After over a year of contentious debate, sweeping health care reform legislation was enacted this week. For this historic occasion, President Obama used 22 pens to sign the Patient Protection and Affordable Care Act, H.R. 3590, into law on March 23. In the coming days he will also affix his signature to the Health Care and Education Reconciliation Act of 2010, a smaller measure that contains significant improvements to the new health care law and alters college student lending. (See education article in this issue of the Human Needs Report for more information on the changes to the student loan program). Thanks to the new health care legislation 95 percent of non-elderly legal residents will have health insurance in the coming years, consumers will be better protected in the insurance market, and health care costs will be curbed.
The Final Steps to Enactment

Over the last week the House and the Senate took a series of decisive votes to adopt health care legislation. To get to the finish line, Democrats, having lost their 60 vote supermajority in the Senate in January and without seeing any signs that a Republican would support their health care overhaul proposal, decided on a two-step strategy. First, the House would attempt to approve the Senate-passed bill, H.R. 3590, and then both chambers would vote on a reconciliation bill that contained a set of agreed-upon modifications to the Senate bill. (“Reconciliation” is a key Senate procedure in which debate is time-limited and there are no filibusters, so that legislation can be adopted with a simple majority of 51, as long as it will save more than it costs and does not include provisions that are unrelated to the budget.) This approach, which was by no means foolproof, proved successful in the end.

On March 21, the decisive votes were cast in the House. By a vote of 219-212 the House passed the Senate bill, H.R. 3590. All Republicans and 34 Democrats voted against the measure (see roll call vote 165).  Shortly after this vote, the House voted 220-211 in favor of the reconciliation bill, H.R. 4872, 220-211. Again all Republicans voted in the negative and 33 Democrats joined them (see roll call vote 167).

On March 23, the same day the President signed into law H.R. 3590, the Senate began debating the reconciliation measure, H.R. 4872. Republicans prepared a number of amendments to cut away at the bill. They did not succeed in undercutting the health care pieces of the bill, but they did find a couple of parliamentary problems within the student lending section.  This language was deleted from the bill, leaving the student loan provisions largely intact. On March 25, the Senate passed H.R. 4872, by a vote of 56-34. Democrats Blanche Lincoln (AR), Ben Nelson (NE), and Mark Pryor (AR) and all Republicans voted against the bill (see vote record 105). Since H.R. 4872 was altered because of the technical changes that needed to be made to the student lending piece, the bill went back to the House for a final vote. Wasting no time, the House approved the measure 220-207 on March 25 (see roll call vote 194). President Obama is expected to sign the final piece of the health care package on March 30.

Reforms to Come

Taken together, the reconciliation bill, H.R. 4872, and the new health care law, PL 111-148, will bring sweeping changes to the U.S. health care system. The Congressional Budget Office (CBO) estimates that 32 million people will gain coverage by 2019 through the new law and that it will reduce the deficit by $138 billion over this same time period.

Starting in 2014, Medicaid will be expanded, making it available to non-elderly individuals with incomes below 133 percent of the federal poverty line (FPL). (Low-income elderly receiving Supplemental Security Income (SSI) were already eligible for Medicaid.)  Enhanced and uniform federal funding will be provided to all states to cover the cost of the newly-eligible pool in the Medicaid program. Between 2014 and 2017 all states will receive an enhanced matching rate of 100 percent for the new participants, which will phase down to 90 percent in 2020 and subsequent years. The Children’s Health Insurance Program (CHIP), originally set to expire in 2013, will continue through at least 2019 and funding will be assured through September 30, 2015. CBO estimates that in 2019 an additional 16 million individuals will obtain coverage through Medicaid and CHIP.

The new health legislation will also establish state-based health insurance exchanges in 2014 where the uninsured can shop for coverage.  Subsidies will be provided on a sliding scale to people with incomes above the level needed to qualify for Medicaid but below 400 percent of FPL so that they can purchase health insurance in the exchange. According to CBO 29 million people will obtain coverage through the exchanges. Also in 2014, individual and employer mandates will go into effect, as well as consumer protections and insurance market reforms banning lifetime limits and denials of coverage for preexisting conditions.

Although some of the major changes will not kick in for a few years, significant benefits will go into effect starting this year. In a matter of months, seniors who experience a gap in prescription drug coverage (the “donut hole”) will receive $250 rebates (this coverage gap will be completely eliminated by 2020). Young adults will be able to remain on their parent’s health care plan until their 26th birthday. Insurance companies will no longer be able to drop coverage for children with pre-existing conditions, nor will they be able to set lifetime limits on coverage. Greater funding will be provided to temporary high-risk pools so that individuals who are currently uninsured because of pre-existing health conditions are able to obtain coverage until they receive full protection in 2014.

Some important pieces pertaining to immigrant access to health care did not make it into the final legislation. Congress did not include a repeal of the five-year waiting period which states can impose on lawfully residing immigrants who are eligible for Medicaid, and undocumented immigrants will not be able to purchase health coverage in the exchange. For a summary of how immigrants are included in the new law see the National Immigration Law Center’s fact sheet. Advocates will continue to press on these fronts so that greater equity in our health care system is attained.

Now that health care reform legislation has been signed into law, the implementation and education process must begin.

These initial set of resources provide detailed and helpful reviews of the new health care legislation that was signed into law:

• “Key Medicaid, CHIP, and Low-Income Provisions in the Health Care Reform Package” by the Georgetown University Center for Children and Families.
• “Side-by-side comparison of the new health reform law, the House-passed Health Care and Education Reconciliation Act of 2010, and last year’s House-passed bill” by the Kaiser Family Foundation.
• “Health Reform Package Represents Historic Chance to Expand Coverage, Improve Insurance Markets, Slow Cost Growth, and Reduce Deficits,” by the Center on Budget and Policy Priorities.
• “Health Care Advocates:  We Can’t Let Up Now” blog post by Deborah Weinstein, Coalition on Human Needs, in the Huffington Post, March 22, 2010.

More summaries and educational pieces pertaining to the new health care law will be posted on the Coalition on Human Needs website as they become available.

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