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Understanding health care reform: The basics

By Kurt Manwaring, KSL.com Contributor  |  Posted Aug 3rd, 2011 @ 11:05am


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SALT LAKE CITY -- On March 22, 2010, President Barack Obama ushered in the era of American health care reform by signing the Patient Protection and Affordable Care Act. He referred to the moment as the fulfillment of “decades of trying, and nearly a year of sustained effort and debate.

The pomp and circumstance of that day and the heated debates which have followed beg the questions: What exactly is health care reform and how did it come to be?

Simply stated, the goals of the Affordable Care Act are to make low-cost, high-quality health insurance more universally available. These goals are born out of three widely recognized problems.

First, not everybody has access to health insurance. Second, when insurance is available, it is typically expensive, and third, even those who can afford insurance find that the quality of the health care they receive is often poor. Thus the goals of the Affordable Care Act are to solve — or at the very least, alleviate — these three problems.

The pursuit of a solution to some of these problems has a nearly 100-year-old history in the United States. Beginning in 1912, the now-extinct Progressive Party included health insurance as part of its platform. From 1912 to 2010, numerous presidents, lawmakers, and advocacy groups have attempted to make high-quality health care more affordable and accessible.


"Simply stated, the goals of the Affordable Care Act are to make low- cost, high-quality health insurance more universally available."

No one succeeded when it came to universal reform and few managed to make even incremental steps (some of the notable exceptions to these repeated failures include Social Security, Medicaid and Medicare, and government health insurance for military families and federal employees).

When President Obama ran for President in 2008, he made health care reform a key part of his platform. Yet many doubted that an effort that had failed so many times in the past would be successful. And the naysayers were nearly right.

The legislation, which ultimately became the Affordable Care Act, went through numerous changes and fierce debates. Perhaps two of the greatest obstacles to passing health care reform were the public option and abortion (the battles over both of which are documented in "Landmark: The Inside Story of America's New Health-Care Law and What It Means for Us All," by the staff of the Washington Post).

What became known as the “public option” was actually a government-run health insurance program that would compete with private insurers. The idea angered Republicans and gave rise to right-wing cries of socialism. But perhaps more importantly, it was rejected by Senator Joseph Lieberman.

Lieberman was a long-time Connecticut Democrat who had become known as something of a maverick for many of his middle-of-the-road political preferences. In 2006, he lost his state’s primary and decided to run as an Independent.

His re-election campaign was successful and Lieberman returned to the Senate, bruised, but undeterred. When health care reform was put on the table, Lieberman’s vote represented the last one needed in order to prevent a Republican filibuster.

He recognized his power — and used it. Lieberman persisted in opposing the public option and refused to fall in line with his Democratic colleagues unless it was removed. Much to the relief of Republicans — and the chagrin of many Democrats — party leaders eventually succumbed and removed the public option.

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Abortion was another major issue that threatened health care reform. The original legislation called for the funding of abortions in the plans of participating insurance companies, although tax dollars and private monies were to be kept separate in order to claim that there was no use of federal funds for the controversial procedure.

The proposal outraged pro-life Republicans (whose votes were already discounted by Democratic leaders), Catholic bishops (who exerted tremendous sway over many Catholic lawmakers), and Bart Stupak, a Democratic Representative from Michigan.

Stupak proposed an amendment that prohibited insurance companies in state exchanges from offering abortions to anyone receiving public subsidies. House Speaker Nancy Pelosi fought hard against the amendment, even trying to adroitly cut a deal while Stupak was out of town for a funeral. But when all was said and done, there was simply no way to get enough votes to pass the legislation without including restrictions on abortion. Stupak’s amendment passed.

In the end, after scores of debates, heart-wrenching compromises, and late-night meetings (the Senate even convened on Christmas Eve for the first time since 1895), the legislation had enough votes to pass both the House and the Senate. Thus President Obama signed the Affordable Care Act into law on March 22, 2010.

The history of health care reform is lengthy and complex, much like the final legislation which weighed in at more than 2,400 pages.

The remaining eight articles in this series will seek to shed some light on several of the most important issues in the legislation.

  • First, what was it that caused health care reform legislation to be passed in the first place?

  • Second, how does the health care reform legislation work and when will it take effect?

  • Third, what is the “individual mandate?” What are some of the major concerns regarding the mandate and why does it play such an important role in the overall legislation?

  • Fourth, what are state insurance exchanges and how do they function?

  • Fifth, will health care reform legislation actually work as intended?

  • Sixth, what are some of the most common myths about health care reform?

  • Seventh, what are some of the major political controversies surrounding the legislation?

  • Lastly, what is the role of the 2012 elections and what are some of the possible long-term implications of health care reform?



Kurt Manwaring is pursuing a graduate degree in public administration at the University of Utah. He is the owner of Manwaring Research & Consulting and maintains a personal blog at www.kurtsperspective.blogspot.com.

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