, the three committees held hearings on health reform, and witnesses called by both parties testified. In June, the committee chairmen described above, with the blessing of House Speaker Pelosi, released a working draft of their bill.3 It required all Americans to obtain health insurance, created a health insurance exchange where plans could be purchased, expanded Medicaid (the health insurance plan for the poor) to cover more of the working poor, required larger employers to provide insurance to their employees or pay a fine and, reflecting the liberal dispositions of the three chairmen as well as liberal strength in the House Democratic caucus, included a public option.

On July 14, the House’s first legislative attempt since the early nineties at universal health care was formally introduced as HR 3200, entitled America’s Affordable Health Choices Act of 2009. The bill, which included a number of new provisions—most significantly a new tax on the wealthiest Americans to pay for the expansion of health coverage—was then referred to the three committees mentioned above for their consideration. During committee markups of the bill, Republican members offered amendments to gut the underlying legislation, all of which were defeated. Efforts to restrict coverage for abortions, while also defeated, were the first warning signs that Democratic supporters of the bill would face resistance from a group of Democrats who opposed abortion rights and threatened to derail the bill if their concerns were not addressed.4

During the committees’ consideration of HR 3200, Republicans were outnumbered by their Democratic counterparts in the majority, and were unsuccessful in their attempts to alter the bill. Moreover, Democratic supporters of health-care reform viewed Republican efforts to amend the bill as part of a strategy to kill (rather than improve) the underlying legislation. Democrats, skeptical if not incredulous about Republicans’ claims to be acting in good faith, saw no rationale for negotiating with the minority in the hopes of achieving a bipartisan deal. (A very different process played out in the Senate, where Baucus led negotiations among a group of senators from both parties. Those negotiations, it should be noted, did not prove fruitful, as will be discussed shortly.)

The liberal Democratic membership on the Ways and Means and Education and Labor Committees managed to keep the bill relatively intact during their markups. During the Energy and Commerce Committee’s markup of HR 3200, however, the Democrats encountered resistance from a moderate-to-conservative bloc known as the “Blue Dog Coalition.”5 By threatening to align with Republican members of the committee to form a coalition capable of defeating the bill, the Blue Dogs had enormous leverage in their negotiations with Democratic leaders. House liberals, who did not want to see their party’s signature domestic policy initiative watered down, were furious. Negotiations between the Blue Dogs, led by then-Rep. Mike Ross (D-AR) (who retired in 2012), and Chairman Henry Waxman (D-CA) grew increasingly heated. Bristling at their demands, Waxman at one point threatened to abandon the committee’s consideration of the bill, and urge Democratic leaders to bring the bill directly to the House floor for a vote and bypass his committee entirely. “We’re not going to let them empower Republicans to control the committee,” Waxman declared.6

Despite Waxman’s rhetoric, circumventing Blue Dog opposition to the bill on the Energy and Commerce Committee by bringing the bill directly to the House floor was likely never a viable option. The Blue Dog Coalition claimed a membership of 52 House Democrats in 2009,7 and such a brazen move to undermine their influence would likely have cost the Democrats the votes they needed to pass the bill. Thus, negotiations continued, and in the end, the Blue Dogs did in fact win major concessions. While the public option survived, it was significantly watered down. Rather than creating a public insurance plan that used Medicare’s pricing system—as the bill initially called for in order to drive down insurance costs—the public option envisioned in the bill reported by the Energy and Commerce Committee forced the new program to negotiate prices with medical providers.8 This change would have made it difficult for the new insurance program to fulfill the function envisioned by its proponents—that through the mechanism of market competition, it would result in lower health costs for consumers of private plans.

While the weakening of the public option was the most substantial policy concession made by party leaders, the Blue Dogs won another victory in their negotiations that, arguably, was devastating to the prospects of passing health-care reform in the House. Specifically, Democratic leaders had acquiesced to Blue Dog demands that the House delay voting on a health bill at least until September. Such a delay, the Blue Dogs contended, would give members time to gauge the mood of the public with respect to a comprehensive health-care overhaul.9 Thus, the Energy and Commerce Committee concluded its consideration of HR 3200 on July 31, in time for the House to adjourn for its traditional August recess, in which members typically fulfill duties in their districts. As Democratic members returned home to greet their constituents, they were woefully unprepared for the onslaught of attacks launched against the health-care reform effort at town hall meetings. In competitive districts—those in which Democrats would be vulnerable to challenges by GOP opponents—angry constituents showed up to voice their displeasure, outrage, and disgust at the legislative process that was unfolding in Washington. Moreover, they expressed disdain, scorn, and in many cases unbridled hatred toward the still-recently elected President Obama.

At town hall meetings that would become infamous, members were heckled, shouted down, and drowned out by their constituents. At times, rage appeared about to boil over. At a meeting in Tampa held by Rep. Kathy Castor (D-FL), police arrived to calm a crowd that had grown disorderly and even violent as a fistfight broke out between constituents on opposing sides of the health-care debate.10 In Maryland, an activist burned an effigy of Rep. Frank Kravotil, a Democrat who represented a Republican-leaning district.11

While members were generally restrained in their responses, some saw no reason to handle those who vote to reelect or defeat them with kid gloves. After one town hall attendee told Rep. Pete Stark (D-CA), “Don’t pee on my leg and tell me it’s raining,” to which Stark responded: “I wouldn’t dignify you by peeing on your leg. It wouldn’t be worth wasting the urine.”12

In the midst of the chaos of the summer of 2009, Senator Kennedy succumbed to brain cancer. He died on August 25. Given the heavily Democratic nature of Massachusetts’s electorate, it seemed assured that a supporter of health reform would replace the Senate’s Liberal Lion. A special election to replace Kennedy was scheduled for January 19, 2010, and the state’s Democratic governor, Deval Patrick, appointed a former Kennedy staffer to serve as an interim senator until the newly elected senator could be sworn in.13

If the goal of delaying a vote on health-care reform legislation was to generate support for it in the electorate, all did not go remotely according to plan. A CNN poll released on September 2, 2009 found a bare majority of Americans (51 percent) now opposed the reform effort moving through Congress,14 which represented a slight (although statistically insignificant) erosion in support from earlier in the summer, when a bare majority had supported an effort. Moreover, vulnerable Democrats could not ignore what they had seen and experienced in their districts. There could be no mistake: the Democratic push to overhaul the nation’s health-care system was fraught with peril, particularly for those who had to run for reelection in competitive and Republican-leaning districts.

Recognizing that the cornerstone of his domestic policy agenda was in serious jeopardy, President Obama addressed a joint session of Congress on September 9, 2009. In his address, he called for action and vowed to keep an open mind to Republican suggestions to improve the bill. He sharply rebuked, however, critics who had deliberately misrepresented the bill, as some had indisputably done. Opponents had raised the specter of so-called “death panels” in which the proposed health-care law would supposedly euthanize the old and the vulnerable. Sen. Chuck Grassley (R-IA), a key figure in the health-care reform negotiations in the Senate, told a crowd that they were right to fear a “government program that determines if you’re going to pull the plug on grandma.”15 In his speech, Obama took aim at these attacks, excoriating the death-panel claim as “a lie, plain and simple.”16 Obama also reiterated that the bill would not provide coverage to undocumented immigrants, at which point Rep. Joe Wilson (R-SC), in an unprecedented display of hostility and disrespect during a presidential address, shouted “You lie!” After refusing to apologize publicly on the House floor, Wilson was formally admonished by the House for his actions by a vote of 240–179.17

THE HOUSE PASSES ITS HEALTH-CARE REFORM BILL

On October 29, a reconciled version of the legislation that passed the three House committees was finally introduced, this time as HR 3962, the Affordable Health Care for America Act. This bill contained the weakened public option negotiated between the Democratic leadership and the Blue Dogs, as well as a 5.4 percent surtax on Americans earning more than $1 million per year. On November 7, the House passed the “rule” providing for debate on the bill. In addition to providing for debate time, the rule allowed for two amendments to be considered—one by Rep. Bart Stupak (D-MI), that would have prohibited federal funding for health plans that covered abortion, and a second amendment that served as the Republicans’ “alternative” health bill, and contained a number of their proposals.18

Sixty-four Democrats joined 176 Republicans to pass the Stupak amendment that restricted funding for abortion coverage.19 Despite their victory, pro-choice Democrats still hoped that Stupak’s language would be negotiated out of the bill in the Senate, or in negotiations between the two chambers. At 11:15 p.m. on November 7, the House passed its comprehensive health-care reform bill by a narrow vote of 220–215. Democratic leaders were jubilant, and understandably so. The vote was historic, and marked a turning point in the fight for universal health care in the United States. Yet there were clear signs of danger for the Democratic majority. Thirty-nine Democrats had abandoned their party, nearly all of them vulnerable members who faced an uphill battle for reelection.20 And health-care reform’s fate in the Senate was far from assured.

THE SENATE PASSES ITS HEALTH BILL

Indeed, even as proponents of health-care reform hoped that its passage in the House portended momentum, they watched proceedings in the Senate with increasing concern. While the Senate HELP Committee had reported the bill on July 15, the Senate Finance Committee, which was made up of a more conservative membership (and led by the more conservative Chairman Max Baucus [D-MT]), appeared to be stalled in its efforts to produce a bill.

Adamant that health-care reform legislation needed to be bipartisan in order to be lasting, Baucus led negotiations among the “Gang of Six,” a group made up of three Democrats and three Republicans. The three Democrats were Baucus, Sen. Kent Conrad (D-ND), a deficit hawk who at the time was chairman of the Senate Budget Committee, and Sen. Jeff Bingaman (D-NM), a low-key and experienced legislator with a moderate-to-liberal voting record. The Republican half of the Gang of Six was comprised of Senator Grassley (R-IA), the ranking Republican on the Senate Finance Committee and someone who had in the past worked with Baucus to produce bipartisan legislation, Sen. Mike Enzi (R-WY), a mild-mannered conservative who was the ranking Republican on the HELP Committee, and Sen. Olympia Snowe (R-ME),21 a moderate Republican whose support Senate Democrats—and Baucus in particular—courted aggressively in the hopes that they could claim the backing of at least one GOP senator. The Gang of Six’s talks continued throughout the summer of 2009, as public support for health-care reform continued to erode. In the end, it looked to observers—particularly those who supported the reform effort—that Grassley had played Baucus for a fool. The Washington Post’s Ezra Klein likened the Iowa Republican to a manipulative boyfriend. He wrote: “Grassley’s friendship with Baucus is long and deep. And he has made Baucus look like a weak, ineffectual fool. He has absolutely hung him out to dry.”22

Regardless of whether Baucus shared Klein’s view of his Republican colleague’s behavior, he certainly seemed to eventually come to the conclusion that further negotiations were a fool’s errand. He disbanded the Gang of Six, and introduced his proposal on September 16, 2009. His bill expanded coverage to fewer people than did the House bill, and did not include a public option, which he saw as an insurmountable obstacle to garnering the 60 votes needed to overcome a filibuster. The Finance Committee reported the bill by a vote of 14–9 on October 13. Senator Snowe was the only Republican on the Finance Committee to support the bill.23

Senate Majority Leader Harry Reid introduced his own bill that reconciled the differences between the measures reported by the Finance and HELP committees. His legislation did include a public option. As the Senate debated the measure for more than three weeks in December, Democrats worked furiously to maintain the support of Snowe, who by this time was seen as the only Republican senator still open to supporting the bill, as well as conservative Democratic senators. Sen. Ben Nelson (D-NE) was a key holdout and an opponent of the public option. Perhaps more surprisingly, Sen. Joseph Lieberman of Connecticut, a former Democrat who became an independent and who caucused with the Democrats for procedural purposes, made clear that he would vote with the Republicans to defeat the bill if it contained the public option.

Lieberman, who was the Democratic nominee for vice president as Al Gore’s running mate in 2000, had undergone a political transformation since leaving the Democratic Party (which he did after losing the Democratic primary to liberal challenger Ned Lamont in 2006). Although he had championed a proposal during his 2004 presidential campaign to let uninsured individuals buy into Medicare (which some liberals saw as a viable alternative to the public option), he now indicated that such a provision would make the health-care bill unacceptable to him. Acquiescing to his and Nelson’s demands, the public option was removed from the underlying bill, and the effort to expand Medicare was abandoned.24

Most of what constituted the heart of the Democratic health-care reform effort, however, remained intact. It still created exchanges, provided subsides for people to purchase insurance, expanded Medicaid to cover more of the working poor, and imposed a host of new consumer protections for patients. Rather than impose a new tax on the wealthiest Americans (as the House bill had done), it instead proposed to tax the most expensive health plans, known as “Cadillac” plans. After a debate that monopolized Senate floor debate for much of the holiday season, Senate Democrats had rounded up the 60 votes necessary to break the Republicans’ filibuster of the bill. Having voted finally to end debate on the measure on December 23, the Senate passed its health-care reform bill in a dramatic 60–39 vote on Christmas Eve. The bill passed with the support of all 60 Democrats. Snowe, the lone Republican to support the bill in the Finance Committee, joined with her party in the end to vote against it.25

IN SPECIAL ELECTION, MASSACHUSETTS GOES RED

Given the considerable differences between the House and Senate–passed health-care bills, negotiations between the two chambers to produce a reconciled package was sure to be an arduous process. Yet shortly after the New Year, the Democrats suffered a setback that no one had seen coming, and that was psychologically devastating to supporters of health reform. In a special election to fill the remainder of the late Sen. Ted Kennedy’s (D-MA) term, the Democrats were caught flat-footed by a surprisingly strong challenge from Scott Brown, a state senator who opposed the health bill that had passed the Senate. The Democratic nominee, Martha Coakley, was also regarded as an exceptionally poor candidate. On January 19, Brown triumphed by a 52–47 percent margin, a result that reverberated around Capitol Hill instantly and powerfully, and seemed to have dealt a deathblow to health-care reform efforts.26

Stripped of their 60-vote supermajority, Democrats were now left without the votes they needed to defeat a Republican filibuster on the final health-care reform package that supporters hoped could be negotiated between the House and Senate. Moreover, the damage to the Democrats’ psyche was not limited to those serving in the Senate. In the House, a number of stalwart supporters of the bill—including those who had fought for universal coverage for decades—seemed ready to give up. Rep. Barney Frank (D-MA), a long-time champion of liberal causes, released a statement that reflected Democrats’ despair in the moment: “I feel strongly that the Democratic majority in congress must respect the process and make no effort to bypass the electoral results.”27 Rep. Bill Pascrell (D-NJ) urged a scaled-back effort to pass smaller health bills in a piecemeal fashion.28

What happened next was arguably one of the most remarkable political turnarounds in legislative history. On the night Scott Brown had prevailed in Massachusetts, President Obama met with Speaker Pelosi and Majority Leader Reid. The emerging consensus in Washington was indeed that health-care reform was dead. Yet there was still a way to pass a comprehensive reform bill, and it was fairly simple: the House could take up the Senate-passed bill. Once it cleared the House, Obama could sign it into law. Obama pressed Pelosi to do just that, but Pelosi countered that the Senate bill could not pass the House because it lacked sufficient support among their party’s progressive wing.29

The compromise that began to take place was two-fold. First, the House would pass the Senate bill. Then the Senate would take up a second bill implementing changes favored by House Democrats, and would do so under a special procedure called “budget reconciliation,” which allows bills to be passed with a simple majority of 51 votes rather than the supermajority of 60. Senate Democratic leaders had been reluctant to employ this process because it was viewed as a bare-knuckled tactic that might result in their losing the support of conservative Democrats. Having no other option at this point, however, Reid and his team began to reconsider their earlier stance.

OBAMA INTERVENES

President Obama, meanwhile, was no longer content to allow congressional leaders to remain in the driver’s seat with respect to the centerpiece of his domestic agenda. Determined to rally support for health-care reform, he took a number of steps that would have been unthinkable just months earlier. First, on January 29—just ten days after Brown’s victory—he attended a summit of House Republicans. Standing before the entire Republican conference, he made remarks supporting the legislation of which he had begun to take greater ownership. Then, in a move that attracted the kind of positive media coverage he had not enjoyed in quite some time, Obama began to take questions from his Republican adversaries. One by one, he took on his fiercest critics and pushed back against what he characterized as an intransigent and uncompromising opposition.30 In the end, the event had gone just as Obama’s team had hoped. His performance signaled to his allies that he was reenergized, and he seized the opportunity to build momentum behind passing the bill. In a televised summit a few weeks later, he tangled with Republican senators, including his former rival for the presidency, Sen. John McCain (R-AZ).31

With the effort to pass a health bill revived, Obama’s team turned its attention to the House. Having given up any hope of Republican support, they worked in concert with Speaker Pelosi and her deputies to build a coalition of House Democrats that could pass the Senate bill. They lobbied moderate-to-conservative members of their party who were fighting for their political lives in their districts, as well as liberals who regarded the legislation as insufficiently progressive. When dealing with deficit hawks, the bill’s supporters pointed to the bill’s provisions to reduce the budget deficit. Other times, they appealed to members’ consciences. Rep. Jason Altmire (D-PA), who represented a Republican-leaning district in Pennsylvania, received overtures from Obama as well as his chief of staff, former Rep. (and current Chicago mayor) Rahm Emanuel.32 In the end, he would not budge.

A small voting block of vulnerable Democrats who opposed the House-passed bill in November, 2009, proved critical. Rep. John Boccieri, an Ohio Democrat facing intense headwinds as he fought for a second term in a Republican-leaning district, held an emotionally charged press conference to announce he was switching his vote. Invoking the story of an ill and uninsured constituent—whose name (Natoma Canfield) had become a rallying cry for Obama as he barnstormed the country in the final days of the battle for health reform—he said: “In this job, if I can save one life, one person, one Natoma, this job is worth it.”33 Rep. Bart Gordon, a Democrat who had represented a middle Tennessee district in the House for twenty-six years, also switched from “no” to “yes.”34

The Democratic leadership also courted Rep. Betsy Markey, a freshman Democrat from Colorado who had toppled Rep. Marilyn Musgrave, Congress’s leading antigay crusader, in 2008. Although she had defeated Musgrave by a surprising, ten-point margin, her district’s Republican lean would make her reelection fight an uphill battle. On March 18, she announced she would vote in favor of the bill.35 At the eleventh hour, on March 21, Rep. Brian Baird, who had represented a swing district in Southwest Washington State since 1998, also signaled he would vote “yes.”36 Rep. Suzanne Kosmas (D-FL), another freshman representative who had ridden the Democratic wave of 2008 to victory but who appeared vulnerable in 2010, had voted against the House bill back in November. This time, she voted with her party to pass the measure.37

One Democratic holdout was not a Blue Dog, but a longtime liberal voice in Democratic politics. Rep. Dennis Kucinich (D-OH) was a staunch supporter of a single-payer system, and had been adamant that he could not vote for a bill that further entrenched private insurers as a central component of the American health-care system. Obama, drawing on the personal relationship he had developed with Kucinich when they were both competing in the 2008 Democratic primary, made repeated personal appeals to the congressman from and one-time mayor of Cleveland. In the end, Kucinich voted “yes.”38

FINAL PASSAGE

Increasingly confident that they had the votes needed to pass the bill, Democrats brought the measure to the House floor. As Speaker Pelosi gaveled the House into session at 1:00 p.m., she could be seen grinning as she made her way to the seat on the top tier of the dais at the front of the chamber. After the chaplain gave the prayer, she handed the Speaker’s gavel to Rep. John Salazar (D-CO) to preside over the House.

Debate on the bill was at times tense and spirited, and both Speaker Pelosi and Minority Leader Boehner took the microphone to speak for their respective parties. Boehner, reflecting the predominant message of the Republican House conference that the Affordable Care Act (or what had come to be known as “Obamacare”) was a cataclysmic mistake, was scathing in his criticism of the bill. Moreover, his conviction that its passage cleared the way for his own Speakership was clearly evident:

If we pass this bill, there will be no turning back. It will be the last straw for the American people. And in a democracy, you can only ignore the will of the people for so long and get away with it. And if we defy the will of our fellow citizens and pass this bill, we are going to be held to account by those who have placed us in their trust. We will have shattered those bonds of trust. I beg you. I beg each and every one of you on both sides of the aisle: do not further strike at the heart of this country and this institution with arrogance, for surely you will not strike with impunity. I ask each of you to vow never to let this happen again—this process, this defiance of our citizens. It is not too late to begin to restore the bonds of trust with our nation and return comity to this institution.39

Pelosi, who was about to go down in history as the Speaker who presided over the passage of historic health-care reform legislation long championed by her party, was ebullient in her remarks:

It would not be possible to talk about health care without acknowledging the great leadership of Senator Edward Kennedy, who made health care his life’s work. In a letter to President Obama before he passed away—he left the letter to be read after he died. Senator Kennedy wrote that: “Access to health care is the great unfinished business of our society.” That is until today.… After a year of debate and hearing the calls of millions of Americans, we have come to this historic moment. Today, we have the opportunity to complete the great unfinished business of our society and pass health insurance reform for all Americans. That is a right and not a privilege.

In that same letter to the President, Senator Kennedy wrote, what is “at stake are not just the details of policy but … the character of our country.” Americans will look back on this day as one which we honored the character of our country and honored our commitment to our nation’s founders for a commitment to “life, liberty, and the pursuit of happiness.”

As our colleague [Rep.] John Lewis [D-GA] has said, “We may not have chosen the time, but the time has chosen us.” We have been given this opportunity.… I urge my colleagues in joining together in passing health insurance reform—making history, making progress, and restoring the American dream.40

At approximately 10:30 p.m., the House proceeded to vote on passage of the Senate’s health-care reform bill. At 10:44, with the vote tally at 214–202 in favor of the bill, chants of “Four more votes!” could be heard from the Democratic side of the aisle. By 10:46 p.m., the tally was 217–207, with 7 members not yet having voted. As it became clear that the bill was going to pass—thereby clearing the way for Obama to sign it into law—Democratic members could be seen exchanging hugs and beginning to applaud. At 10:48, with all members having voted, the tally was 219–212. Representative Obey, in his role as the presiding officer, brought the vote to a close and announced the bill’s passage.

Yet, health-care reform legislation was not yet passed in its entirety. Recall that House Democrats agreed to pass the Senate bill on the condition that both houses also vote on an additional “budget reconciliation” (see explanation above) bill containing a series of changes to the Senate bill favored by House Democrats—changes that, in the broader context of the Senate bill, were relatively minor. Thus, immediately following passage of the Senate’s health-care bill, the House Democratic leadership brought up the second health-care measure.41

One late-breaking development that played out during floor consideration of the reconciliation bill concerned the issue of abortion. The Senate-passed bill that the House was to vote on shortly did not go as far as the original House measure in restricting federal funding for insurance plans that cover abortions. In order to bring Representative Stupak and his bloc of pro-life Democrats into the coalition to pass health-care reform, President Obama agreed to sign an executive order that effectively reiterated current law prohibiting public funding for abortions.

The debate over funding for abortion reached the House floor toward the end of floor debate on the reconciliation bill as Republicans used their motion to recommit—which was, as is customary, allowed by the rule—to try to insert antiabortion language into the bill’s text. Republicans hoped that if pro-life Democrats voted with the GOP, the motion would pass, and leave Democratic leadership with a bill that was unacceptable to their caucus. As generally is the case (regardless of which party is in the minority), the motion to recommit was intended to torpedo the underlying health-care bill. In one of the more dramatic moments during floor debate on health-care reform, it was Stupak himself who rose to lead the opposition to the motion. Upon taking the microphone, Stupak was greeted by a round of applause from his Democratic colleagues seated behind him. In his remarks, he excoriated the Republican motion as cynical ruse:

The motion to recommit purports to be a right-to-life motion, in the spirit of the Stupak amendment. But as the author of the Stupak amendment, this motion is nothing more than an opportunity to continue to deny 32 million Americans health care. The motion is really a last-ditch effort of 98 years of denying Americans health care … Democrats guarantee all life from the unborn to the last breath of a senior citizen is honored and respected. For the unborn child, his or her mother will finally have pre- and postnatal care under our bill. If the child is born with mental problems, we provide medical care without bankrupting the family. For the Republicans to now claim that we send the bill back to committee [the technical purpose of a motion to recommit] under the guise of protecting life is disingenuous. This motion is really to politicize life, not prioritize life.42

In a sign of just how heated debate on this issue had become, Stupak was heckled by Republican members during his speech. Obey, who was still presiding over the House with the Speaker’s gavel, warned members against such interruptions. Shortly thereafter, Rep. Randy Neugebauer (R-TX) shouted “Baby Killer!” at Stupak, drawing outraged protests from the Democratic side. Rep. Steny Hoyer (D-MD), then the Majority Leader, could be heard hushing his members, urging them to remain quiet.43

Ultimately, the House rejected the motion to recommit by a vote of 232–196.44 The House then proceeded to pass the reconciliation bill by a vote of 220–211. The Senate then took up and passed the reconciliation bill four days later, on March 25. Yet in one last legislative wrinkle, Senate Republicans succeeded in removing two provisions from the House-passed reconciliation bill. (These provisions pertained to financial aid for college students, and were actually unrelated to health care.) Since the House and Senate had passed different versions of the reconciliation bill, the House then had to vote one last time to pass the measure as amended by the Senate, and did so later that day, by a vote of 220–207.45 With that, legislative work on health-care reform was complete. President Obama signed both measures into law in Rose Garden ceremonies at the White House.

EPILOGUE

While Pelosi’s Democratic caucus had succeeded in achieving arguably the greatest unfinished work of the New Deal and Great Society era, the ambitious effort to make such major change to social policy was not without political consequences. Just four years after having won back the majority, Democrats lost the House in a landslide defeat in the 2010 midterm elections. To be sure, a stubbornly sluggish economy also played a major role in laying the groundwork for the Republican wave. Yet it also seems clear that Democrats were, at least in the short term, punished by the voters for their efforts. Many vulnerable Democrats—and even those who were not considered to be vulnerable—went down to defeat. Representatives Betsy Markey (D-CO) and John Boccieri (D-OH), both of whom were referenced above, lost their reelection bids.

Rep. James Oberstar (D-MN), who had represented a sprawling district that included Minnesota’s Iron Range, and who was not expected to face a difficult reelection fight, was also defeated. Yet Oberstar expressed a sentiment shared by other Democrats whose careers became causalities of the fight for universal health care: he had lost in service of what he had come to Congress to achieve, and he did not regret it. In a press conference after the election, he was asked whether he regretted his vote in favor of health-care reform. Oberstar, whose father was a founder of the Steelworkers’ Union, recalled the history of those workers’ fight for health insurance, and said: “I wish my father had lived to see the day that we cast that vote and we passed this legislation.…” He then went on to describe the bill’s provisions, and the people whose suffering it had the power to alleviate. His voice growing uncharacteristically gravelly, he added: “I do not regret ever that vote. Ever.”46

The customs of the House of Representatives can seem byzantine, its structure and procedures unnecessarily complex, and its culture mystifying. Livelier—and considerably less genteel—than the Senate, the House as an institution reflects the political reality of its composition. That is, it is the place where the micro-political cultures of 435 localities converge, clash, and, in some form, coexist. Each member, to some degree, represents the political sensibilities and legacies of the district from which he or she was elected.

This stands in contrast to the “upper chamber,” where senators represent entire, often politically diverse states. To be sure, the political culture of New York State differs in many ways from that of the State of Kansas. Yet the senators who represent New York do not exclusively represent New York City and its surrounding areas. They represent Chautauqua County, which borders western Pennsylvania. Similarly, while Kansas’s two senators represent its more conservative rural and suburban areas, they also represent the city of Topeka, as well as Lawrence, a liberal bastion. In other words, senators represent states in their entirety, including their cities, college towns, rural areas, and suburbs. House members, however, are anchored to smaller and often more politically homogenous constituencies.

The chamber’s rules put the majority party firmly in control of its legislative agenda. After a first two years in which President Obama saw much of his domestic policy platform enacted, he now largely uses his limited executive authority to pursue his agenda. Since the Democrats did not regain control of the House in the 2014 midterm elections, the legislative standoff may well continue through the end of Obama’s presidency, with the president using his executive powers to make policy changes, and with the Republican-controlled House effectively pursuing a shadow governing agenda. The House could serve as a legislative engine for substantive change once again if the Democrats regain control of the chamber in 2016 while electing a Democratic president—or if the Republicans win the White House while retaining their majority. For now, the status quo seems likely to endure, with Speaker Boehner serving as the president’s most prominent adversary in Washington, yet constantly looking over his right shoulder to monitor a fractious conference of House Republicans with a conservative wing eager for greater confrontation.

It is my hope that this book will provide readers with a guide by which to observe and better understand the House as it plays a critical role in national debates. I intend for it to serve as a tool by which readers can better follow the national debates that shape government policy and ultimately affect all of our lives.