POSC 459 — Social Welfare Politics and Policy · Week 10, Wednesday 28 October 2026
Accessible text version of the Week 10 Wednesday slides — same content in linear order, with no slide-scaling container. Reading: Jacobs and Skocpol, Health Care Reform and American Politics, chapters 2–4.
POSC 459 — Social Welfare Politics and Policy Week 10 · Wednesday, October 28
Jacobs and Skocpol, chapters 2–4. Page numbers are from the chapter files on Canvas; each chapter starts at page 1.
| When | What happened |
|---|---|
| Feb.–Mar. 2009 | Obama asks Congress for health reform and holds a White House summit with both parties and the industry |
| Spring–summer 2009 | Five congressional committees write bills; the White House cuts deals with hospitals, doctors, and drug makers |
| August 2009 | Congress goes home; angry Tea Party crowds take over members’ town-hall meetings |
| Sept. 9, 2009 | Obama addresses Congress: “I am determined to be the last” president to take this up |
| Nov. 7, 2009 | The House passes its bill, 220–215 |
| Dec. 24, 2009 | The Senate passes a different bill, 60–39, with exactly the 60 votes it needs |
| Jan. 19, 2010 | Republican Scott Brown wins a Massachusetts Senate seat. Democrats now have 59. Reform looks dead |
| Mar. 21–23, 2010 | The House passes the Senate bill plus a package of fixes, 219–212. Obama signs the Affordable Care Act |
Jacobs and Skocpol, ch. 2, pp. 1–4; ch. 3, pp. 1–2
| Term | Plain meaning |
|---|---|
| Filibuster / cloture | In the Senate, any 41 senators can block a bill by refusing to end debate. Ending debate (“cloture”) takes 60 votes. The House has no such rule |
| CBO score | The Congressional Budget Office’s official estimate of what a bill costs over ten years. Members often won’t vote for a bill that “scores” badly |
| Individual mandate | A requirement that everyone carry health insurance or pay a penalty |
| Exchange | A marketplace where people without job coverage shop for private plans, with government subsidies to help pay |
| Public option | A government-run insurance plan, like Medicare, that would compete with private plans on the exchange |
| “Cadillac tax” | A tax on very expensive employer health plans |
| Reconciliation | A budget procedure that needs only 51 Senate votes, but can change only taxes and spending, not rules |
Hacker said reform passed because of three things: a bad economy, an industry that split instead of uniting against reform, and Democrats who agreed on one plan.
Which of the three do you see in today’s story?
Which one almost failed?
Were the deals with the industry corruption, or how laws get made?
Hacker (2010), pp. 864–867
What happened: In 1993 President Clinton had a task force of 500+ experts spend nine months writing a detailed plan and sent it to Congress. It never got out of committee, and Democrats lost Congress in 1994. Obama did the opposite: he set broad goals and left the writing to the committees.
| Clinton, 1993 | Obama, 2009 | |
|---|---|---|
| Who wrote the bill | A White House task force | Five congressional committees |
| Result | No bill passed either chamber | Both chambers passed bills in under a year |
| The cost | A big, early target for opponents | Missed deadlines; supporters unsure what he wanted |
The point: A president can’t order Congress to pass a domestic law. Obama traded control over the details for a better chance of getting any bill at all.
Jacobs and Skocpol, ch. 2, pp. 2–6
Who they are: Nancy Pelosi was Speaker of the House. Harry Reid was the Senate’s Democratic leader.
| House: Pelosi | Senate: Reid | |
|---|---|---|
| Votes needed | A simple majority, 218 | 60, to stop a filibuster |
| What she/he had | 255 Democrats, 75 more than Republicans | 58 Democrats + 2 independents = exactly 60 |
| What that meant | Could lose dozens of Democrats and still win | Could lose no one |
The point: With exactly 60, every Democratic senator was the deciding vote, so each could demand a price. Two did: extra Medicaid money for Nebraska (Ben Nelson) and for Louisiana (Mary Landrieu).
Jacobs and Skocpol, ch. 2, pp. 1–2, 6–8
The point: In a negotiation, the side that wants the deal most has the least power over its terms. That is why the Senate bill leaned toward the moderates.
Jacobs and Skocpol, ch. 2, pp. 8–9
The point: Provisions that “scored” well got into the bill even when the public disliked them, like the mandate and the Cadillac tax. Remember this at the end of class.
Jacobs and Skocpol, ch. 2, pp. 10–11
What happened: The White House and Senate Finance negotiated with each health industry in private. The pitch: reform brings 32 million new paying customers. In return, give back some money and don’t attack the bill.
| Group | What it gave up | What it got |
|---|---|---|
| Hospitals (American Hospital Assn.) | $155 billion in future Medicare payments | ~$171 billion from newly insured patients |
| Doctors (American Medical Assn.) | ~$80 billion in payment cuts | ~$228 billion; it backed even the House bill |
| Drug makers (PhRMA) | $85 billion in discounts and fees | New customers; no imports of cheaper foreign drugs |
| Insurers (AHIP) | Accepted new rules on how they sell insurance | The mandate: everyone must buy coverage |
The point: In 1993–94 these groups killed Clinton’s plan. In 2009 most of them stayed quiet or paid for ads supporting reform. The White House’s rule: “no peace, no reform.”
Jacobs and Skocpol, ch. 2, pp. 11–16
What happened: The insurers negotiated all year. Then in September 2009 the Senate Finance Committee, under Republican pressure, cut the penalty for not buying insurance.
The point: Insurers ran ads against a “government takeover,” but what pushed them into open opposition was a mandate too weak to deliver healthy customers.
Vote: were the deals corruption, or how laws get made?
Jacobs and Skocpol, ch. 2, pp. 14–16
Who they were: about 25% of adults; older, richer, and whiter than the country; the most conservative part of the Republican base. 90% disapproved of Obama on health care (the public overall: 51%).
The point: The Tea Party’s power over Congress ran through Republican primaries. Any Republican who bargained with Democrats risked losing to a challenger from the right.
Jacobs and Skocpol, ch. 2, pp. 17–18, 21
What happened: Liberals had already given up on single payer. Their compromise was the public option, a government plan to compete with private insurers. A coalition of 1,000+ groups (Health Care for America Now) pushed for it, and polls showed majorities in favor.
The point: The left lost the public option but used it as a bargaining chip. In exchange for dropping it, liberals won larger subsidies and higher taxes on the rich.
Jacobs and Skocpol, ch. 2, pp. 18–21
What happened: All summer, Max Baucus negotiated with a “Gang of Six” senators, three Democrats and three Republicans (Chuck Grassley, Mike Enzi, Olympia Snowe). They met 31 times.
The point: Social Security and Medicare both passed with Republican votes. No major social law since the New Deal had passed with none.
Jacobs and Skocpol, ch. 2, pp. 21–23
“If we’re able to stop Obama on this, it will be his Waterloo. It will break him.” — Senator Jim DeMint, July 2009
Mitch McConnell, the Senate Republican leader, told his members it was “absolutely critical that everybody be together,” so Democrats could never call the bill bipartisan.
The point: The bill was full of Republican ideas (the mandate and exchanges came from Mitt Romney’s Massachusetts law). Republicans opposed it anyway, betting it would win them the 2010 election, as killing Clinton’s plan had in 1994.
Jacobs and Skocpol, ch. 2, pp. 23–24
What happened: There was never an “Obama plan.” Obama set four goals (cover more people, regulate insurers, pay for it, slow costs), and each chamber wrote its own bill.
| Issue | House bill, Nov. 7 | Senate bill, Dec. 24 |
|---|---|---|
| How to pay | Tax incomes over $1 million | Cadillac tax on expensive job-based plans |
| Employers | Firms of 50+ must provide coverage or pay | Much weaker |
| Exchange | One national exchange | 50 state exchanges |
| Public option | A weak one | None |
| Medicare cost commission | No | Yes |
| Vote | 220–215 | 60–39 |
The point: The House taxed the rich and employers. The Senate cut costs. In January the two had to be merged.
Jacobs and Skocpol, ch. 2, pp. 25–32
Jacobs and Skocpol, ch. 2, pp. 1–2, 27, 32
What happened: Ted Kennedy, the Senate’s leading health reformer, died in August 2009. In the special election for his Massachusetts seat, Republican Scott Brown beat Democrat Martha Coakley. Brown ran as the 41st vote, the one that would let Republicans filibuster the bill.
The point: The House and Senate bills agreed on 85% of their provisions, but they still had to be merged and passed again, and the Senate could no longer reach 60.
Jacobs and Skocpol, ch. 3, pp. 1–4
What you know: The Senate passed its bill, but can’t pass a new one. The Senate bill includes the Cornhusker Kickback, the Cadillac tax unions hate, state exchanges, and abortion language your pro-choice members resent. Every House member faces voters in nine months.
| Option | Vote you lose | Vote you need |
|---|---|---|
| A. Rush a merged bill through the Senate before Brown is sworn in | ||
| B. Have the House pass the Senate’s bill exactly as is | ||
| C. Shrink it: children’s coverage and a few insurer rules | ||
| D. Something else. Say what. |
Groups of three, 5 minutes. Pick one and fill in its row
Jacobs and Skocpol, ch. 3, pp. 4–9
What happened: The House passed the Senate’s bill unchanged, plus a second bill of fixes. The Senate passed the fixes by reconciliation, with 51 votes. But reconciliation can change only taxes and spending.
| Could be fixed (money) | Stuck as the Senate wrote it (rules) |
|---|---|
| Cornhusker Kickback removed | State exchanges, not one national exchange |
| Cadillac tax reduced and delayed | The abortion language |
| New 3.8% tax on investment income; new taxes on health industries | Anything else that wasn’t taxes or spending |
| Student-loan savings of $60 billion+, about half used for the bill |
The point: Losing the 60th vote strengthened the bill in places. At 51 votes, Ben Nelson’s vote no longer mattered, so Nebraska lost its deal.
Jacobs and Skocpol, ch. 3, pp. 9–12
Jacobs and Skocpol, ch. 3, pp. 2, 12–13
| Share of Americans insured | 83% → 92% projected; 26 million more people |
| Medicaid | Open to all low-income adults up to 138% of poverty, not only parents and children |
| Exchange subsidies | Help up to 4× poverty; premiums capped at 2% to 9.5% of income |
| New rules for insurers | No denying coverage for preexisting conditions; no canceling policies when people get sick; no lifetime caps |
| Young adults | Can stay on a parent’s plan until 26 |
The point: Chapter 4 argues for the law. Read it like any advocacy document: a claim, its evidence, and who is making it.
Jacobs and Skocpol, ch. 4, pp. 2–9, 14
“Conservative means to pursue progressive ends” (p. 8): private insurers and tax credits, with the benefits going to people of modest income
Jacobs and Skocpol, ch. 4, pp. 8–10, 13–14
What Jacobs and Skocpol said: reformers postponed the cost controls that would hurt someone specific. Will future officials keep them? “We think they will” (p. 17).
| Provision | Why it was in the bill | What happened later |
|---|---|---|
| Individual mandate penalty | Kept healthy people in the pool; scored well | Penalty cut to $0 from 2019 (Tax Cuts and Jobs Act, 2017) |
| Medicare cost commission (IPAB) | Projected savings | Never appointed; repealed 2018 |
| Cadillac tax | Revenue and cost control | Delayed twice; repealed Dec. 2019, never collected |
The point: The benefits (coverage to 26, preexisting conditions, Medicaid, subsidies) survived. The three provisions that cost someone something were all undone, and each was in the bill because it scored well with CBO.
Jacobs and Skocpol, ch. 4, pp. 15–17; “What happened later” is from outside the readings
Mon 11/2: Poverty, Politics and Profit (PBS Frontline, 2017, 54 min.), on the companies that profit from running safety-net programs
Fri 11/6, 11:59 p.m.: Discussion Paper 4, on the film with the welfare reform and ACA units
The question: which reform better survives its own politics?
The White House bought the industry’s cooperation with new customers; the insurers turned against the bill only when the mandate was weakened.
Republicans voted as a bloc against a bill built on their own ideas, and when Scott Brown’s election took away the 60th vote, Democrats passed the fixes with 51.
The law’s benefits survived; the cost controls that scored best with CBO were later repealed.
Tonight: the brief at 11:59