Philadelphia Reflections

The musings of a physician who has served the community for over six decades

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Obamacare: Examination and Response
An appraisal of the Affordable Care Act and-- with some guesswork-- its tricky politics. Then, a way to capture major new revenue, even paying down existing Medicare debt, without raising premiums or harming quality care. Then, an offering of reforms even more basic, but more incremental. Finally, the briefest of statements about the basic premise.

Health Care and Education Reconciliation Act of 2010

Obamacare is actually the product of two laws, which is an interesting commentary on Congressional procedure, but merely a distraction from a comprehension of the health care reform. For completeness it is briefly summarized here.

Over the years, the ability of the Senate to filibuster important issues was hampered by potentially applying the filibuster to every vote taken. In particular, the Budget Act contained a vast number of changes to individual dollar authorizations, many of them surfacing at the last moment, after the final compromises had been made and everyone wanted to go home. So it was decided to make an exception for budget changes, but it called on Senator Byrd of West Virginia to devise language which would prevent tricky things for sliding through in the rush toward adjournment.

The result was the Byrd Rule, which defined permissible material for such special allowance. It did two things: it defined a permissible item for inclusion in budget reconciliation as one which was financial but did not change the total budget. The second thing it did was hedge this exception around with controls by the majority leader, right up to the ability of the majority leader to replace the Speaker and anyone else he felt was getting around the rule. The rules surrounding this matter were incorporated into the Congressional Budget Act of 1974, including a provision that there would only be one Budget Reconciliation Act per year. The volume of such technical amendments grew to be so great that there were multiple Reconciliation Acts, automatically incorporated into one big one by a special automatic amendment from the Rules Committee. That explains why the technical amendments to the Affordable Care Act are only part of the Health Care and Education Reconciliation Act of 2010, which was never intended to become law.

Many parts of the Affordable Care Act were thought to be suitable for this exclusion, particularly since the complete ACA did not fit completely within the requirements for filibuster protection. Pages of these technical amendments were added to a Reconciliation Bill mostly designed for the student loan program. Most readers will not find these numerous provisions contribute much to an understanding of what the Act actually does, or what it means. But you never know, for sure.

The President signed the Affordable Care Act on March 23, 2010. He signed the Health Care and Education Reconciliation Act a week later. When the Supreme Court handed down the NFIB v. Sibelius decision, further rearrangement of the indexing and wording became necessary to make the whole thing coherently unified as Chapter 48 of Subchapter D of the Internal Revenue Code of 1986. The whole episode is reminiscent of the epitaph of Leonidas, at Thermopylae.

Go tell the Spartans, passerby,
That here, obedient to their laws, we lie.

Originally published: Wednesday, July 09, 2014; most-recently modified: Tuesday, May 21, 2019