How was the agenda set for the passage of the Affordable Care Act?

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One could describe the origins of the mammoth congressional bill that became the "Patient Protection and Affordable Care Act of 2010," otherwise known as "Obamacare," with the previous Democratic presidential administration of William Clinton.  During that presidency, then-First Lady Hillary Clinton was famously -- or infamously, depending upon one's perspective -- given the responsibility for leading a task force assigned to devise an overhaul of the nation's health care system.  Known as the "Health Security Act of 1993," that initial effort at providing universal health care for all American citizens foundered under the considerable weight of political battles raging between Republicans in Congress and the Clinton White House.  While Hillary Clinton's task force was not successful in passing legislation along the lines envisioned, the effort did provide the basis for the later efforts of the next Democratic president, Barack Obama.

Barack Obama had not been in the United States Senate long when he decided to run for the presidency.  Consequently, his national exposure on public policy issues was very limited.  As described in a September 2013 article in Politico, then-Senator Obama had given the issue of health care little thought, but was persuaded to make health care reform a defining issue when asked to address a forum on the topic:

"Soon-to-be-candidate Obama, then an Illinois senator, was thinking about turning down an invitation to speak at a big health care conference by the progressive group Families USA, when two aides, Robert Gibbs and Jon Favreau, hit on an idea that would make him appear more prepared and committed than he actually was at the moment.  Why not just announce his intention to pass universal health care by the end of his first term?  Thus was born Obamacare . . . 'We needed somthing to say,' recalled one of the advisors . . . I can't tell you how little thought was given to that other than it sounded good. . . It just happened.  It wasn't like a deep strategic conversation'."

While the idea of promoting health care reform may have been conjured up as a political maneuver, however, there was considerable support for changes to the existing manner in which health care is provided in the United States among many Americans and their elected officials.  The task was enormous, and the implications yet to be fully determined, but the 2,000-page bill that became the "Patient Protection and Affordable Care Act" represented one of the most formidable public policy initiatives since the 1960s, with then-President Lyndon Johnson's efforts at forging a "Great Society."  

The agenda for President Obama's health care reform efforts, then, originated during the infancy of his presidential candidacy, and quickly became one of his most important public policy initiatives.  The pressures placed on members of Congress by constituencies both for and against the "Affordable Care Act" were tremendous, with patients, medical providers, insurance companies, public policy research institutes, pharmaceutical companies and other large and powerful groups all taking sides and investing a great deal of money to influence the outcome.  That President Obama was successful in passing his health care reform bill was a remarkable political achievement.  That it is proving contentious and difficult to implement was widely expected.

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