The Obama Healthcare Bill: A Pragmatic Approach

This article is an excerpt from the Shortform book guide to "A Promised Land" by Barack Obama. Shortform has the world's best summaries and analyses of books you should be reading.

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What was in the Obama healthcare bill? Is there an Obama healthcare bill summary that explains it?

A lot went into creating the healthcare bill, as well as the strategy for trying to get it to pass. The Obama healthcare bill aimed to make healthcare more accessible and more affordable.

Keep reading for the Obama healthcare bill summary and the strategy for getting the bill passed.

Obama and Building the Framework for Universal Healthcare

As the Obama team began studying different health care reform proposals, they saw that a landmark piece of state legislation from Massachusetts provided a sustainable, successful, and politically viable model. There, Republican Governor Mitt Romney had worked with the Democratic state legislature to pass a centrist health care reform law that dramatically expanded coverage.

There were three essential components to the system.

  • An individual mandate, requiring all state residents to have medical insurance
  • A “community rating” system, requiring insurers to cover everyone and charge all customers the same premiums, regardless of age, gender, or, importantly, health conditions—meaning that insurers could not deny coverage or overcharge on the basis of pre-existing conditions
  • State subsidies for those who couldn’t afford private coverage or weren’t eligible for Medicare or Medicaid.

The Massachusetts law would become the framework for the federal Patient Protection and Affordable Care Act.

A Pragmatic Approach

As with the stimulus and the bank stress test, Obama showed his pragmatic streak on the health care issue. He wasn’t looking to blow up the system as it was. He wanted to make it work better and deliver real results for people. As ever, he was a reformer—not a revolutionary. Even so, the Obama healthcare bill faced its struggles.

The Massachusetts model wasn’t perfect—the state subsidies were often too stingy, and the system still preserved a crucial role for the for-profit insurance industry. Nonetheless, it was the best model available with a genuine track record of real-world success. 

As Obama told his team, if they’d been designing the U.S. health care system from scratch, they wouldn’t have chosen to replicate the Massachusetts model. But they weren’t starting from scratch. They were trying to reform an existing system with which most people were already familiar and highly resistant to changing. If they wanted to get something done to improve the lives of Americans, they needed to work within the framework of that existing system.

Forming a Legislative Strategy

Fortunately, political conditions had become somewhat more favorable for the passage of a major health care bill by the spring of 2009. By the end of April, Senate Democrats had a filibuster-proof, 60-seat majority, thanks to the long-delayed certification of Democrat Al Franken’s victory in his race in Minnesota and the decision of Pennsylvania Republican Arlen Specter to switch parties and join the Democratic caucus.

This meant that Democrats could pass the bill and overcome a filibuster without needing any Republican votes. But, as Obama would learn, the 60-seat majority was more of a mirage than it was a concrete reality. With Senate Republican Minority Leader Mitch McConnell signaling early in the process that he was unwilling to yield any Republican votes on health care, Democrats would have to pass the measure entirely on their own—and would need all 60 members to vote “yes,” with no defections, in order to defeat a near-certain GOP filibuster.

This meant that the most conservative members of the Senate Democratic caucus—figures like Ben Nelson of Nebraska, Joe Lieberman of Connecticut, Blanche Lincoln of Arkansas, and Mary Landrieu of Louisiana—would have effective veto power over the bill, giving them enormous leverage to make demands and extract concessions. Furthermore, there was no guarantee that badly ailing Senators Ted Kennedy and Robert Byrd would be healthy enough to be present for a floor vote when it came time to pass the bill.

Max Baucus Takes the Lead

Given their substantial leverage over the entire process, congressional Democrats would naturally play a decisive and leading role in crafting the legislation. The Democrats’ point person for drafting the bill in the Senate was Max Baucus, a conservative Democrat from Montana and chairman of the Senate Finance Committee. Obama had some early reservations about Baucus’s ability to draft an acceptable bill and shepherd it through his committee for a full floor vote. Although he was an able and hardworking legislator, Baucus was also significantly to Obama’s right politically and was more friendly with corporate interests than the president would have preferred.

But Baucus was confident that he could secure bipartisan support for the bill, which would give his fellow red-state Democrats political cover to vote for it. In particular, he believed that he could get his Republican colleague on the Senate Finance Committee, Chuck Grassley of Iowa, to support the bill, thanks to their longtime personal friendship.

Based on the hyper-partisanship Republicans had already exhibited during the fight over the stimulus the previous winter, Obama was skeptical about Baucus’s belief that a personal friendship would trump ideological concerns and political strategy for a figure like Grassley. Obama warned Baucus not to let Grassley or any other Republicans string him along and waste valuable time in getting the bill to the president’s desk. Baucus assured the president that the legislation would be ready for him to sign into law by the end of the summer.

The Obama Healthcare Bill: A Pragmatic Approach

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  • How Barack Obama went from relative obscurity to the first Black president
  • What principles guided his political leadership style
  • Why Obama retained an unshakable faith in the potential and promise of America

Carrie Cabral

Carrie has been reading and writing for as long as she can remember, and has always been open to reading anything put in front of her. She wrote her first short story at the age of six, about a lost dog who meets animal friends on his journey home. Surprisingly, it was never picked up by any major publishers, but did spark her passion for books. Carrie worked in book publishing for several years before getting an MFA in Creative Writing. She especially loves literary fiction, historical fiction, and social, cultural, and historical nonfiction that gets into the weeds of daily life.

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