Sure, there are House Democrats who are choking on that very thought — folks like Rep. Anthony Weiner (N.Y.), who thinks parts of the bill are too conservative, and Rep. Bart Stupak (Mich.), who thinks other parts are too liberal. But the alternative is to have Democrats take to the campaign trail this year with the following message: “Yes, Congress spent most of 2009 haggling over health care as unemployment leapt, but it was just too hard to get the thing passed.” Not exactly the inspirational bulletin that wins elections.

Which leaves the question: What exactly would House Democrats be forced to swallow if they agree to adopt the Senate bill as it stands? A few biggies:

Funding: A central disagreement between House and Senate Democrats has been how to pay the tab of covering tens of millions of uninsured Americans. House leaders proposed a 5.4-percent tax hike on those earning more than $500,000 per year, while the Senate bill proposed a 40-percent tax on high-cost insurance plans. The loser here is the labor movement, which had recently negotiated a deal with Democratic leaders of both chambers to exempt union-negotiated plans from being hit by that tax for another eight years — a deal that would be nullified if the existing Senate bill becomes the final word. Even so, some of the labor leaders who pushed for that deal are already urging the House to pass the Senate proposal.

Illegal Immigrants: Members of the Hispanic Caucus lose big here. While both chambers have proposed to ban illegal immigrants from receiving subsidies on the exchanges, the Senate bill takes the strange step of also prohibiting those folks from paying full price for exchange coverage through U.S. companies using U.S. dollars. (The House bill would allow those unsubsidized purchases). The result? There will probably be more uninsured illegals making the emergency room their primary care stop — the very type of behavior that health reform was supposed to discourage.

Kids’ Care: At issue here has been the fate of the Children’s Health Insurance Program, the state-federal partnership that covers roughly 9 million low-income kids nationwide. The House has proposed to do away with CHIP at the end of 2013, while the Senate proposal would keep it alive and provide new funding through 2015. Many children’s welfare advocates, concerned that kids would lose coverage if they’re shifted to more expensive private plans on the exchange, prefer the Senate provision.

Abortion: Both the House and Senate bills include new restrictions on coverage of abortion among plans operating on the exchanges. The House provision, sponsored by Stupak, would prohibit such coverage on exchanges altogether; the Senate bill is a touch less strict, allowing abortion coverage but requiring women to write a separate check for those services to ensure that no federal funds go toward them. This allegedly leniency is the reason Stupak is threatening to vote against the Senate bill.

Anti-Trust: For more than six decades, the nation’s insurance companies have enjoyed an exemption to federal anti-trust laws, justifying the perk with the argument that sharing information encourages smaller companies to enter otherwise unknowable new markets. But critics say the exemption simply allows the companies to collude on pricing at the expense of competition. The House bill eliminates the anti-trust exemption; Senate leaders — bowing to Sen. Ben Nelson (D-Neb.), a former insurance company CEO — stripped that provision from their bill. Advantage: insurance industry.

That $80 Billion Pharmaceutical Deal: Hoping to get the nation’s drug makers to support health reform before the heavy negotiating began, Sen. Max Baucus (D-Mont.) made a pact last summer with the pharmaceutical lobby: If the drug makers put up $80 billion toward reform over the next decade, the deal went, Democrats would withhold support for a proposal allowing states to negotiate drug prices on behalf of their lowest income seniors. The White House quickly signed on, but House Democrats didn’t. Instead, Rep. Henry Waxman (D-Calif.) went ahead and included in the House bill the very provision that Baucus and Obama vowed to oppose. Adopting the Senate bill leaves the deal with Big Pharma intact. Advantage: Pfizer.

The Public Option: House liberals, behind Speaker Nancy Pelosi (D-Calif.), won a major victory in the lower-chamber bill by including a provision to create a national, not-for-profit insurance plan to compete with private companies. The Senate bill contains no such thing. This, on the surface, appears to be a big loss for House Democrats. But in reality, the merged bill would likely have dropped the provision anyways, because it doesn’t have the support of 60 senators.

All of this, of course, could change as the years go by and Congress dabbles at the edges of these provisions. But for the time being, it’s looking like the more industry-friendly Senate bill will form the backbone of health care reform.

Waxman, though, wasn’t a part of those negotiations and has said that he doesn’t feel obliged to honor a deal to which he never agreed. His latest comments, via FireDogLake, came yesterday:

“The President and the Senate made very poor deals with PhRMA,” Waxman said, explaining the deal whereby the drug industry offered $80 billion dollars in givebacks in exchange for their support for the overall bill. “Rahm (Emanuel) said that’s OK,” Waxman said, but he noted that under the deal, the industry would get millions of new customers and Americans would still pay far more than the rest of the industrialized world for prescription drugs.

“I have said that I am not bound by that agreement,” Waxman said, noting all the provisions in the House bill which go further than the PhRMA deal. … Waxman said that in the conference, where he expected the President to sit down personally, “I’m going to say, ‘Are we interested in protecting the profits of the drug companies or protecting seniors?’”

Although the House does not reconvene until Jan. 12, and the Senate is out until the Jan. 19, leaders from both chambers have returned to Washington this week to begin ironing out the differences between the chambers’ health reform bills, of which Waxman’s drug provision is just one.

Yet two days before that high-profile White House announcement, Senate Finance Committee Chairman Max Baucus (D-Mont.) was trumpeting the fact that he had negotiated the deal. There were no secrets being kept here. Indeed, here’s part of Baucus’ June 20 statement:

Senate Finance Committee Chairman Max Baucus (D-Mont.) announced he secured an $80 billion commitment from the pharmaceutical industry to reduce Medicare prescription drug costs for seniors. The deal struck by Baucus and the nation’s pharmaceutical companies with the participation of the White House includes a provision to narrow the gap in coverage, often called the “doughnut hole,” with payments from the drug companies to cover up to 50 percent of the cost of brand name medicine in Medicare’s Part D prescription drug program.

So it was Baucus to cut the deal and the White House to endorse it. OK, fine. What makes this notable is that Baucus more recently seems to have forgotten that he was the primary negotiator on behalf of the Democrats. For example, when the Finance Committee shot down an amendment to the health reform bill that would have fully closed the doughnut hole, Baucus voted against it because he said it would undermine the deal with Big Pharma — a deal he placed squarely on the shoulders of the administration.

“We have to find some other time, some other way [to close the doughnut hole],” Baucus said. “The White House did reach an agreement.”

It’s worth remembering that, as Senate leaders are now promising to close the doughnut hole 100 percent, it was those same leaders who limited their options in paying for it.

The Democratic opponents argued that the drug re-importation amendment — sponsored by Sen. Byron Dorgan (D-N.D.) and Olympia Snowe (R-Maine) — would threaten the safety of Americans. Yet, as The Washington Post’s Dana Milbank points out today, it’s difficult to argue that position with a straight face considering that a large bulk of the ingredients for the drugs manufactured domestically originate from the same countries thought to be the most unsafe.

These [safety] arguments don’t hold up well, considering that 40 percent of the active ingredients in American prescription drugs come from India and China, and that the latter slipped tainted heparin past the FDA. But fright was about the best argument opponents could use to defeat a popular proposal that would save the federal government $19 billion over 10 years.

The hypocrisy wasn’t lost on Sen. Sherrod Brown (D-Ohio), who said so on the chamber floor just before yesterday’s vote.

This is not about importing drugs from China or India or Mexico, where drug safety standards are not up to par, although American drug companies have outsourced a lot of their manufacturing to those countries and [we've] found all kinds of problems with the ingredients that they import into American drugs.

But that’s not the issue here. That only underscores the hypocrisy of U.S. drug companies in opposing the Dorgan amendment.

No matter. Pressured by the drug lobby, Senate lawmakers shot down the provision 51 to 48 — well shy of the 60 needed to pass the measure.

The count was 51 to 48, nine shy of the supporters needed to overcome a filibuster. Thirty Democrats and Independent Sen. Joe Lieberman (Conn.) voted to kill the provision.

The amendment, sponsored by Sens. Byron Dorgan (D-N.D.) and Olympia Snowe (R-Maine), has been a week-long thorn in the side to Democratic leaders — not because they opposed the provision, but because it threatened to undermine a deal cut earlier in the year between the White House and the nation’s pharmaceutical companies. Under that agreement, the drug makers pledged up to $80 billion toward health-care reform over the next decade if Democratic leaders would withhold their support for several proposals that would cut further into the companies’ profits, including the drug re-importation provision. As a result, White House officials in recent days had urged Democrats to oppose the Dorgan-Snowe amendment, with the FDA writing a letter to senators warning that the agency “does not have clear authority over foreign supply chains.”

Under the provision, Americans would be allowed to buy FDA-approved drugs from certain countries with well-established drug-safety regimes, such as Canada, Australia Japan and those in Europe. Supporters say it will save U.S. consumers roughly $80 billion over the next decade. The Congressional Budget Office estimates that the federal government would save an additional $20 billion over the same span, the result of savings to federally funded programs like Medicare.

The reason is clear: Americans pay more for pharmaceuticals than any other country in the world. Dorgan pointed out that the same Nexium prescription that costs $424 in the U.S. would cost just $67 in France, $40 in the United Kingdom, $37 in Germany and $36 in Spain.

“We shouldn’t be paying the highest prices in the world for prescription drugs,” Dorgan said. “I think it’s flat-out unfair.”

Aside from Snowe, the provision attracted the support of such influential Republicans as Sens. John McCain (Ariz) and Charles Grassley (Iowa), the ranking member of the Finance Committee.

Opponents of drug re-importation argue (1) that there’s no good way to ensure that imported drugs are safe for American consumers, and (2) that the resulting loss in drug-maker revenues would curb the research conducted by those companies, leading to the discovery and development of fewer new innovative drugs.

Critics of the latter are quick to point out that the pharmaceutical industry is perennially among the most profitable. Indeed, last year it ranked third among all industries, reaping 19.3 cents in profits for every $1 in revenues, according to Fortune Magazine.

Senate lawmakers on Tuesday also killed a weaker substitute to the Dorgan-Snowe amendment, sponsored by Sens. Frank Lautenberg (D-N.J.) and Robert Menendez (D-N.J.). Both argued on Tuesday that the Dorgan amendment simply wouldn’t guarantee that the imported drugs were safe. (Strangely enough, both also voted in 2007 in favor of proceeding to a similar Dorgan-Snowe bill.)

“It’s regressive,” Menendez said Tuesday. “It hearkens back to a time when the lack of sufficient drug regulation allowed people to sell snake oil and magic elixirs that promised everything and did nothing.”

Critics in and out of the Capitol, however, say the substitute was so stringent that it will effectively prohibit drug importation. The AARP, which for years, has endorsed the Dorgan-Snowe amendment, argued that the Lautenberg-Menendez provision represents “a thinly veiled effort to undermine importation and preserve the status quo of high drug prices.”

The substitute amendment was shot down by a count of 56 to 43.

The debate proved a pickle for President Obama, who had endorsed reimportation on the campaign trail but was forced to change his tune this year for fear of losing the pharmaceutical lobby’s support for the underlying health-care reform bill.

“When you become president, you realize that the sound bites don’t always work in reality,” Ken Johnson, senior vice president of the Pharmaceutical Research & Manufacturers of America, told The Washington Post this week.

The money that the drug makers have pumped into Congress in recent months couldn’t have hurt their case. Indeed, the industry has contributed roughly $7.5 million to lawmakers this year, with 57 percent going to Democrats — up from 33 percent in the 2006 cycle, and 50 percent in the 2008 cycle – according to the Center for Responsive Politics.

In terms of lobbying, the dollar figures are even higher. PhRMA, representing the brand-name drug makers, has spent more than $20 million lobbying Congress this year alone, CRP says.

“It’s really regrettable that the special interests prevail, and the power of the pharmaceutical lobby,” McCain said Tuesday. “It’s not one of the most admirable chapters in the history of the United States Senate.”

During an hourlong oral argument, Merck was in the unusual position of arguing that investors should have filed their lawsuits earlier because there was an overwhelming amount of public information available by late 2001 suggesting the possibility the company committed securities fraud. Merck, however, also argued that the investors don’t have enough evidence to make a case against the company.

Merrill Goozner, the great health care reporter behind GoozNews, provides a bit of historic context to the case.

What happened in 2001? Merck-funded researchers published the original clinical trial showing a fourfold increase in heart attack risk from the pain reliever. At the time, those results were explained away by Merck and the researchers with the suggestion that the comparison drug was cardioprotective.

In other words, the risks should have been known to investors even though Merck was denying those risks existed.

The absurdity wasn’t lost on Justice Anthony Kennedy, who told a Merck lawyer, “Companies can’t have it both ways.”

In a letter yesterday to GAO, Reps. Henry Waxman (D-Calif.), Charlie Rangel (D-N.Y.), Pete Stark (D-Calif.) and John Lewis (D-Ga.) voiced concerns that the companies are “artificially raising prices for certain pharmaceutical products in expectation of new reforms that could otherwise reduce prescription drug prices or price growth by encouraging patients and the government to be more efficient purchasers.”

Any price gouging is unacceptable, but anticipatory price gouging is especially offensive. We request that the GAO prepare on an expedited basis a report that analyzes recent trends in prescription drug pricing. In addition, we request that you prepare a proposal to ensure ongoing monitoring of pharmaceutical manufacturer pricing practices, and periodically report to the Congress on your findings.

Not that the pharmaceutical industry is taking the Times’ report sitting down. In a statement released Monday, Ken Johnson, senior vice president of the Pharmaceutical Research and Manufacturers of America, said the price increases represent “the natural result of market forces.”

But Baucus wasn’t the only Democrat on the panel to vote against the Democratic proposal. Sens. Robert Menendez (D-N.J.) and Tom Carper (D-Del.) were also vocal opponents of the amendment, and offered “no” votes to back their words.

It’s not tough to surmise the reasons.

New Jersey is one of the nation’s great pharmaceutical hubs, housing such drug giants as Johnson & Johnson, Merck, Wyeth and Schering-Plough. Earlier this year, Bausch and Lomb moved in as well.

As for Carper’s Delaware, it boasts the headquarters of AstraZeneca, a top-10 drug maker with revenues topping $31 billion last year.

And the industry has never been shy about showering local lawmakers with campaign cash. Indeed, Menendez has accepted more than $357,000 from the pharmaceutical industry over his congressional career, according to the Center for Responsive Politics. Carper, for his part, has taken in nearly $208,000 from drug makers, CRS reports.

Sen. Charles Schumer (D-N.Y.) pointed out yesterday that it was perfectly understandable that the drug makers, being publicly traded companies, would fight to preserve their profit margins for the sake of shareholders. But Congress, Schumer added, is bound to different interests. “We don’t represent their stockholders,” he said. “We represent our stockholders — the U.S. taxpayers.”

Someone please inform the Senate Finance Committee.

“Even with PhRMA’s offer to help seniors,” says Dorgan, “American consumers will continue to pay the highest price for prescription drugs in the world.”

“The fact is,” adds Snowe, “that while the announced savings are substantial, they amount to less than 4 percent of our nation’s annual prescription drug spending, and when you consider that other developed nations pay 35-55% less for their medications, it certainly doesn’t close the gap much.”

For years, the two lawmakers have pushed legislation — anathema to drug companies — allowing U.S. pharmacists to import Food and Drug Administration-approved drugs from some countries abroad, where costs are much lower, and pass the savings on to domestic consumers. (Current law limits the importation of prescription drugs exported by the United States).

Obama, as senator, was a sponsor of the same bill. By agreeing to take an estimated $80 billion haircut under Medicare’s drug benefit, however, the drug makers are surely hoping to stave off further cuts, like the Dorgan-Snowe bill certainly represent.

As it is, Medicare patients are forced to pay the full cost for their prescription drugs when annual expenses fall between $2,700 and $6,154. Under the new agreement, drug companies would pick of 50 percent of the tab for some of those patients falling into Medicare’s so-called doughnut hole.

“This gap in coverage has been placing a crushing burden on many older Americans who live on fixed incomes and can’t afford thousands of dollars in out-of-pocket expenses,” Obama said today, with key Democratic lawmakers and the head of AARP by his side.

Our goal, our imperative, is to reduce the punishing inflation in health care costs while improving patient care. And to do that, we’re going to have to work together to root out waste and inefficiencies that may pad the bottom line of the insurance industry, but add nothing to the health of our nation. To that end, the pharmaceutical industry has committed to reduce its draw on the health care system by $80 billion over the next 10 years as part of overall health care reform.

For the industry, it’s not quite the sacrifice it appears to be. Big Pharma has already profited handsomely from the creation of the prescription drug program. And, as The Hill’s Jeffrey Young points out today, their $80 billion commitment could pay dividends in the end.

Drug makers may be seen as forfeiting $80 billion but the reality is not so simple. Many seniors who would avail themselves of half-price medicines would simply have done without in the absence of discounts.

Indeed, the Kaiser Family Foundation reported last year that about 3.4 million Medicare beneficiaries hit the doughnut hole in 2007, of which roughly 15 percent stopped taking their medicines as a result.

“Moreover,” Young adds, “PhRMA’s collaboration with [Senate Finance Committee Chairman Max Baucus (D-Mont.)] also could shield them from legislative proposals that would cut deeper into their revenue.”

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