1. The Process of Health Reform Legislation Alan Schlobohm Senior Program Administrator Kaiser Family Foundation July 2009 Chart 1

2. The Process of Health Reform Legislation The Congressional budget and health reform Health reform: some key players in the Administration House and Senate Committees with health jurisdiction Committee procedures Senate floor procedures House-Senate conference; final passage Signed into law or vetoed Health reform on the agenda House floor procedures Chart 2

3. Health Reform and the National Agenda President Obama at the White House Forum on Health Care Reform, March 5, 2009 Heath reform is unlikely to be adopted if it is not at or near the top of the national political agenda Chart 3

4. Health Reform: Some Key Players in the Administration HHS Secretary - Kathleen Sebelius Nancy-Ann Min DeParle, Director White House Office for Health Reform Peter Orszag, Director White House Office of Management and Budget Rahm Emanuel White House Chief of Staff Melody Barnes Director of the White House Domestic Policy Council Lawrence Summers Director of National Economic Council Chart 4

5. House and Senate Committees with Jurisdiction Over Health Reform Energy & Commerce Rep. Henry Waxman (D-Calif.) chairman Ways & Means Rep. Charles Rangel (D-N.Y.) chairman Education & Labor Rep. George Miller (D-Calif.) chairman House Committees Senate Committees Health, Education, Labor & Pensions Sen. Edward Kennedy (D-Mass.) chairman Finance Sen. Max Baucus (D-Mont.) chairman Chart 5

6. House and Senate Committees with Jurisdiction Over Health Reform Energy and Commerce has primary oversight over health issues, specifically public health and health programs that are funded by general revenue (as opposed to specific taxes) Health jurisdiction: National health insurance Medicaid Medicare (Part B only)* Children’s Health Insurance Program (CHIP) Public Health and Quarantine Hospital construction Mental health and research Biomedical research and development House Committees Chart 6 * Jurisdiction over Medicare Part B shared with the Ways & Means Committee Chair: Rep. Henry Waxman (D-Calif.) Ranking: Rep. Joe Barton (R-Tex.) Health Subcommittee Chair: Rep. Frank Pallone (D-N.J.) Ranking: Rep. Nathan Deal (R-Ga.)

7. House and Senate Committees with Jurisdiction Over Health Reform Ways and Means has primary oversight over tax policy in general, and specifically health programs that are supported by payroll deductions Health jurisdiction: Medicare* Chair: Rep. Charles Rangel (D-N.Y.) Tax policy Ranking: Rep. Dave Camp (R-Mich.) Health Subcommittee Chair: Rep. Pete Stark (D-Calif.) Ranking: Rep. Wally Herger (R-Calif.) House Committees Chart 7 * Jurisdiction over Medicare Part B shared with the Energy & Commerce Committee

8. House and Senate Committees with Jurisdiction Over Health Reform Education and Labor has primary oversight over pension, health, and other employee benefits, including the Employee Retirement Security Act (ERISA) House Committees Chart 8 Chair: Rep. George Miller (D-Calif.) Ranking: Rep. John Kline (R-Minn.)

9. House and Senate Committees with Jurisdiction Over Health Reform Finance has primary oversight over tax policy in general, as well as federal health programs financed by a specific tax or trust fund, and other programs under the Social Security Act Health jurisdiction: Medicare Chair: Sen. Max Baucus (D-Mont.) Children’s Health Insurance Program (CHIP) Medicaid Senate Committees Ranking: Sen. Charles Grassley (R-Iowa) Health Subcommittee Chair: Sen. Jay Rockefeller (D-W.Va.) Ranking: Sen. Orrin Hatch (R-Utah) Chart 9

10. House and Senate Committees with Jurisdiction Over Health Reform Health, Education, Labor and Pensions (HELP) has primary oversight over pension, health, and other employee benefits, including the Employee Retirement Security Act (ERISA); HELP also has oversight over public health and biomedical research and development Chair: Sen. Edward Kennedy (D-Mass.) Senate Committees Ranking: Sen. Mike Enzi (R-Wyo.) Sen. Chris Dodd (D-Conn.) – in Senator Kennedy’s absence Chart 10 Working Groups: Insurance Coverage Prevention Quality

11. Committee Procedures Formal hearings Informal meetings (“Walk-Throughs”) Drafting legislation Formal meetings to consider, debate, amend and approve or disapprove legislation (“Mark-Ups”) CBO cost estimate Committee Report Chart 11

12. House Floor Procedures Rule Debate Amendments Passage Chart 12

13. Senate Floor Procedures Debate Amendments Filibuster Cloture Passage Regular Order Budget Reconciliation Chart 13

14. Budget Reconciliation Adopted by Congress in April 2009 Authorizes (but does not require) health reform legislation to be protected from Senate filibuster through the use of “budget reconciliation” Budget Reconciliation Limited Debate Amendments Passage Chart 14 The Congressional Budget Resolution

15. House-Senate Conference Conference appointed to resolve differences between House and Senate Informal negotiations Formal meeting Conference report Final bill voted on separately by the full House and Senate Chart 15

16. Bill Signed Into Law or Vetoed Bill approved and signed into law by the President Bill vetoed by the President or Chart 16

17. Overview – Committees and Floor Debate HOUSESENATE COMMITTEE PROCEDINGS FLOOR CONSIDERATION Debate Full House vote on Bill (simple majority to pass) Three Bills combined into One Rules Committee sets terms for debate; confirmed by full House House-Senate Conference Committee Energy & Commerce Ways & Means Education & Labor FinanceHELP Full Senate vote on Bill (simple majority to pass) Debate Filibuster Cloture Debate Debate terms negotiatedLimited debate; no filibuster Regular OrderReconciliation Two Bills combined into One Hearings Legislation Cost estimate Mark-Up Hearings Legislation Cost estimate Mark-Up Chart 17

18. Overview – Conference House-Senate Conference Committee Conference Report Debate Full House vote on Bill (simple majority to pass) Rules Committee sets terms for debate; confirmed by full House Full Senate vote on Bill (simple majority to pass) Debate Filibuster Cloture Debate Debate terms negotiatedLimited debate; no filibuster Regular OrderReconciliation HOUSESENATE President signs or vetoes the bill Chart 18

19. Resources Oleszek, W.J., “Congressional Procedures and the Policy Process” (Fifth Edition), CQ Press, Washington, 2001 Schick, A., “The Federal Budget: Politics, Policy, Process”, Brookings Institution Press, Washington, 2000 Beth, R.S., and Bach, S., ‘Filibusters and Cloture in the Senate’, Report for Congress, Congressional Research Service, Updated March 28, 2003 House Energy and Commerce Committee http://energycommerce.house.gov/ House Ways and Means Committee http://waysandmeans.house.gov/ House Education and Labor Committee http://edworkforce.house.gov/ Senate Finance Committee http://finance.senate.gov/ Senate Health, Education, Labor and Pensions Committee http://help.senate.gov/ White House – health reform website http://www.healthreform.gov/ Chart 19