On January 20th, President Biden was sworn into office, along with Jon Ossoff and Raphael Warnock who were sworn in as Senators representing Georgia. This marks the transition of majority control for both bodies of the legislative branch and the Presidency to the Democrats. The idea of a united government, or one party having majority control, is not rare with ~56% of Congresses and the Presidency (23 Republican, 22 Democrat) being controlled by one party at the same time since the formation of the modern-day political parties in 1861. However, we will note that one party having majority control is decreasing in frequency, with rates falling to 45% over the last 20 years and occuring only a third of the time over the last 10 years.
For years, prominent opinions have expressed that democratic control of Congress and Presidency would be the only hope for any healthcare reform. Now with control of all three seats, we are seeing many news reports of all that is planned to be accomplished. This week, as we prepare for what could be a productive Congress, we review this idea of a united versus divided government’s impact on healthcare bills, and the process by which new bills may move through the current Congress.
Healthcare reform does not require one party control of the government
There have been many bills introduced and passed through Congress that impact the healthcare system. Anecdotally, we have heard from experts, friends, and colleagues (and have even expressed in conversation ourselves), that passage of a major healthcare bill in the U.S. requires one party to have majority control of the government, and likely that party needs to be the democrats. However, as we look to history, we quickly realize that this may not be true. We have compiled a list of major healthcare bills that have passed and the party that held majority control at the time in table 1, below. In table 2 at the end of this article, we provide a more comprehensive, but not exhaustive, list of healthcare bills.
As one can see, despite ~56% of Congresses being majority controlled by one party, most healthcare bills have been passed in a state of divided government. It is important to note that the most major reforms of healthcare in the U.S. did occur when one party controlled the government in 1965 and 2010 with the establishment of Medicare/Medicaid and the passage of the Affordable Care Act, respectively. Relevant to pharmacists, the Medicare Drug, Improvement, and Modernization Act (MMA), which established the Medicare Part D program, was passed in 2003 when Republicans controlled all seats of federal government.
An example of a bill that did not pass during majority control is The Health Security Act, also known as President Clinton’s health plan. The bill was introduced in November of 1993 into the 103rd Congress which had a democratic majority of 82 members (total 258 democrats in the House in 103rd Congress) in the House and 14 members (total 57 democrats in the Senate in 103rd Congress) in the Senate with Democratic President Clinton in the White House. After much debate and media coverage, the bill, which would have been a step towards universal healthcare, was declared dead by then Democratic Senate Majority Leader George Mitchell. The reason for its downfall is multifaceted, however, a large reason is attributed to a series of ad campaigns that rallied public support to oppose the plan. This exemplifies the power of constituent’s voices as advocates and that the public can make an impact on the legislative process outside of just voting at the ballot box. Grassroots advocacy at it’s finest!
As you can see, just because one party controls Congress and the Presidency does not guarantee that a healthcare bill will pass. In fact, the majority controlled by democrats now is slimmer than the majorities when the ACA was passed and when Clinton’s health plan was defeated. The introduction of any healthcare bill is likely going to result in significant debate and it is up to us as constituents and healthcare providers to inform our elected leaders of our opinions on a bill. In an effort to understand where advocacy efforts may be focused over the coming two years, let’s examine how a healthcare bill will likely move through Congress.
How a health bill may move through Congress
There are many complicated rules for how a bill can work its way through Congress. For the purposes of this overview we will not be getting into too much detail (however, if you are interested in learning more click here). The typical pathway is for a bill to first be introduced into both the Senate and the House of Representatives. Following introduction, the bill is then assigned to a committee or a subcommittee. Once assigned, it is then up to the leadership of that sub/committee to determine prioritization of bills to receive hearings. A bill will receive several hearings where proponent and opponent testimony can be heard and legislators can ask questions, debate the bill, and amend the bill. If the leadership of a sub/committee decides to, the bill can be brought to a vote. If a majority votes in favor of the bill, it is then sent to the floor of whichever chamber it was introduced in for debate and potentially a vote. The only difference is if the bill is in a subcommittee, to which a successful vote then moves the bill on to the full committee. If the Senate and House end up passing bills with different language, the bills are then sent to a Conference Committee to reconcile differences in the bills and then are sent to the Senate for a final vote before going on to the President to sign or veto the bill.
Understanding the committee process is incredibly important because this is where most bills “die” or become void due to no action being taken on them before the Congress ends. Knowing the elected leaders on these committees, especially if you are a constituent of theirs, can be vitally important. If a piece of legislation that could improve the healthcare system is referred to a committee, constituents have an opportunity to contact their legislators and advocate on behalf of the profession and their patients. In table 3, we include the most common committees in the Senate and the House that health related bills are referred to and links to the members of each committee.
Table 3: Common committees health related bills are referred to and their members
*The membership of some house committees are still being assigned but the links provided will be the location of committee assignments once updated
Generally, a majority is needed to advance a bill out of the House and 60 out of 100 Senators are required to pass a bill out of the Senate. This need for 60 votes in the Senate is to be able to stop a filibuster, which is one of the only tools of the minority to prevent a piece of legislation from passing. However, there is a word that is prominent across healthcare legislation which indicates a different process used to advance the bills, reconciliation.
Reconciliation is a process by which legislation can be passed if it is going to have a fiscal impact on the government and only requires a 51 majority (instead of the normal 60) in order to pass out of the Senate. This is because rules for reconciliation bills limit debate to a certain period of time, thus essentially banning the filibuster. This is how the bills listed in table 1 and 2 with reconciliation in their name and more prominent healthcare reform bills like the ACA were able to pass. There are additional limitations on the reconciliation process, for example the number of times it can be used by each Congress, which is the reason it is not used for all legislation. However, given the slim majority the democrats hold, any healthcare bill is likely dependent on the use of reconciliation.
Most historical healthcare bills were passed under a divided government, though often using the reconciliation process. Healthcare continues to be one of the most important policy issues, exacerbated by the pandemic, and there will likely be the introduction of a major healthcare bill during the current Congress that could increase patient access to quality affordable healthcare provided by pharmacists and other members of the healthcare team. Regardless of democrats having control of the Presidency and Congress and the reconciliation process, we cannot assume a bill will pass, as exemplified by the Clinton health plan. Grassroots advocacy is needed, especially at the committee level, to educate our elected leaders on our viewpoints of legislation as constituents and healthcare providers. Over the next two years, there will be the opportunity to improve the healthcare system, but a key piece of the advancement of any bill will be dependent on constituents speaking up and advocating for the change we wish to see in the world.