Health Care Debate Just Heating Up

Sen. Max Baucus (D-Mont.) (WDCpix)

In the wee hours of last Friday, as the Senate Finance Committee was wrapping up its marathon markup of sweeping health reform legislation, Chairman Max Baucus (D-Mont.) showered a very weary audience with a message of optimism about the fate of the bill.

“We’re within striking distance,” Baucus said. “I can see the light at the end of the tunnel.”

Well, not quite.

Illustration by: Matt Mahurin

After a year’s worth of haggling over health reform proposals, Democratic leaders have a number of formidable hurdles to clear before their hopes become law. From the right, not only do they face a Republican caucus hell-bent on killing their plans and starting anew, but they’ll also have to appease a host of conservative-leaning Democrats wary of hiking taxes, increasing deficits and encroaching on private insurance markets. From the left, they’ll have to placate liberal Democrats threatening to oppose the legislation unless it includes a public insurance plan to compete with private companies. On top of that, there remain two floor debates to manage, hundreds of amendments to consider, countless cost estimates to crunch, and multiple bills to reconcile — first within each chamber and later between them. Casual observers might be surprised to learn that the health reform debate is just heating up.

Eyes on Montana

Baucus will take the first step. Although the Finance Committee completed the amendment process last week, the Congressional Budget Office has yet to estimate the cost of the bill with all its new attachments — an analysis expected to arrive early this week. If the CBO score comes back deficit neutral, committee members will vote on the final bill shortly thereafter. If it doesn’t, the panel will consider more amendments in search of savings, delaying the vote further.

Baucus on Friday said he would leave “a reasonable time” between the arrival of the CBO score and the panel’s vote — time to allow lawmakers, staff and the public to review the proposal. Baucus wouldn’t commit, however, to a 72-hour window.

If the Finance bill passes the committee, as expected, Democratic leaders next face the thorny task of uniting that proposal with another enormous health reform bill passed in July by the Senate Health, Education, Labor and Pensions Committee. That process will be well-watched, if only because the more liberal HELP panel included a public plan, while conservative-leaning Finance leaders opted to create non-profit health cooperatives instead. Baucus has said the public plan simply can’t win 60 votes in the Senate — a position disputed by Sen. Tom Harkin (D-Iowa), the newly installed chairman of the HELP panel, who has said repeatedly in recent weeks that the upper chamber can, indeed, pass a strong public option.

“Reports of the public option’s death are greatly exaggerated,” Harkin said last Thursday.

The World’s Most Deliberative Body

Once unified, the Senate bill will move to the chamber floor, where lawmakers will offer hundreds of amendments to tweak the bill to their liking. Liberal Democrats are already vowing (if need be) to bring up proposals to add a public option, which failed twice in the Finance Committee. Republicans, meanwhile, will likely continue efforts to reduce billions of dollars in proposed insurance subsidies, scale back a proposed Medicaid expansion and eliminate new taxes on high-cost insurance plans. Indeed, Senate Majority Leader Harry Reid (D-Nev.) said last week that the floor debate will have much greater influence on the final bill than the prior unification of the Finance and HELP proposals.

Reid has canceled a week-long Columbus Day recess to allow more floor time for the debate.

Wrangling 60

After weeding through amendments, Democratic leaders will have to wrangle the 60 votes needed to defeat a likely GOP filibuster — no easy task despite the 60-seat majority Democrats currently command. Indeed, Sen. Ben Nelson, a conservative-leaning Democrat from Nebraska, said last week that the health reform bill should be bipartisan — attracting at least 65 votes — to be credible with the American people. Almost every Republican in the chamber, however, is adamantly opposed to the bill’s framework.

“The poll data is pretty constant, pretty steady that people do not think this is a good idea,” Senate Minority Leader Mitch McConnell (R-Ky.) said Friday.

Complicating matters, 91-year-old Sen. Robert Byrd (D-W.Va.) has been in and out of the hospital in recent months, and his availability to vote on the floor is a lingering uncertainty.

Reconciling in the House

Meanwhile, House Democrats face troubles of their own. Although three separate committees — Energy and Commerce, Ways and Means, and Education and Labor — have all passed versions of health reform this year, those bills still need reconciling in order to get a single proposal to the floor. As in the Senate, lawmakers from both sides of the aisle will use the floor debate to try modifying the bill — Republicans in hopes of killing it, and conservative Democrats in hopes of scaling back some of the spending. Several members of the Blue Dog coalition have already said they won’t support a public option, which House Speaker Nancy Pelosi (D-Calif.) is insisting be in the bill.

“We don’t intend to go to the floor without a public option,” Pelosi said last Thursday.

There is some wiggle room here. The Finance Committee last week passed an amendment, sponsored by Sen. Maria Cantwell (D-Wash.), empowering states to create public insurance plans to negotiate with providers on behalf of some of their poorest residents. That’s not the national public option many Democrats were hoping for, but it’s a public option nonetheless. Time will tell if it satisfies the liberals pushing for something more robust.

House leaders have this going for them: there are no filibusters in the lower chamber. If Pelosi can rally enough Democrats, she can ignore the complaints of Republicans and push through a bill.

A House-passed proposal would then have to be reconciled with whatever bill comes out of the Senate, with leaders from both chambers and the White House charged with ironing out the differences. Aside from likely discrepancies over the public plan, leaders will also have to decide whether to leave intact an $80 billion deal between the pharmaceutical industry and Baucus — a deal House leaders have said they aren’t bound to honor.

The conferenced bill would require another vote of approval in both the House and Senate. If it survives that gauntlet, it would move to the White House for the president’s signature. Obama himself appears aware that there’s plenty of work remaining. “We have a long way to go,” he said in a statement last Friday.

Sen. Olympia Snowe (R-Maine) echoed those sentiments, telling reporters early Friday morning that the process has really just begun.

“This is the first step in a long journey.”