After a Rocky Year, No Celebrating for Health Care Reform

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President Obama speaks after the Senate passed their version of health care reform on December 24, 2009.

It was the ultimate Christmas Eve present for Barack Obama. Around 7 a.m. one year ago today, every Democratic senator in office — 60 in all — voted in favor of enacting comprehensive health care reform. Senate Majority Leader Harry Reid had leveraged the threat of spending Christmas in the Capitol to force even reticent Democratic senators to support the landmark legislation, close a major chapter of the debate over health care and head home for the holiday.

In a brief press conference after the vote, Democratic Senate leaders lauded each other and celebrated their historic victory. Max Baucus, chair of the Senate Finance Committee, which assembled most of the bill, referred to a "finish line." Sen. Chuck Schumer argued that negative rhetoric over the bill had "peaked" and that the legislation would soon become more popular. Obama, before flying to Hawaii for his family Christmas vacation, said, "Let's make 2010 the year we finally reform health care in the United States of America."

By March 2010, Obama's Christmas wish had been granted — and the final version of the law did closely resemble the bill passed by the Senate on Dec. 24, 2009. But getting that done required a much more torturous path than the President or Senate Democrats could have imagined. And that, in retrospect, has a lot to do with why Baucus's and Schumer's optimism about the public's view of health reform turned out to be misguided.

Just a month after the historic vote, Republican Scott Brown, riding a wave of Tea Party support, was elected to represent the state of Massachusetts in the Senate. In one swoop, Brown took over the seat of liberal lion Ted Kennedy and destroyed the Democratic supermajority in the chamber. This left Democrats with no choice but to ram through the final reform legislation by resorting to the parliamentary maneuver known as reconciliation, allowing them to avoid a filibuster and pass a later version of health care with just a simple majority.

Because of this ungainly process and a stubbornly consistent drumbeat of Republican criticism, the Affordable Care Act did not, as Democrats predicted, suddenly become popular. In fact, it remained unpopular enough — opposed by about half of all Americans — that Republicans successfully used the issue to retake the House of Representatives in the 2010 mid-term elections. (Other issues were at play, including a still sagging economy, but there's no doubt the frequent charges of a "government takeover of health care" hurt scores of Democratic incumbents who had supported reform.)

Now, instead of smoothly rolling out the new law they celebrated triumphantly on Dec. 24, 2009, President Obama and congressional Democrats will begin 2011 by trying to beat back Republican attempts to repeal health reform. Thanks to their enduring, albeit shrunken, Senate majority, Democrats will be able to swat most attacks away, although the mere spectacle of the assault on health care reform will be an unwelcome distraction in 2011.

Republicans' first targets, aside from the health reform law in its entirety, will be provisions that are particularly unpopular or misunderstood. Republican senators have already unveiled legislation, for instance, to repeal health reform's new Independent Payment Advisory Board (IPAB), a group charged with limiting the growth of Medicare spending, saying it wrongly hands Medicare decisions typically made by Congress to "politically appointed Washington bureaucrats." The name of their bill is "The Health Care Bureaucrats Elimination Act."

In addition, beginning in January, Republican-controlled committees in the House are expected to summon Administration officials to Capitol Hill frequently to testify about health reform. These hearings will give Republicans a fresh chance to suggest health reform will lead to "rationing" and drive up costs. Republicans are also promising to cut off funding needed to implement the law, even though such efforts would, like repeal, require approval from the Senate and President. A fight over appropriations could have the effect of simply bungling implementation, while not halting it altogether. Republicans may maneuver to successfully block some Affordable Care Act-specific funding if just a few Democrats sign on, which would mean Democrats would have to implement the law using general Department of Health and Human Services funding — doable, but not ideal. In addition, some Republican governors have pledged to slow implementation, which could have an effect on rollout as the Affordable Care Act gives states significant power over certain important aspects of the law like new insurance exchanges. "There's a lot of tricks up our sleeve in terms of how we can dent this, kick it, slow it down, to make sure it never happens," incoming Republican House Speaker John Boehner has said. "Trust me, I want to make sure this health care bill never, ever, ever is implemented."

And Republicans have already put themselves in a stronger position to make mischief. The week before Christmas this year, Reid tried to pass a massive spending bill that would have included, among other things, funds for federal agencies charged with implementing the Affordable Care Act. The effort failed, which means House Republicans will be in charge of the purse strings next time a big spending bill comes up for a vote — in March. A showdown over health reform spending is likely.

Meanwhile, the Department of Justice is furiously trying to defend the Administration's signature legislative achievement in court. Although two federal judges previously ruled that the Affordable Care Act is constitutional, a third said earlier this month that a central tenet of the law is not. At the heart of the legal debate is the individual mandate, a requirement that all Americans carry health insurance beginning in 2014. A final decision on the matter will likely be made by the Supreme Court years from now, casting a shadow of doubt over the law until then.

After the 2009 Senate vote for health reform, Sen. Chris Dodd stepped in front of a Capitol Hill microphone and triumphantly declared, "On this Christmas Eve, I can't think of a better gift the United States Senate could give to our fellow citizens." That may be debatable. But some Democrats may be wondering if, politically, the Senate passage of health reform has turned out to more like a lump of coal for them.