page_title: Affordable Care Act
section_title: Healthcare debate, 2008–10
hierarchical_section_title: Affordable Care Act / Legislative history / Healthcare debate, 2008–10
caption_attribution_description: English: President Barack Obama discusses his plan for health care reform in a speech delivered to a joint session of the 111th United States Congress on September 9, 2009.
context_page_description: The Patient Protection and Affordable Care Act, also known as the Affordable Care Act or colloquially as Obamacare, is a United States federal statute enacted by the 111th United States Congress and signed into law by President Barack Obama on March 23, 2010. Together with the Health Care and Education Reconciliation Act of 2010 amendment, it represents the U.S. healthcare system's most significant regulatory overhaul and expansion of coverage since the passage of Medicare and Medicaid in 1965.
  ACA's major provisions came into force in 2014. By 2016, the uninsured share of the population had roughly halved, with estimates ranging from 20 to 24 million additional people covered. The law also enacted a host of delivery system reforms intended to constrain healthcare costs and improve quality. After the law went into effect, increases in overall healthcare spending slowed, including premiums for employer-based insurance plans.
  The increased coverage was due, roughly equally, to an expansion of Medicaid eligibility and to changes to individual insurance markets.
context_section_description: Healthcare reform was a major topic during the 2008 Democratic presidential primaries. As the race narrowed, attention focused on the plans presented by the two leading candidates, Hillary Clinton and the eventual nominee, Barack Obama. Each candidate proposed a plan to cover the approximately 45 million Americans estimated to not have health insurance at some point each year. Clinton's proposal would have required all Americans to obtain coverage (in effect, an individual mandate), while Obama's proposal provided a subsidy without a mandate.
  During the general election, Obama said fixing healthcare would be one of his top four priorities as president. Obama and his opponent, Senator John McCain, both proposed health insurance reforms, though their plans differed. McCain proposed tax credits for health insurance purchased in the individual market, which was estimated to reduce the number of uninsured people by about 2 million by 2018. Obama proposed private and public group insurance, income-based subsidies, consumer protections, and expansions of Medicaid and SCHIP, which was estimated at the time to reduce the number of uninsured people by 33.9 million by 2018 at a higher cost.
  Obama announced to a joint session of Congress in February 2009 his intent to work with Congress to construct a plan for healthcare reform. By July, a series of bills were approved by committees within the House of Representatives. On the Senate side, from June to September, the Senate Finance Committee held a series of 31 meetings to develop a proposal. This group—in particular, Democrats Max Baucus, Jeff Bingaman and Kent Conrad, along with Republicans Mike Enzi, Chuck Grassley and Olympia Snowe—met for more than 60 hours, and the principles they discussed, in conjunction with the other committees, became the foundation of a Senate bill.
  Congressional Democrats and health policy experts MIT economics professor Jonathan Gruber and David Cutler argued that guaranteed issue would require both community rating and an individual mandate to ensure that adverse selection and/or "free riding" would not result in an insurance "death spiral". They chose this approach after concluding that filibuster-proof support in the Senate was not present for more progressive plans such as single-payer. By deliberately drawing on bipartisan ideas—the same basic outline was supported by former Senate majority leaders Howard Baker, Bob Dole, Tom Daschle and George J. Mitchell—the bill's drafters hoped to garner the necessary votes.
  However, following the incorporation of an individual mandate into the proposal, Republicans threatened to filibuster any bill that contained it. Senate minority leader Mitch McConnell, who led the Republican response, concluded Republicans should not support the bill.
  Republican Senators, including those who had supported earlier proposals with a similar mandate, began to describe the mandate as "unconstitutional". Journalist Ezra Klein wrote in The New Yorker, "a policy that once enjoyed broad support within the Republican Party suddenly faced unified opposition." 
  The reform attracted attention from lobbyists, including deals between lobby groups and the advocates to win the support of groups who had opposed past proposals.
  During the August 2009 summer congressional recess, many members went back to their districts and held town hall meetings on the proposals. The nascent Tea Party movement organized protests and many conservative groups and individuals attended the meetings to oppose the proposed reforms. Threats were made against members of Congress over the course of the debate.
  In September 2009 Obama delivered another speech to a joint session of Congress supporting the negotiations. On November 7, the House of Representatives passed the Affordable Health Care for America Act on a 220–215 vote and forwarded it to the Senate for passage.
caption: President Obama addressing Congress regarding healthcare reform, September 9, 2009
exif: {"Image Orientation": "Horizontal (normal)", "Image Rating": "0", "Image Tag 0x4749": "0", "Image Copyright": "This photograph is provided by THE WHITE HOUSE as a courtesy and may be printed by the subject(s) in the photograph for personal use only. The photograph may not be manipulated in any way and may not otherwise be reproduced, disseminated or broadcast, without the written permission of the White House Photo Office. This photograph may not be used in any commercial or political materials, advertisements, emails, products, or promotions that in any way suggests approval or endorsement of the President, the First Family, or the White House.", "Image ExifOffset": "2714", "Image XPAuthor": "Pete Souza", "Image XPSubject": "[80, 0, 114, 0, 101, 0, 115, 0, 105, 0, 100, 0, 101, 0, 110, 0, 116, 0, 32, 0, ... ]", "Image Padding": "[]", "EXIF ExposureTime": "1/200", "EXIF FNumber": "4", "EXIF ExifVersion": "0221", "EXIF ShutterSpeedValue": "477741/62500", "EXIF ApertureValue": "4", "EXIF ExposureBiasValue": "0", "EXIF MaxApertureValue": "4", "EXIF MeteringMode": "Pattern", "EXIF FocalLength": "200", "EXIF WhiteBalance": "Auto", "EXIF Padding": "[]"}