Posted on 19 Oct 2009
Democratic lawmakers, fresh from one of their biggest legislative victories in the health-care debate, must now navigate fault lines in their own party over how to remake the U.S. medical system.
Leaders this week will try to heal rifts over issues such as whether to create a government-run insurance program, whether to require employers to offer insurance and how to fund the nation’s broadest health-care changes in four decades.
The legislation, President Barack Obama’s top domestic priority, got a boost last week when the Senate Finance Committee approved an $829 billion plan to curb medical costs and extend coverage to tens of millions of the uninsured.
“We have a ways to go,” said Montana Senator Max Baucus, the panel chairman. “But we are going to get health-care reform passed this year because the need is so great.”
Senate Majority Leader Harry Reid is working with White House aides and committee chairmen to merge that bill with one passed by the Senate health panel. Speaker Nancy Pelosi is doing the same in the House. If each passes legislation, they would fashion a compromise for new votes in both chambers.
Some elements that would be part of final legislation are clear. Americans would be required to buy insurance, helped by purchasing exchanges and government aid. Insurers would face new rules, with preventive care, electronic records and cost- effectiveness research playing a larger role in treatment.
Many ideas, such as requiring insurers to accept clients regardless of preexisting medical conditions, have bipartisan support, said Senator John Thune, a South Dakota Republican. Still, only one Republican, Maine Senator Olympia Snowe, has voted for any of the congressional committee plans.
“It really comes down to Senate Democrats,” Thune said. “They’re writing this bill in Senator Reid’s office.”
Democrats control 60 Senate votes, enough to overcome delaying tactics and pass legislation. So far, they aren’t unified, and some including Nebraska Senator Ben Nelson say they won’t vote for legislation that lacks Republican support.
Much of the debate in meetings this week will center on the public option, a government-run program to compete with insurers such as Hartford, Connecticut-based Aetna Inc. Republicans and Democrats including Senator Blanche Lincoln of Arkansas oppose the idea, saying it would undercut the market.
Reid must steer a path between the health panel, which approved a public option, and the finance committee, which rejected it. Snowe wants a trigger for a public option if insurance isn’t affordable enough in the future, an idea the White House may accept.
“The trigger seems to me a place they may well wind up,” said Rogan Kersh, a public policy professor at New York University. “It lets the big majority of members in the middle, and I think the administration, say ‘this feels good enough.’”
Pelosi said the House is set on a government-run program; the question is its structure. One possibility is to allow the plan to harness federal purchasing power while requiring it to negotiate rates with providers, as private insurers do.
Another way is pegging a public option’s payments to the lower rates of Medicare, the government program for the elderly. The Congressional Budget Office says this method would save the most money.
There are compromises, such as one offered by Delaware Democrat Thomas Carper, that would allow state-created public options.
One of the thorniest issues is how to pay for programs and subsidies that help people buy insurance.
House members oppose Baucus’s proposal to tax insurers on high-end plans. The No. 2 Senate Democrat, Dick Durbin of Illinois, said he expects changes after unions warned the idea would hurt workers.
The House would place a surtax on couples earning $1 million or more. And lawmakers are considering taxing insurer profits.
The House and Senate health committees also approved a mandate that employers offer insurance or pay a penalty, an idea that Baucus knocked down.
Insurers will fight for stronger penalties on people who don’t buy coverage and drugmakers will attempt to fend off changes such as allowing Medicare to negotiate prices.
And the Senate must resolve how to spare doctors a 21 percent fee cut next year for treating Medicare patients, which stems from a 1997 law intended to cut the federal program’s cost by ratcheting down those fees. Congress has postponed the cuts for seven years to encourage doctors’ participation in Medicare.
Senate leaders are considering allowing doctors to be paid an additional $247 billion over the next decade, a price that drew criticism from some Democrats.
Reid is negotiating with Republicans to allow votes on amendments to the legislation, said spokesman Jim Manley. Minority Leader Mitch McConnell said Republicans “will probably concede the need” to cancel the cuts for at least a year “but pay for it.”
At the end of the wrangling, the odds of final passage of some legislation are “100 percent,” said Ira Loss, senior health analyst at Washington Analysis.
“This president got elected promising to do something about the health-insurance problem,” he said. “The worst thing that can happen to his presidency is if he doesn’t get a bill.”