[The legislation] is important, medical experts say, because it opens the door to medical care for millions of people who were shut out because they could not afford insurance or because they had pre-existing conditions or had reached lifetime caps on insurance payments. But controlling overuse is not its focus.

The reason is clear. While the reforms include additional funding for comparative effectiveness studies — research that tests different treatments for the same ailment to discover which work best on which patients — charges of rationing prevented lawmakers from stipulating that the more ineffective treatments be weeded out.

The argument of those rationing critics goes something like this: Even if a pill or test or procedure is found to be ineffective in 99 cases out of 100, it should remain available for that 1 percent of patients that respond to it. And that means that insurers (both public and private) will still have to cover it in all cases, even when there’s no health benefit at all.

“The minute you attack overutilization you will be called a Nazi before the day is out,” Uwe E. Reinhardt, a health economist at Princeton University, told the Times.

As proof of that, look no further than the outcry — and quick congressional intervention — that accompanied last fall’s scaled-back mammogram recommendations by an independent panel of preventive care experts.

The issue has split some of the most powerful members of the medical-industrial complex, with insurers in support of stronger links between effectiveness and coverage (i.e., they don’t want to be obligated to cover treatments with little medical value) and the pharmaceutical and medical device industries very much opposed (because they don’t want any restrictions on coverage of their products, even the ineffective ones.)

It’s a thorny issue, for sure. If you or a loved one is in that anomalous 1 percent of patients that responds to a drug, you don’t want anyone telling you it’s unavailable. Yet health care spending was $2.5 trillion last year, representing roughly 17.3 percent of the nation’s economy. And that figure is projected to jump to $4.5 trillion in just 10 years, representing 19.3 percent of projected GDP in 2019.

Robert D. Truog, a medical ethics professor at Harvard Medical School, told the Times that something has to give. “The point is that as long as a health care system has anything less than an infinite budget, there is a need to decide which types of health care will be funded and which will not.”

Congress, though, has so far declined to do so.

The vote was a technicality. The House had passed the bill Sunday night, sending it over to the Senate. But obscure rules governing the reconciliation process forced Senate lawmakers to strip two small provisions before they passed the bill this afternoon. The changes meant that the House would have to approve the proposal again before it could go to the president’s desk — which it did by a vote of 220-207.

Here’s a recap of how reconciliation tweaks the larger bill:

1) Funding: The Senate bill would hit the wealthiest Americans — individuals earning more than $200,000 and families earning more than $250,000 — with a 0.5 percent increase in the Medicare payroll tax. The reconciliation bill would add a 3.8 percent tax on unearned income — a category that includes things like interest, dividends and capitol gains on investments.

The Senate bill also applies a 40 percent tax (beginning in 2013) to the highest-priced insurance plans — those costing more than $8,500 for individuals and $23,000 for families. The reconciliation bill keeps the tax, but hikes the dollar threshold that trigger it — to $10,200 for individuals and $27,500 for family plans. In both the Senate and reconciliation bills, the thresholds are even higher for those in high-risk jobs like coal mining and firefighting. The reconciliation bill also postpones the tax until 2018.

2) Doughnut Hole: As part of its $80 billion deal with Sen. Max Baucus (D-Mont.), the pharmaceutical lobby agreed to cut the cost of name-brand drugs by 50 percent when seniors hit the doughnut hole, which is the not-meant-to-be-flattering name of the coverage gap in Medicare’s prescription drug benefit. And that’s where the Senate bill leaves it.

The reconciliation bill builds on that foundation, giving seniors in the doughnut hole an additional $250 toward their drugs in 2010, and then hiking that amount incrementally until the doughnut hole is fully closed by 2020.

3) Individual Mandate: The Senate bill requires most Americans to buy health insurance or pay a financial penalty of either $750 or 2 percent of income, whichever is larger. The reconciliation bill would alter the penalty slightly, to the larger of $695 or 2.5 percent of income.

4) Medicaid Rates: While expanding Medicaid coverage to include most folks living below 133 percent of the federal poverty level, the Senate bill would leave Medicaid rates alone. This is a problem, because Medicaid rates are so low that more and more doctors are refusing to see those patients. Recognizing that there’s little value in a health insurance program that doctors don’t accept, House leaders in their reconciliation bill hiked Medicaid rates for primary care services to at least the level that Medicare pays.

5) Cornhusker Kickback: The Senate bill includes the now infamous sweetheart deal that Democratic leaders carved out to win the vote of Nebraska Democrat Ben Nelson. Under that provision, the federal government would pay 100 percent of the cost of expanding Medicaid in Nebraska — forever. (By contrast, the other states would begin paying a portion of those costs over time.)

The reconciliation bill strikes the Cornhusker Kickback dead.

The reconciliation bill also eliminates $61 billion in federal subsidies to the private middlemen who make student loans.

Senate Democrats had been hoping to defeat all of the amendments proposed by Republicans and to prevail on parliamentary challenges so that they could approve the measure and send it to President Obama for his signature. But the bill must comply with complex budget reconciliation rules, and Republicans identified some flaws.

One of those flaws involved the maximum reward for Pell grants, the Times reported, while the second was “a technical matter” that Democrats described as “mostly insignificant.” Neither provision is thought to threaten the underlying bill.

Fixing the flaws, though, means changing the proposal. And because the House and Senate must pass an identical proposal before it can move to the president’s desk, House Democrats will have to stage another vote on the reconciliation package after it passes the Senate later this week.

Congress is scheduled to leave town Friday for a two-week Spring recess. But earlier this week, House Majority Leader Steny Hoyer (D-Md.) told reporters that if there were changes to the bill in the Senate, “our members are prepared to vote.” He was talking about staying in town as long as it takes to send the reconciliation bill to the president.

On Tuesday, President Obama signed the larger health reform bill, making it law.

The best amendment so far is a proposal from Sen. Tom Coburn (R-Okla.) “prohibiting coverage of Viagra for child molesters and rapists.”

Why just Viagra, and not everything in the erectile-dysfunction family? Because he knows it won’t pass, and because Viagra would create a much better jingle than Sildenafil. You can already see the ads on the campaign trail: “Democrats voted to sustain the steady flow of Viagra to child molesters — with taxpayer dollars!”

More amendments after the jump:

• David Vitter (La.): To repeal the government takeover of health care. (#3553)
• Vitter: Prohibiting use of funds to fund the Associate of Community Organizations for Reform Now (ACORN). (#3554)
• Coburn: To require that each new bureaucrat added to any department or agency of the Federal Government for the purpose of implementing the provisions of the Patient Protection and Affordable Care Act be offset by a reduction of 1 existing bureaucrat at such department or agency.  (#3557)
• Coburn: To help the President keep his promise that Americans who like the health care coverage they have now can keep it. (#3559)
• Coburn: To require all Members of Congress to read a bill prior to casting a vote on the bill. (#3566)
• Robert Bennett (Utah): To protect the democratic process and the right of the people of the District of Columbia to define marriage. (#3568)

1) President Obama at 11:15 this morning will sign the Senate’s sweeping health reform bill, which the upper chamber had passed on Christmas Eve and the House approved Sunday night. That moves the second House-passed bill — a reconciliation proposal that amends the larger Senate bill — to the Senate this afternoon. The upper chamber is expected to convene at 2:15 p.m.

2) Republicans, depending on their mood, could put up a few procedural hurdles to stall the process of bringing the bill to the floor, and McConnell’s office said there could be a few “parliamentary things” brought up during this process. But because this is a reconciliation bill, the filibuster isn’t an option. And both sides anticipate that the bill will be on the calendar later today.

3) Once the bill is on the floor, 20 hours of debate are required before the final vote. (That’s actual, active, in-session debate time.) During those 20 hours, however, lawmakers can offer amendments, and voting on those amendments won’t count toward the 20-hour clock. Because any alteration of the reconciliation bill would send the measure back to the House, Democrats aren’t likely to offer any amendments. Republicans don’t have the same motivations, though, so it’s likely we’ll see the 20 hours of debate broken up through the week by proposed GOP add-ons.

4) After the 20 hours has expired, the so-called vote-o-rama begins. That’s the term for the amendment free-for-all where any member of either party can propose changes to the bill. The only rule governing those amendments is that they have to be germane to either the Finance or HELP committees — the two panels through which the health reforms passed last year. That opens the door to an enormous number of amendments (the jurisdictions of those two committees are huge). But two factors will make this process less eternal than it might sound at first. (1) Once the vote-o-rama begins, it’s non-stop until the end. Meaning the Senate can’t adjourn, rest up and come back for more. And (2) the Easter recess is scheduled to begin on Friday. No lawmaker wants to be in Washington any longer than he or she has to, and if it’s apparent early that the Democrats are united in killing every GOP amendment, Republicans will likely recognize the futility in prolonging the process.

For a sense of what would happen if reconciliation is derailed and the Senate bill alone becomes law, look here.

1) Insurance Subsidies: The Senate bill, while requiring most Americans to buy health insurance, also subsidizes plans for those living below 400 percent of the federal poverty level ($88,200 for a party of four). The subsidies would come on a sliding scale such that premiums would be capped at 2.8 percent of income for those living at 134 percent of poverty, and 9.8 percent of income for those living between 300 and 400 percent of poverty.

The reconciliation bill increases those subsidies for most income brackets. Those living between 300 and 400 percent of poverty, for example, would pay premiums capped at 9.5 percent of their income.

2) Funding: The Senate bill would hit the wealthiest Americans — individuals earning more than $200,000 and families earning more than $250,000 — with a 0.5 percent increase in the Medicare payroll tax. The reconciliation bill would add a 3.8 percent tax on unearned income — a category that includes things like interest, dividends and capitol gains on investments.

The Senate bill also applies a 40 percent tax (beginning in 2013) to the highest-priced insurance plans — those costing more than $8,500 for individuals and $23,000 for families. The reconciliation bill keeps the tax, but hikes the dollar threshold that trigger it — to $10,200 for individuals and $27,500 for family plans. In both the Senate and reconciliation bills, the thresholds are even higher for those in high-risk jobs like coal mining and firefighting. The reconciliation bill also postpones the tax until 2018.

3) Doughnut Hole: As part of its $80 billion deal with Sen. Max Baucus (D-Mont.), the pharmaceutical lobby agreed to cut the cost of name-brand drugs by 50 percent when seniors hit the doughnut hole, which is the not-meant-to-be-flattering name of the coverage gap in Medicare’s prescription drug benefit. And that’s where the Senate bill leaves it.

The reconciliation bill builds on that foundation, giving seniors in the doughnut hole an additional $250 toward their drugs in 2010, and then hiking that amount incrementally until the doughnut hole is fully closed by 2020.

4) Individual Mandate: The Senate bill requires most Americans to buy health insurance or pay a financial penalty of either $750 or 2 percent of income, whichever is larger. The reconciliation bill would alter the penalty slightly, to the larger of $695 or 2.5 percent of income.

5) Medicaid Rates: While expanding Medicaid coverage to include most folks living below 133 percent of the federal poverty level, the Senate bill would leave Medicaid rates alone. This is a problem, because Medicaid rates are so low that more and more doctors are refusing to see those patients. Recognizing that there’s little value in a health insurance program that doctors don’t accept, House leaders in their reconciliation bill hiked Medicaid rates for primary care services to at least the level that Medicare pays.

6) Cornhusker Kickback: The Senate bill includes the now infamous sweetheart deal that Democratic leaders carved out to win the vote of Nebraska Democrat Ben Nelson. Under that provision, the federal government would pay 100 percent of the cost of expanding Medicaid in Nebraska — forever. (By contrast, the other states would begin paying a portion of those costs over time.)

The reconciliation bill strikes the Cornhusker Kickback dead.

Senate leaders are hoping to pass the reconciliation bill before the Easter recess, which begins Friday. Republican leaders, though, are working to prevent that from happening.

Tea Partiers on Capitol Hill this weekend (Photo by David Weigel)

The Tea Party activists huddled on the south lawn of the Capitol got the news of health care reform’s passage in the cruelest way. As their enthusiasm had flagged, a small group of pro-health care reform activists had nestled into space right next to the Capitol wall. Outnumbered ten to one, none of them looking a day under thirty, they learned via Twitter when the House crossed the 216 vote mark to pass the Senate version’s of health care reform. Bouncing up and down, waving faded and crumpled signs, they mugged for TV cameras. That prompted a few Tea Party activists to lower a massive American flag between the pro-”Obamacare” forces and the lights and lenses. The liberals cried foul. Park police broke the tension. And the Tea Partiers looked back at the Capitol and chanted “Na na na, hey hey, goodbye.” Just because the bill had passed didn’t mean they couldn’t kill it.

[GOP1]“The most important thing to remember,” said Jenny Beth Martin of Tea Party Patriots, throwing her hoarse voice into a megaphone, “is that the fight for freedom, it never ends! In the next days, you’re going to find out what you can do to stop it in the Senate. If it becomes law, we’re going to fight to repeal it in the next Congress!”

The roughly 250 activists, some of them wiping away tears, cheered for Martin, then belted out “The Star-Spangled Banner,” then recited the pledge of allegiance. Rep. Pete Hoekstra (R-Mich.) slipped through their ranks unnoticed, then politely took the megaphone for himself.

“The American people lost today,” said Hoekstra, “but we’ve got some opportunities. We’ll fight this in the courts. We’ll fight this at the ballot box. Hopefully, in January, we’ll have enough votes to begin the process of repealing this bill.” The crowd cheered as Hoekstra — who is leaving Congress to run for governor of Michigan — walked out and Rep. Steve King (R-Iowa) walked in.

“I just came down here,” said King, “so I could say to you, God bless you.”

“God bless you!” shouted one activist.

“We’re here whenever you need us!” said another activist, patting King on the back.

“You are the awesome American people,” said King. “If I could start a country with a bunch of people, they’d be the folks who were standing with us the last few days. Let’s hope we don’t have to do that! Let’s beat that other side to a pulp! Let’s chase them down. There’s going to be a reckoning!” One by one, the people gathered outside the Capitol, who’d spent the day cheering and singing whenever Republicans appeared and egged them on, came to the realization that they’d been beaten in this round. They’d have to redouble their efforts.

As King spoke, FreedomWorks campaign director Brendan Steinhauser looked on, pondering over the last year of Tea Party activism — especially the last two months. On January 19, the Tea Parties helped elect Sen. Scott Brown (R-Mass.) to the seat of the late Ted Kennedy and — so they thought — put the stake in health care reform. “ObamaCare,” wrote The Weekly Standard’s Fred Barnes after the Brown victory, “is dead with not the slightest prospect of resurrection.” A popular sign at the evening’s rally, spotted again at the Saturday rally that Steinhauser helped organize, portrayed President Obama as a vampire climbing out of a coffin marked “health care.” Opponents of health care reform, pondered Steinhauser, did not quite see the health care bill recovering and passing as it did.

“The media’s going to promote it as a victory for Democrats,” he said. “But I think enough people are out there — maybe they weren’t following it as closely today — who are going to pay attention now. We’re looking at what’s going to happen in the states, we’re possibly looking at legal challenges.”

Tea Party activists and Republicans were in total agreement after the call of the vote — they would go all-in on legal and legislative attacks on health care reform. But the lateness with which they considered a post-Brown Democratic victory on health care, and the speed with which they moved to a hardcore responses, mirrored the decision-making process of Democrats just a few months ago.

“We were roommates in Massachusetts, working for Brown,” said Mark Falzone, a New Jersey activist, pointing to his friend, Virginia activist David Morchek. “When we left there, we thought all this crap was over.”

Democrats had been slow to see the threat posed by Brown, a talented politician facing a creaky establishment and weak candidate, with the issues on his side. And once Brown won, Democratic leaders picked up the suggestion their left-leaning allies had been making all year — to break the logjam created by the GOP’s abuse of Senate procedure and pass a bill through the up-or-down reconciliation process. Similarly, Republicans and Tea Partiers saw Brown’s election as a game-changing event that would scare Democrats away from a comprehensive health care bill. When it became clear that Democrats would push forward, the Tea Partiers mobilized quickly. For much of Saturday and Sunday, they hoped that their response would keep Democrats from cobbling together the votes they needed. But around 4 p.m., when news got out that Rep. Bart Stupak (D-Mich.) would accept a compromise on abortion funding and swing his support to the bill, the mood outside the Capitol grew dark, and the activists who’d been talking all this time about Constitutional challenges, and the essential evil of President Obama, got vindication.

“We had a dream,” said Deborah Welch, who joined her husband Chris on an eight-hour drive to the rally from Dayton, Ohio. “All of the Democrats and all of the Republicans were on this teeter-totter, and they were falling off. Nancy Pelosi was hanging on to Barney Frank by his pants — his pants were coming down. And Obama was standing out in the grass, watching it. What that meant was that Obama doesn’t care what happens to Congress. He has an agenda. He wants to collapse America.”

Joe Chalmers, an unemployed activist who’d come to the rally in camouflage, told TWI he wasn’t in the military — he “didn’t want to fight for oil.” But he won both criticism and nods of the head as he talked to protesters about the need for a real uprising against the Democrats. As a Democratic victory looked more and more likely, Tea Partiers got more ornery about the liberals who’d showed up to cheer for reform and take commemorative photos of what, to them, looked like the end of a year of agenda-slowing right-wing activism.

“Look at that idiot!” said Linda Cocsy, a New Yorker who’d spent the weekend in Washington for the protests, pointing at one of the young Democrats who’d infiltrated the protest, holding up a pro-reform sign provided by a pro-choice Catholic group. “This one, here with the stupid grin on his face! He looks likes he’s brainless. You look at these people and, they really look like jerks. You look at the other people, with the Don’t Tread on Me [flags], and they look like real people!” Cocsy stared off at another protester, waving a sign he’d picked up from a pro-immigration reform protest that had broken up around the time that Stupak announced his flip. “I just wanna kill them!” said Cocsy.

That rhetoric didn’t have too many takers. After passage, after King had finished talking, Rep. Michele Bachmann (R-Minn.) adressed the crowd and beseeched it to commit “no violence” as it fought for health care repeal. Instead, they needed to focus on the elections, and on holding Democrats accountable.

“Remember who caused this bill to pass!” said Bachmann. “Not only was it Nancy Pelosi, it was the so-called pro-life Democrats, who can no longer call themselves pro-life.”

Former Republican House speaker Newt Gingrich said Obama and the Democrats will regret their decision to push for comprehensive reform. Calling the bill “the most radical social experiment . . . in modern times,” Gingrich said: “They will have destroyed their party much as Lyndon Johnson shattered the Democratic Party for 40 years” with the enactment of civil rights legislation in the 1960s.

So by Gingrich’s logic, lawmakers should really just shy away from the toughest issues of the day because changes in the status quo might haunt their political careers. And this guy wants to be president?

Update (March 22): Gingrich has contested the Post’s characterization of his comments, claiming that he never meant to imply that the Civil Rights Act was a bad move on Johnson’s part. That claim led Post reporter Dan Balz to issue this addendum on March 22. (More about that here.) It’s worth noting that Balz did not change the original story, meaning that he stands by his characterization that Gingrich compared the health care vote directly to the civil rights votes of the 1960s.

1) Faced with criticisms over their “deem and pass” strategy, House leaders dropped it. The deeming plan would have allowed the Democrats to pass the health care reconciliation bill — which tweaks the Senate-passed reform proposal — and “deem” the Senate bill passed without an actual vote on it. The new plan is to vote separately on both bills. Obama would then sign the Senate version, after which the Senate would take up the reconciliation bill.

2) The Rules Committee finalized the guidelines that will govern today’s events, setting formal debate time at two hours (split between the parties), and allowing the Democrats to postpone the vote if they fail to rally enough support to pass the bill.

3) Some Tea Partiers reportedly showed their racist stripes yesterday, allegedly showering several black lawmakers — including the civil rights hero Rep. John Lewis (D-Ga.) — with racial slurs as they walked from their offices to the Capitol. And the office of Rep. Emanuel Cleaver said that a protester spat on the Missouri Democrat, issuing this statement:

This afternoon, the Congressman was walking into the Capitol to vote, when one protester spat on him. The Congressman would like to thank the US Capitol Police officer who quickly escorted the other Members and him into the Capitol, and defused the tense situation with professionalism and care. After all the Members were safe, a full report was taken and the matter was handled by the US Capitol Police. The man who spat on the Congressman was arrested, but the Congressman has chosen not to press charges. He has left the matter with the Capitol Police.

Tea Party leaders are condemning the episode today, but it still hurts the image of a movement already seen to be dominated by bitter-class whites.

Meanwhile, those anti-abortion Democrats who continue to insist that the Senate reform bill would open doors to federal funding for abortions have been negotiating with the White House over whether the administration will issue an executive order reiterating the federal ban on abortion subsidies. Their beef is this: While the Senate bill bans federal subsidies of abortion services (requiring women to write a separate check for abortion coverage to ensure the funds are segregated), the anti-abortion folks want to ban subsidies for any plans that include abortion as part of their coverage package. The reason? They want those plans either to go out of business or to drop abortion coverage altogether.

Yesterday, Senate Majority Leader Harry Reid (D-Nev.) attempted to appease some of the chamber’s most ardent public option supporters, vowing to hold a separate vote on the issue later this year, the Huffington Post reported today. In a letter to Sens. Jeff Merkley (D-Ore.) and Bernie Sanders (I-Vt.), Reid said he was “very disappointed” that the Democrats didn’t have the votes to keep the provision as part of the reform bills.

“I remain committed to pursuing the public option,” Reid wrote.

While I believe that the legislation we are considering does much to provide affordable coverage to millions of Americans and curb insurance company abuses, I also believe that the public option would provide additional competition to make insurance even more affordable. As we have discussed, I will work to ensure that we are able to vote on the public option in the coming months.

Unmentioned, of course, is the tiny inconvenience that, if Democrats didn’t have the votes to pass the public option by reconciliation (which requires just a simple majority), they certainly won’t have the votes to pass it later in the year, when the filibuster will be back requiring 60 votes to pass anything.