Getting to the Affordable Care Act

Congress finished with the Affordable Care Act late at night on March 21, 2010. Weary White House staffers watched the proceedings. When things concluded, President Obama invited some fifteen or twenty of them back to the White House for an impromptu celebration. They assembled after midnight in the White House residence, and the president served champagne and hors d’oeuvres on the Truman balcony. “No matter what you do,” the president said, “this will be the hallmark of the rest of your careers.” As one participant noted, “Everyone was humbled that we were part of this effort that had previously failed.” ¹

The formal signing ceremony for the Patient Protection and Affordable Care Act occurred on March 23. It was the usual elaborate ceremony, celebrating a legislative triumph for the president and his party. The bill, according to the president, “set in motion reforms that generations of Americans have fought for and marched for and hungered to see.” The Affordable Care Act (ACA), then, marked the end of a long process that stretched back at least as far as President Truman.²

In explaining a modern event like the passage of the Affordable Care Act, historians need to understand the technical complexity of modern public policy, such as the complicated formula for computing federal payments to hospitals in the Medicare program. Unlike other social scientists, however, they do not have to allow their theories to do all the heavy lifting. In particular, historians have the luxury of uncovering the large role of serendipity in the creation of policy. Random events color what happens and, in so doing, affect what will happen as well. An unexpected election result and an unanticipated Supreme Court decision influenced the passage and implementation of the Affordable Care Act.

Historians who write on the subject of national health insurance have tended to be critics of the status quo. Despite the idiosyncratic approach of historians to politics and policy, they typically identify an aspect of our health insurance system that is less than optimal—and there are many such aspects— and proceed to examine the historical roots of the deficiency.³ Although this approach has much to recommend it, it tends to emphasize structural deficiencies, such as racism, sexism, or income inequality, and to omit other factors that are closer to the institutions that make health policy. This article takes an institutional rather than an ideological approach and highlights such things as bureaucratic politics that has motivated changes in the federal agency responsible for health insurance (from the Social Security Administration and Welfare Administration to the Health Care Financing Agency to the Centers for Medicare and Medicaid Services). These arcane details matter in such things as the dominance of Medicare over Medicaid that lasted for many years, the battle to be the score keeper for health-care legislation, and the way that private companies have been used for public purposes as in prescription-drug benefits. A similar bureaucratic politics applies to the congressional committees that have governed Medicare and Medicaid. This politics helps to account for things like the remarkable role that Congressman Henry Waxman (D-Calif.) played in the expansion of Medicaid.

This article uses a new data set, composed of interviews with former heads of CMS and its predecessor, to illuminate the contents of the Affordable Care Act. As an act of policy history, it tries to examine those contents by placing them in their historical contexts.

Barack obama and past presidents

If one were to ask a Washington insider, the key to final passage of the Affordable Care Act was Speaker Nancy Pelosi’s (D-Calif.) ability to hold her caucus together and get the House to pass an identical bill to the one that the Senate had already passed in November 2009. That avoided a conference committee report, which was critical to the process because the election of conservative Scott Brown to the very liberal Edward Kennedy’s seat had altered dynamics within the Senate.⁴ In fact, the unusual procedure probably made the bill more liberal than it would otherwise have been. Veteran health policy observer Gail...