Passing comprehensive healthcare reform in the House on Saturday took a lot of sweat – and a few tears. But passage in the Senate will be even tougher, raising questions about the effort’s ultimate viability.
In fundamental ways, the two houses agree on key aspects of reform. Both would require that most people must carry health insurance or pay a penalty. Both would provide “affordability credits” to lower-income people who otherwise could not afford insurance. Both would expand Medicaid, the government-run health program for low-income people, by reducing the thresholds for eligibility.
Still, much remains to be resolved between the competing House and Senate versions. In fact, the final Senate version has yet to be revealed in full detail; all that's known are the outlines as unveiled by Senate majority leader Harry Reid (D) of Nevada.
Here are five flash points to watch:
1. Public option. The House version includes creation of a government-run insurance plan, to promote competition with private insurers, with reimbursement rates for doctors and hospitals to be negotiated. The Senate version, per Senator Reid, would also include a public option, but would allow individual states to opt out.
Sen. Joe Lieberman of Connecticut, an independent who caucuses with the Democrats, has said unequivocally that he will vote against any plan with a public option. Sen. Ben Nelson (D) of Nebraska has linked his vote to that of Sen. Olympia Snowe of Maine – the only Republican in the Senate Finance Committee to vote for health reform. Senator Snowe opposes the public option, even with an opt-out provision, and thus Senator Nelson is also not seen as on board.
2. Cost. The Senate version is awaiting its cost analysis from the Congressional Budget Office, but it is expected to be less expensive than the House version, which has clocked in at $1.1 trillion over 10 years. President Obama has said he wants to hold the cost of reform to about $900 billion, and if the new Senate version comes near there, that could weigh heavily in its favor.
3. “Payfors.” That’s Capitol Hill jargon for how legislators plan to fund the project. Mr. Obama has insisted that healthcare reform not add one dime to the deficit, and the two houses differ dramatically in how they would get there. The House bill would assess a 5.4 percent income surcharge on individuals with an adjusted gross income of more than $500,000 a year and on couples with more than $1 million.
This proposal is a deal-breaker in the Senate. Instead, the Senate Finance Committee bill would charge an excise tax on the high-end “Cadillac plans” and also charge new annual fees to various industry sectors: $6.7 billion from insurance companies, $4 billion from manufacturers of medical devices, and $2.3 billion from drugmakers.
4. Coverage. Both houses would require most people to carry health insurance, and both would provide subsidies to those who cannot afford it. Americans who still decline to purchase insurance would pay a penalty – though the penalty laid out in the Senate Finance Committee bill is much weaker than it is in the House bill. The insurance industry is concerned that some people will decline to buy insurance until they get sick, and insurers will be barred from turning them down.
5. Abortion. In an 11th-hour deal, House Speaker Nancy Pelosi allowed a vote on an amendment that restricts coverage of abortion in that chamber’s version of reform. The amendment passed by a wide margin. This paved the way for passage of the bill, as many conservative Democrats had threatened to vote no over the issue. Now the battle goes to the Senate, and at least two anti-abortion Democrats – Nelson of Nebraska and Bob Casey of Pennsylvania – are pushing for the same language. If this provision reaches the final version of both houses’ reform, it will be difficult to get it removed. Abortion-rights members in both houses are furious. But would enough of this mostly pro-Obama camp walk away over abortion rights to kill the whole reform? They’re hoping the legislative path doesn’t reach this point.
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