Health care conferees still face a lot of work
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WASHINGTON -- In the Senate, Majority Leader Harry Reid carefully worked behind closed doors, moving weighty policy proposals and home-state pork like pieces on a chessboard until he emerged with the necessary 60 votes in hand.
In the House of Representatives, Speaker Nancy Pelosi unveiled a bill, then unleashed a furious lobbying effort -- joined by the president -- and weathered an uprising over abortion in the tense hours before the final roll call.
Differing processes to produce health care reform legislation in the two chambers resulted in markedly different bills that now must be merged by a conference committee.
The House bill, passed Nov. 7, contains a government-run insurer, known as the public option. The Senate version passed yesterday does not. The House version takes a harder line on abortion funding, essentially barring all health insurers in the newly created exchanges from offering abortion coverage.
And the two chambers take very different approaches to fund the historic expansion in health coverage: The House favors an income tax on top earners, while the Senate advocates a tax on high-cost health plans.
Creating a merged bill that can pass both chambers -- and fulfill the top domestic priority for President Barack Obama and congressional Democrats -- will be an enormous challenge.
On big issues, the Senate bill's language would appear more likely to be replicated in the final bill because it passed, 60-39, without a vote to spare. Republican Sen. Jim Bunning of Kentucky did not vote. Also, Sen. Ben Nelson, D-Neb., the final holdout in his caucus, promised to vote against a merged bill that's much different from the one he backed.
"This is very precarious," said Sen. Christopher Dodd, D-Conn., a senior member of his chamber's health committee and likely participant in the conference committee process. "Anybody who thinks this is done hasn't been around here very long. It's a delicate, delicate process."
If the process follows tradition, the leaders of the committees that wrote both bills will be the conferees: Mr. Dodd; Sen. Max Baucus, D-Mont.; Sen. Tom Harkin, D-Iowa; Rep. George Miller, D-Calif.; Rep. Henry Waxman, D-Calif.; and Rep. Charles Rangel, D-N.Y.
But Mr. Reid and Ms. Pelosi will certainly have a hand in the process, as will the White House, and the form the conference will ultimately take remains unclear.
The committee leaders, Mr. Dodd noted, have collaborated for years. Mr. Dodd, Mr. Baucus, Mr. Harkin, Mr. Miller and Mr. Waxman even were in the same congressional class, sworn in as House members on Jan. 3, 1975.
"We have known each other, worked with each other literally for years," Mr. Dodd said. "So we come into this with a lot of understanding of each other and a desire to get this done."
The three House leaders issued a joint statement expressing support after yesterday's Senate vote, saying, "While there are clear differences between the bills passed by the Senate and the House, both bills will bring peace of mind and fundamental health care coverage to millions of Americans who are currently uninsured."
Perhaps the most divisive difference is over abortion.
The Senate compromise, negotiated in part by Sen. Bob Casey, D-Pa., to help sway Mr. Nelson, stiffens a wall between taxpayer funds in the exchanges and private premiums that would pay for abortion coverage. It also allows states to ban insurers in their individual exchanges from offering abortion coverage.
Anti-abortion House members passed a stricter amendment, written by Rep. Bart Stupak, D-Mich., that banned anyone who receives a government health insurance subsidy from purchasing a plan that covers abortions. Anything less, pro-life groups argue, would be backdoor government funding of abortions -- which is illegal.
Mr. Stupak and a couple dozen House members -- including Rep. Kathy Dahlkemper, D-Erie, who signed on as a co-sponsor -- threatened to vote against the bill if it didn't include the Stupak amendment. They won the standoff.
The Senate voted against a similar amendment offered by Mr. Nelson before striking the compromise that earned the support of abortion-rights advocates like Sen. Barbara Boxer, D-Calif.
The compromise did not appease supporters or opponents of abortion among House Democrats, and both groups have enough members that a revolt within their ranks could kill the bill. The House bill passed 220-215, with one Republican vote.
Mr. Casey was a key player in trying to find middle ground on the issue in the Senate, and he expects to be involved once again. "I hope to be able to have an impact on a whole series of issues," he said. "Certainly, on children and the abortion issue as well as some of the issues we didn't get to in our amendments."
A larger policy point of contention concerns the public option. Many Democrats -- and a majority of Americans, according to opinion polls -- support a government-run insurer that would compete with private plans.
Some moderate senators, including Sen. Joseph Lieberman, I-Conn., opposed the plan as a potential money pit and an overreach of government. That was enough to get Mr. Reid to remove the public option in favor of national, privately run nonprofit plans.
Many House Democrats remain steamed by the change. "I don't think anybody in the House likes what the Senate's doing," Rep. Mike Doyle, D-Forest Hills, said in a recent interview during the Senate negotiations.
Rep. Joe Sestak, D-Delaware County, who is mounting a Democratic primary challenge for the seat held by Sen. Arlen Specter, wrote a letter last week to Ms. Pelosi asking her to fight in conference for the public option, along with other provisions in the House version.
Those aims could be achieved if Mr. Obama is forceful in guiding the conference, Mr. Sestak said. The president "should be intimately involved in this because it's so critical to the future," he said. "This isn't hands-off anymore. His hand needs to be stronger on the tiller of what's good for America."
Mr. Sestak also is advocating that the House's tax on high earners be included in the final bill, instead of the Senate tax on high-cost health plans. The congressman said the Senate's method would hurt middle-class Americans. Organized labor also strongly opposes the tax on so-called Cadillac plans, as unions often negotiate for better health plans in exchange for wage concessions.
The Senate horse-trading also left a bad taste in the mouth of Mr. Sestak and other House Democrats, who have cast a skeptical eye on provisions like the full Medicaid reimbursement for Nebraska, which was written in at the end of the process to help secure Mr. Nelson's vote.
While some Senate provisions upset liberal House Democrats, the bill could earn support from centrists who did not back their chamber's version.
Rep. Jason Altmire, D-McCandless, may fall into that category. He said last week that he was warming to the Senate bill because it gives the Health and Human Services secretary authority to impose new cost-cutting measures now included in the bill as demonstration projects. The House bill would require that such measures, including a shift from the traditional fee-for-service model, be approved by Congress.
Mr. Altmire said the fragile Senate coalition means that the big issues in the final version likely must remain close to what the Senate crafted. Assuming unanimous GOP opposition, Senate Democrats have no margin for vote losses, while House leaders can woo other members of their caucus, such as Mr. Altmire.
Bills have died before in conference committee, but Mr. Altmire said he thinks this one will pass because of the urgency attached to it by the White House and both chambers of Congress.
"I just believe that cooler heads will prevail on all these issues," he said. "And the people will realize that there is a need, if the bill is done right on the health care side, to get this bill done."
First Published December 27, 2009 12:00 am
