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Published by:
Harvard Kennedy School (2012)
40 pages
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In March 2010, Congress passed and President Barack Obama signed the Patient Protection and Affordable Care Act, a contentious, massive bill representing the most significant change to federal health care policy since Medicare. The legislation requires every American to purchase health insurance, expands Medicaid, and establishes insurance exchanges to pool and lower costs for buyers without access to other affordable coverage. It also bars insurers from denying coverage based on pre-existing medical conditions and allows adults to remain on their parents’ family insurance plan until the age of 26. President Obama had won a narrow legislative victory, fulfilling a campaign promise and achieving health care reform that had eluded US presidents for decades. Over the course of his effort, however, the President’s approval rating plunged nearly 20 percentage points, and soon after the bill’s passage, the Democratic Party lost its majority in the House as well as six seats in the Senate. Throughout the deliberations, President Obama faced criticism that he had not given Congress enough details about his vision for health care reform. As the public’s uneasiness about the proposals manifested in vocal confrontations with both Republican and Democratic members of Congress, any chance of receiving bipartisan support for sweeping reform melted away and he faced calls to scale back the proposed legislation. Though President Obama rejected the piecemeal approach, he eventually agreed to abandon the so-called ‘public option’ for health insurance coverage, angering many liberals in the House. In the Senate, a proposal without the public option passed only after a series of carve-out provisions were made for certain states to win over conservative Democrats. As mid-term elections approached and public ire swelled, reconciling the differences between the two bills proved extraordinarily difficult. President Obama proved successful in passing a significant health care overhaul, but the bill lacked any bipartisan support and consumed much of his political capital. This case explores the strategic choices leaders face in seeking large-scale reforms, the role of public opinion in shaping major pieces of legislation, and how the process by which policies are adopted influences the capacity to implement them effectively.


Health policy

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