With accusations flung from both sides of the isle about health care bills and how they they get moved through Congress, I found myself curious about just exactly what went into the creation of the ACA (the Affordable Care Act, aka the Patient Protection and Affordable Care Act, aka ObamaCare).
I’m still working on fleshing this out with links to full text, but I’m ready to share my initial gathering of all the bills, debates, hearings, reports, and presidential documents that ended up creating what we now call ObamaCare.
In this collection, I included the bills themselves and bills that were related (either directly referring to or incorporating substantial wording from each other) and ultimately building on each other until finally the ACA became law, as well as Hearings and Reports that directly related to or mentioned those bills. I also included a few presidential documents that were directly related to health care reform prior to the ACA’s passage, though I have not combed through all speeches and press releases.
I did not include the 60 committee prints that went into the drafting of this law, but if there’s a compelling reason to go back and list those, please let me know. I also stopped including Congressional Research Service Reports that were produced after the bills were finally passed, though CRS of course continues to study issues and impacts of the ACA.
The Trump administration has released its first federal budget proposal, America First: A Budget Blueprint to Make America Great Again. This proposal has sparked considerable controversy, so I got interested in how the federal budget even works. With my standard caveats,* here are some common questions and the source documents that help answer those questions.
It’s called a proposal. How much control does the President actually have over the Federal Budget? And how does that process work?
The History, Art & Archives site from the House of Representatives gives an overview of the “Power of the Purse,” which the Constitution grants primarily to Congress. The House further outlines the Budget Process and provides a timetable for that budget process. This process begins with the President’s budget proposal and proceeds with the Congress proposing appropriations legislation (12 “regular” appropriations bills emanating from 12 sub-committees of the House and Senate Appropriations Committees) which may or may not take the President’s suggestions. Some or all of these bills may be consolidated into an omnibus bill for passage. Appropriations legislation is just like most other legislation in that it must be passed by both the House and the Senate and then signed by the President. The President can veto the bills (in their entirety, not line-item), Congress can override the veto, etc.
In years where they can’t agree by October 1st (frequent) they can pass Continuing Resolutions to keep things funded at current rates until they can make a decision about the future.
The President’s proposal is available online. Reading it as a message to Congress about this administration’s priorities, the most succinct articulation of Trump’s priorities occurs in the “President’s Message” at the beginning of the document. President Trump entitled this message “America First: Beginning a New Chapter of American Greatness.” Here is an excerpt:
One of the most important ways the Federal Government sets priorities is through the Budget of the United States.
Accordingly, I submit to the Congress this Budget Blueprint to reprioritize Federal spending so that it advances the safety and security of the American people.
Our aim is to meet the simple, but crucial demand of our citizens—a Government that puts the needs of its own people first. When we do that, we will set free the dreams of every American, and we will begin a new chapter of American greatness.
A budget that puts America first must make the safety of our people its number one priority— because without safety, there can be no prosperity. (page 1)
Note that this proposal does not include everything that will be proposed:
The 2018 Budget is being unveiled sequentially in that this Blueprint provides details only on our discretionary funding proposals. The full Budget that will be released later this spring will include our specific mandatory and tax proposals, as well as a full fiscal path. (page 5)
Additional key statements providing policy guidance to Congress include:
“The Federal Government can—and should— operate more effectively, efficiently, and securely.” (page 13)
“Each year, however, Federal agencies issue thousands of new regulations that, taken together, impose substantial burdens on American consumers and businesses big and small. These burdens function much like taxes that unnecessarily inhibit growth and employment.” (page 15)
The phrase “private sector” shows up 12 times in the document, signaling an emphasis on moving support for some activities out of the government and into the private sector.
Following these opening sections, the proposal covers 17 major areas of the federal budget. Below I’ve linked to each of those agencies’ budget pages:
Assuming the legislative process wraps up on schedule, the new budget for Fiscal Year 2018 would swing into effect on October 1st, 2017.
Two caveats: 1) Not all knowable things are knowable using official, original published sources, but that’s the limit I’ve set for myself even when that’s inconvenient or frustrating, and 2) I am a librarian trained in tracking down and evaluating sources — nothing more or less than that. I’m doing my best to find the most authoritative version of the primary sources behind the news, and I welcome suggestions and corrections.
I was recently asked about the often-repeated claim that all new oil pipelines will be made with American steel, whether this really meant all new pipelines, and specifically whether it meant the Dakota Access Pipeline and the Keystone XL Pipeline.
Will these specific pipelines be made from American Steel?
As usual, this turned out to be far more complicated than I anticipated. I’d thought it was easy because there’s an Executive Memorandum calling for American-made steel in pipeline construction from January 24th. But it turns out that this memorandum actually calls for the Secretary of Commerce to come up with a plan to use American-made steel “to the extent permitted by law.” Here’s the actual text:
The Secretary of Commerce, in consultation with all relevant executive departments and agencies, shall develop a plan under which all new pipelines, as well as retrofitted, repaired, or expanded pipelines, inside the borders of the United States, including portions of pipelines, use materials and equipment produced in the United States, to the maximum extent possible and to the extent permitted by law. The Secretary shall submit the plan to the President within 180 days of the date of this memorandum.
Meanwhile, the two Executive Memos dealing with the Keystone XL Pipeline and the Dakota Access Pipeline don’t mention American-made steel. And Deputy Press Secretary Sarah Huckabee Sanders said on March 3rd that in fact those two pipelines would not be covered under the American-made steel memo because steel was bought some time ago and is “already literally sitting there.”
Will any pipelines be made from American Steel?
Secretary of Commerce, Wilbur Ross, has to present a plan for making or repairing all new pipelines with American steel “to the extent permitted by law,” so it’s likely there will be pipelines made with American steel. However it turns out that the World Trade Organization has a say in this that complicates things.
Imported and locally-produced goods should be treated equally — at least after the foreign goods have entered the market. The same should apply to foreign and domestic services, and to foreign and local trademarks, copyrights and patents. This principle of “national treatment” (giving others the same treatment as one’s own nationals) is also found in all the three main WTO agreements (Article 3 of GATT, Article 17 of GATS and Article 3 of TRIPS), although once again the principle is handled slightly differently in each of these.
National treatment only applies once a product, service or item of intellectual property has entered the market. Therefore, charging customs duty on an import is not a violation of national treatment even if locally-produced products are not charged an equivalent tax.
This means that foreign suppliers of goods and services can and do sue if there is preference given to domestic products (assuming equal price and quality) once everything is washing around in the domestic market. Most recently Japan lodged a complaint against India in early January, saying that the “minimum import price” that India imposed on imported iron and steel violates the principle of National Treatment (Article 3.1).
Sometime on or before July 23rd, 2017, we’ll see what the Secretary of Commerce presents as a plan for building pipelines using American-made steel. I’ll update this post as events unfold.
Proponents and opponents alike have been waiting to hear what the plan will be for health care once the Affordable Care Act is repealed. There have also been a lot of statistics thrown around in the course of the public discussion on this topic, and a few people have asked me where some of the numbers they’re hearing are coming from.
Last updated: 6/12/2017
First, the World’s Best Healthcare Act of 2017 is indeed a real bill, but it is not the same bill that people have been anticipating and debating for the last couple months. It’s the 2017 version of a 2016 bill that never made it out of committee. When the bill we’ve been expecting gets an actual number, I’ll add it here.Update 3/25/2017: The “real” bill under discussion was H.R.1628. and as of 3/24/2017 the bill has been pulled from consideration. The bill was pulled “pursuant to clause 1(c) of Rule 19,” which states that “when the previous question is operating to adoption or passage of a measure pursuant to a special order of business, the Chair may postpone further consideration of such measure in the House to such time as may be designated by the Speaker” (see the House rules, page 34). I wonder where this leaves the previous Executive Order (predicated on the idea of prompt repeal of the ACA) and its encouragement for states and companies to play fast and lose with ACA rules.
It was pulled from consideration on 3/24/2017, but then ultimately passed the House on 5/4/2017. The Congressional Budget Office released their report on the ultimate economic impact of this version of the bill.
The Senate has said that they do not plan to move forward with this bill, and there are reports that they have their own bill but that it’s still secret.
What will things cost under the new plan? (section added 3/14/2017)
Update 3/14/2017: The Congressional Budget Office has released its official assessment of the American Health Care Act. This includes estimates of future costs, future numbers of insured Americans, and future market stability. A couple of questions I have about this report are:
Because it was deemed “impracticable” the requirement to investigate the macroeconomic impact of the bill is no longer required (see page 4 of the report, which refers to section 402 of the Congressional Budget Act of 1974 – page 40). So that means that a couple of the major questions I had (effects on jobs, effects on uncompensated care ripples) aren’t covered in this report.
The “Basis of Estimate” section includes:
Effects of Repealing Mandate Penalties (page 8)
Major Changes to Medicaid (pages 8-10)
Changes to Subsidies and Market Rules for Nongroup Health Insurance Before 2020 (pages 10-13) — employer-based insurance is a group insurance, so this is about individual insurance
Changes to Subsidies and Market Rules for Nongroup Health Insurance Beginning in 2020 (pages 13-18)
Market Stability (pages 18-19)
Other Budgetary Effects of Health Insurance Coverage Provisions (pages 19)
The “Net Effects on Health Insurance Coverage” (pages 19-21) section starts “CBO and JCT expect that under the legislation, the number of people without health insurance coverage would increase but that the increase would be limited initially, because insurers have already set their premiums for the current year and many people have already made their enrollment decisions for the year.”
The “Net Effects on Health Insurance Premiums” (pages 21-22) section starts: “The legislation would tend to increase average premiums in the nongroup market prior to 2020 and lower average premiums thereafter, relative to the outcomes under current law.” Prior to 2020 premiums could go up by 15-20%, and after 2020 premiums could go down for the younger population, but go up by an additional 20-25% for people over 65.
Page 22 includes the “Revenue Effects of Other Provisions,”
“Direct Spending Effects of Other Provisions” includes
“Prevention and Public Health Fun,” and Community Health Center Programs” sections (page 22)
The “Provisions Affecting Planned Parenthood” section (page 23)
“Repeal of Medicaid Provisions,” “Repeal of Reductions to Allotments for Disproportionate Share Hospitals,” “Safety Net Funding for States That Did Not Expand Medicaid,” and “Reductions to States’ Medicaid Costs.” (pages 23-24)
“CBO has not completed an estimate of the potential impact of the legislation on discretionary spending, which would be subject to future appropriation action.” (page 25)
Pages 25-26 lay out “Uncertainty surrounding the estimates”
The “Increase in Long-Term Direct Spending and Deficits” section is one sentence long: “CBO estimates that enacting the legislation would not increase net direct spending or on-budget deficits by more than $5 billion in any of the four consecutive 10-year periods beginning in 2027” (page 26).
The final page of content (page 27) analyzes “Mandates on State, Local, and Tribal Governments” and “Mandates on the Private Sector,” which measures new legislation against the Unfunded Mandates Reform Act of 1995.
All the charts and tables are at the end of the document, pages 29-37. Most of these provide costs over time.
Many state senators and representatives have been talking about numbers from their own states, though, so what about the more local numbers? The people who have asked me about these numbers have been interested in Minnesota information, so that’s what I’ll present here, but each state will have something similar. If these numbers look useful to you and you want to know about a state other than Minnesota, the strategies I use for most of this kind of work should work for you. Look especially for state departments of commerce and of health.
Two collections of data and statistics that might be useful to you regardless of state are:
SHADAC – State Health Access Data Assistance Center
In addition to their useful reports, their data center lets you build your own charts based on various official sources, and each chart will tell you which group or agency first published the data so that you can track that group or agency down to see more detail.
If you have access to something like ProQuest Statistical Insight, you can find federal and local government information there as well as industry reports that are hard or impossible to find other places.
And for Minnesota, here are some of the reports that answer the major questions I’ve heard: