Hello, I am Alan Schlobohm with the Kaiser Family Foundation. This tutorial will provide a nuts-and-bolts overview of the many steps in the legislative process that will be required in order to pass health reform in the 111th Congress.
In this tutorial -- We will look at the role of the president in setting the agenda, and highlight the key leaders in the administration working on health reform. We’ll look at roles played by the key Congressional committees involved and discuss how the Congress’ annual budget resolution might affect health reform and finally, we will review the rules that govern how health reform will be debated and voted on before the full House and Senate before it reaches the President's desk.
While health reform has long been a major national concern, it has received serious consideration in Congress only four times in the last 50 years – under Presidents Harry Truman, Richard Nixon, Bill Clinton, and now Barack Obama. To pass, health reform needs to be at or near the top of the national and presidential agenda. President Obama made health reform one of his top priorities during the 2008 Presidential campaign and has continued to do so as President. Health reform encompasses several issues, but foremost are reducing the number of uninsured, controlling health care cost growth, and improving access and quality of care. As a signal of his intent to pass reform, the President set aside a health reform reserve fund of $630 billion over 10 years as part of his budget proposal to Congress, which would cover about half the cost associated with enacting comprehensive health reform legislation.
In addition to the president, many people working in the Obama administration will play key roles on health reform. The Department of Health and Human Services (HHS) administers existing federal health programs including Medicare and Medicaid. HHS Secretary Kathleen Sebelius along with policy experts from HHS and its various divisions, including the Centers for Medicare and Medicaid Services (CMS), will help develop the details of health reform for the administration. In addition, to those working in federal agencies, several White House staff will be directly involved, including Nancy-Ann DeParle , director of the White House Office for Health Reform; Peter Orszag director of the White House Office of Management and Budget (OMB); Rahm Emanuel , White House Chief of Staff; Melody Barnes , director of the White House Domestic Policy Council; and Lawrence Summers , director of the National Economic Council.
Along with the Administration, Congress will play a central role in drafting health reform legislation. Five committees in Congress – three in the House, two in the Senate – have somewhat overlapping responsibilities over health issues, including health reform. The chairmen of the three House committees are working together on a single piece of legislation. The Senate Finance and HELP committees are working on separate bills which are expected to be merged before reaching the Senate floor.
The Energy and Commerce committee has the broadest jurisdiction over health issues in the House of Representatives. It oversees Medicaid, the Children’s Health Insurance Program (CHIP), and most federal public health programs, including the National Institutes of Health and the Centers for Disease Control, and shares jurisdiction over Medicare with the Ways and Means Committee. Among these programs, Medicaid in particular may serve as a major building block under health reform. The Committee Chairman, Democrat Henry Waxman of California, has considerable experience in health legislation, including taking the lead on major expansions in coverage under the Medicaid program. Mr. Waxman was elected Chairman of the Committee after the 2008 elections.
The Ways and Means Committee has primary oversight over tax policy, and in terms of health care, looks after programs that are supported by payroll deductions – specifically, Medicare – and has jurisdiction over federal tax subsidies for health insurance. Representative Charles Rangel, Democrat of New York, has been Chairman of the Committee since 2007, and has served in Congress since 1971. Representative Pete Stark, Democrat of California, served as Chairman of the Health Subcommittee between 1987 and 1994 and from 2007 to the present.
The Education and Labor Committee has primary oversight over pension, health, and other employee benefits, including the Employee Retirement Security Act (ERISA). ERISA is a federal rule that sets minimum standards for most self-funded health plans in private industry. About half of U.S. workers are in these ERISA plans. The Chairman, Democrat George Miller of California, has been the senior Democrat on Education and Labor since 2001 and its Chairman since 2007.
Two Senate Committees share jurisdiction roughly equally over different aspects of health reform. The Finance Committee has primary oversight over tax policy in general (including federal tax subsidies for health insurance), as well as federal health programs financed by a specific tax or trust fund (such as Medicare), and other programs like Medicaid and the Children’s Health Insurance Program (CHIP). The Committee Chairman, Democrat Max Baucus of Montana, has been in the Senate since 1979. He served as Chairman during 2001 and 2002 and from 2007 to the present. Senator Baucus has been very active on health care issues as Chairman. In late 2008, Senator Baucus released a “white paper” outlining his views on health reform. In late April, Senator Baucus began a series of round-tables and other meetings to familiarize committee members with the issues. Senator Jay Rockefeller, Democrat of West Virginia, Chairman of the Health Subcommittee, is one of many Finance Committee members who take a strong interest in health issues. The senior Republican on the Committee, Senator Charles Grassley of Iowa, has worked closely with Senator Baucus for many years on many issues, including passage of the Medicare Part D prescription drug program.
The Committee on Health, Education, Labor and Pensions – as its name suggests – has oversight over pension, health and other employee benefits, including ERISA, and other federal public health programs and agencies, including the National Institutes of Health and the Centers for Disease Control and Prevention, among others. Besides its health jurisdiction, the HELP Committee plays a key role because it is the home base for Senator Edward Kennedy, Democrat of Massachusetts, who has long been the most prominent advocate for health reform among Senate Democrats. During Senator Kennedy’s recent illness, Senator Christopher Dodd, Democrat of Connecticut, has stepped in to lead committee deliberations. The HELP committee also set up three “working groups” that worked on specific components of comprehensive health reform: insurance coverage; prevention; and quality.
There are several important elements to Committee consideration of health reform. In the early stages, Committees have been holding public hearings on specific aspects of health reform, receiving testimony from both government and public witnesses. These hearings provide a forum for important issues to be raised, to hear comments from policy experts and stakeholders and allow Committee members to ask questions and air their views. Given the substantial impact of health reform on the private and public sector, there are many different interest groups that have taken positions and are voicing their opinions both publicly and privately with legislators. These include patients’ rights advocates, the medical community, insurance companies, small and large employers, and labor unions just to name a few. The influence of these groups varies tremendously. Eventually, each Committee begins work on specific legislative language , initially informally, usually in private, and later in formal public meetings. At the direction of the chairman, committee staff work to turn policy ideas and proposals into actual legislative language. Every piece of legislation is subject to analysis by the Congressional Budget Office (CBO), a nonpartisan agency that works for the U.S. Congress. CBO estimates the federal costs of a proposal and its effect on the federal budget. This analysis can be an important consideration for Members of Congress weighing different proposals, particularly with something as potentially large and costly as national health reform. Typically, the Committee Chairman will not finalize his own complete bill until he has received assurances privately from enough Committee members that there are enough votes to pass the bill out of Committee without major substantive changes. When that occurs, and CBO has completed its formal cost estimate of the chairman’s bill, then the Chairman will schedule public committee meetings to vote on the bill. At these meetings – known as mark-ups – the bill is explained by staff, debated by Committee members, amendments are offered, adopted or rejected, and eventually, the bill is either approved or defeated. If the bill is approved, then it is forwarded for consideration by the full House or Senate, along with a committee report , which among other things provides an explanation of each of the bill’s provisions.
House and Senate floor procedures are quite different. In the House, after the three main health committees each adopt health reform legislation, there are a couple of steps before House floor debate begins. First, under the direction of House leaders, the bills approved by the three health committees will be compiled together into a single piece of legislation. Next the House must adopt a rule to set the terms for debate on the House floor. The House Rules Committee – which is controlled by the majority party leadership – will write the rule. The rule will set the total amount of time for debate on the bill, and which amendments, if any, will be allowed to be offered. The full House then votes on whether to adopt the rule. Passage of the rule requires only a simple majority , and such rules are rarely defeated. When the rule is adopted, then debate on the bill can begin. The time for debate is controlled by the Committee leaders – the chairmen and the ranking (or senior) Republican members. Finally, the House votes on the bill itself. Passage requires only a simple majority . If adopted, the bill awaits Senate action and a potential House-Senate Conference.
Senate rules place few limits on the rights of senators during floor debate. A senator who seeks recognition normally has a right to the floor if no other senator is speaking, and then may speak for as long as he or she wishes. With few exceptions, senators may offer as many amendments as they wish to legislation considered on the floor, and the amendments need not be germane, that is, relevant, to the subject of the bill. Senators may offer and debate a wide array of procedural motions as well. These are all elements utilized during a Senate filibuster – the act of blocking legislation by preventing it from coming to a vote. While most Senate bills are not filibustered, the threat of a filibuster is very common. The Senate can end a filibuster only by passing what is known as a cloture motion. The votes of three-fifths of senators duly chosen and sworn are required to approve cloture. In the current senate, with 100 members, cloture requires 60 votes. Once cloture is invoked, total time for consideration is limited to 30 hours. Only germane amendments submitted in writing before cloture was invoked are allowed. Once the 30 hours are concluded, passage of a bill under the regular order requires only a simple majority . Obtaining a super-majority of 60 votes could prove too difficult for health care reform. Senate rules provide one mechanism around this problem: budget reconciliation .
Under Senate rules, there are two types of bills that are not subject to a filibuster, and thus only require a simple majority for passage. These are: (1) budget resolutions ; and (2) budget reconciliation . Congress annually adopts a budget resolution , which provides a broad outline of how much Congress plans to spend on programs and how much revenue it expects to collect during the next fiscal year (and several years beyond). The budget resolution does not actually spend any money or raise any revenue – those decisions are made in subsequent legislation. The budget resolution sets targets for part of the federal budget known as discretionary spending – national defense and education, for example – which are taken care of annually in appropriation bills , which are not exempt from filibuster. However, the budget resolution might also include instructions for Congress to make changes in tax policy, or to make changes to another kind of federal spending known as entitlements, or mandatory programs, such as Medicare or Medicaid. The legislative procedure for enacting such changes is known as budget reconciliation , which is exempt from filibuster. In the budget resolution adopted by Congress on April 29, 2009, Congress has authorized the use of budget reconciliation for health care reform. Under the resolution, the deadline for Committees to report budget reconciliation language is October 15, 2009. The various committee bills will be compiled into one bill by the Budget committee. Floor consideration of a budget reconciliation bill is limited to 20 hours, including time for amendments and votes. A simple majority is required for passage of the bill. Democrats have not made a final decision on whether to use the budget reconciliation process as the vehicle for health care reform. Leading Democrats have said they would much prefer to take up health care reform under the regular order in the Senate, and not under reconciliation. One reason provided is that bills passed under the regular order can be broader in scope than what is allowed under budget reconciliation.
Once the House and Senate have each passed health reform legislation, the next step is to resolve the differences between the two bills into one final piece of legislation. Formally, each chamber will appoint a few members to represent them at a House-Senate Conference Committee . These members – known as conferees – will include a handful of the most senior members of the health-related committees – Finance, HELP, Commerce, Ways & Means, Education & Labor – and possibly members of the leadership. Negotiations over the details will primarily be conducted in private, with representatives from the White House included. Members of the minority party often are excluded from the negotiations, unless they are committed to voting in favor of the final bill. Once an agreement is reached, then the conference committee itself will meet in a public session to formally ratify the compromise bill, which is included in and referred to as the conference report . Besides the bill, the conference report includes an explanation of each of the bill’s provisions. The conference report is then sent back to both the House and Senate for final approval. In the House, a rule will be adopted that will set the terms of debate – likely, a few hours of consideration, at most. Final passage requires only a simple majority. In the Senate, consideration of the conference report depends on whether the legislation is included in budget reconciliation or not. If it is, then debate on the conference report is limited to 10 hours. If it is not protected by budget reconciliation, the conference report could be filibustered. In which case, then, three-fifths of the Senate would again be required to approve a cloture motion cutting off further debate. Once all debate time has been concluded, a simple majority is all that is required to pass the conference report.
If both the House and Senate approve the final version of the bill included in the House-Senate conference report, the bill is sent to the President for his signature or veto.
Clearly, the legislative process for health care reform is complicated, with a lot of moving parts. These final slides summarize major stages in the process. The first stage is preparation of legislation by the interested committees in both chambers of the Congress. The committees debate, evaluate, and make changes to the legislation, which is then merged into one bill each in the Senate and the House of Representatives. The bills are moved to the full floor for consideration and vote.
Once each chamber has passed its own bill, a House-Senate conference committee is appointed to negotiate over the differences and reach agreement on a single bill. The single bill is returned to both chambers for final approval. Final passage in the House requires a simple majority. Final passage in the Senate also only requires a simple majority, but only a budget reconciliation bill is protected from a final filibuster. If the final bill passes both chambers, it is sent to the President to be signed into law or vetoed. As health reform moves forward in the 111 th Congress, we hope this tutorial has made it a little easier to follow.
The Process of Health Reform Legislation
The Process of Health Reform Legislation The Process of Health Reform Legislation Alan Schlobohm Senior Program Administrator Kaiser Family Foundation July 2009 Chart 1
The Process of Health Reform Legislation The Congressional budget and health reform Health reform: some key players in the Administration House and Senate Committees with health jurisdiction Committee procedures Senate floor procedures House-Senate conference; final passage Signed into law or vetoed Health reform on the agenda House floor procedures Chart 2
Health Reform and the National Agenda President Obama at the White House Forum on Health Care Reform, March 5, 2009 Health reform is unlikely to be adopted if it is not at or near the top of the national political agenda Chart 3
Health Reform: Some Key Players in the Administration HHS Secretary - Kathleen Sebelius Nancy-Ann Min DeParle, Director White House Office for Health Reform Peter Orszag, Director White House Office of Management and Budget Rahm Emanuel White House Chief of Staff Melody Barnes Director of the White House Domestic Policy Council Lawrence Summers Director of National Economic Council Chart 4
House and Senate Committees with Jurisdiction Over Health Reform House Committees Senate Committees Chart 5 Energy & Commerce Rep. Henry Waxman (D-Calif.) chairman Ways & Means Rep. Charles Rangel (D-N.Y.) chairman Education & Labor Rep. George Miller (D-Calif.) chairman Health, Education, Labor & Pensions Sen. Edward Kennedy (D-Mass.) chairman Finance Sen. Max Baucus (D-Mont.) chairman
House and Senate Committees with Jurisdiction Over Health Reform Energy and Commerce has primary oversight over health issues, specifically public health and health programs that are funded by general revenue (as opposed to specific taxes) Health jurisdiction: National health insurance Medicaid Medicare (Part B only)* Children’s Health Insurance Program (CHIP) Public Health and Quarantine Hospital construction Mental health and research Biomedical research and development House Committees Chart 6 * Jurisdiction over Medicare Part B shared with the Ways & Means Committee Chair: Rep. Henry Waxman (D-Calif.) Ranking: Rep. Joe Barton (R-Tex.) Health Subcommittee Chair: Rep. Frank Pallone (D-N.J.) Ranking: Rep. Nathan Deal (R-Ga.)
House and Senate Committees with Jurisdiction Over Health Reform Ways and Means has primary oversight over tax policy in general, and specifically health programs that are supported by payroll deductions Health jurisdiction: Medicare * Chair: Rep. Charles Rangel (D-N.Y.) Tax policy Ranking: Rep. Dave Camp (R-Mich.) Health Subcommittee Chair: Rep. Pete Stark (D-Calif.) Ranking: Rep. Wally Herger (R-Calif.) House Committees Chart 7 * Jurisdiction over Medicare Part B shared with the Energy & Commerce Committee
House and Senate Committees with Jurisdiction Over Health Reform Education and Labor has primary oversight over pension, health, and other employee benefits, including the Employee Retirement Security Act (ERISA) House Committees Chart 8 Chair: Rep. George Miller (D-Calif.) Ranking: Rep. John Kline (R-Minn.)
House and Senate Committees with Jurisdiction Over Health Reform Finance has primary oversight over tax policy in general, as well as federal health programs financed by a specific tax or trust fund, and other programs under the Social Security Act Health jurisdiction: Medicare Chair: Sen. Max Baucus (D-Mont.) Children’s Health Insurance Program (CHIP) Medicaid Senate Committees Ranking: Sen. Charles Grassley (R-Iowa) Health Subcommittee Chair: Sen. Jay Rockefeller (D-W.Va.) Ranking: Sen. Orrin Hatch (R-Utah) Chart 9
House and Senate Committees with Jurisdiction Over Health Reform Health, Education, Labor and Pensions (HELP) has primary oversight over pension, health, and other employee benefits, including the Employee Retirement Security Act (ERISA); HELP also has oversight over public health and biomedical research and development Chair: Sen. Edward Kennedy (D-Mass.) Senate Committees Ranking: Sen. Mike Enzi (R-Wyo.) Sen. Chris Dodd (D-Conn.) – in Senator Kennedy’s absence Chart 10 Working Groups: Insurance Coverage Prevention Quality
Committee Procedures Formal hearings Informal meetings (“Walk-Throughs”) Drafting legislation Formal meetings to consider, debate, amend and approve or disapprove legislation (“Mark-Ups”) CBO cost estimate Committee Report Chart 11
House Floor Procedures Rule Debate Amendments Passage Chart 12
Budget Reconciliation Adopted by Congress in April 2009 Authorizes (but does not require) health reform legislation to be protected from Senate filibuster through the use of “budget reconciliation” Budget Reconciliation Limited Debate Amendments Passage Chart 14 The Congressional Budget Resolution
House-Senate Conference Conference appointed to resolve differences between House and Senate Informal negotiations Formal meeting Conference report Final bill voted on separately by the full House and Senate Chart 15
Bill Signed Into Law or Vetoed Bill approved and signed into law by the President Bill vetoed by the President Chart 16 or
Overview – Committees and Floor Debate HOUSE SENATE COMMITTEE PROCEDINGS FLOOR CONSIDERATION Debate Full House vote on Bill (simple majority to pass) Three Bills combined into One Rules Committee sets terms for debate; confirmed by full House House-Senate Conference Committee Energy & Commerce Ways & Means Education & Labor Finance HELP Full Senate vote on Bill (simple majority to pass) Debate Filibuster Cloture Debate Debate terms negotiated Limited debate; no filibuster Regular Order Reconciliation Two Bills combined into One Hearings Legislation Cost estimate Mark-Up Hearings Legislation Cost estimate Mark-Up Chart 17
Overview – Conference House-Senate Conference Committee Conference Report Debate Full House vote on Bill (simple majority to pass) Rules Committee sets terms for debate; confirmed by full House Full Senate vote on Bill (simple majority to pass) Debate Filibuster Cloture Debate Debate terms negotiated Limited debate; no filibuster Regular Order Reconciliation HOUSE SENATE President signs or vetoes the bill Chart 18
Resources Oleszek, W.J., “Congressional Procedures and the Policy Process” (Fifth Edition), CQ Press, Washington, 2001 Schick, A., “The Federal Budget: Politics, Policy, Process”, Brookings Institution Press, Washington, 2000 Beth, R.S., and Bach, S., ‘Filibusters and Cloture in the Senate’, Report for Congress, Congressional Research Service, Updated March 28, 2003 House Energy and Commerce Committee http://energycommerce.house.gov/ House Ways and Means Committee http://waysandmeans.house.gov/ House Education and Labor Committee http://edworkforce.house.gov/ Senate Finance Committee http://finance.senate.gov/ Senate Health, Education, Labor and Pensions Committee http://help.senate.gov/ White House – health reform website http://www.healthreform.gov/ Chart 19