WASHINGTON -- Both houses of Congress are poised to start a historic debate on sweeping legislation to overhaul America's health care system, yet despite months of committee deliberations, some major issues remain unsettled.
This week, the Senate Finance Committee is expected to take the last step that sets the stage for the full chamber's debate when it votes on its version of a bill. Since the committee has a 13-10 Democratic majority, and Sen. Olympia Snowe, R-Maine, may vote yes, approval is expected.
President Barack Obama hailed the committee, which wrapped up its bill-writing work Friday, as achieving "another milestone," saying in a statement, "We are now closer than ever before to finally passing reform." The committee is delaying its final vote until the nonpartisan Congressional Budget Office estimates its proposals' cost and effects on consumers. The Finance committee staff pegged the cost at nearly $900 billion over 10 years.
The five congressional committees that spent the summer and early fall drafting health care legislation have found agreement, at least among Democrats, that nearly everyone should be required to have basic insurance, get subsidies if their incomes are low and have easy access to "exchanges," or marketplaces, where they can shop for coverage.
Insurers would be barred from denying policies because of someone's health status, and be subject to limits on premiums because of age or family size.
However, the Senate Finance Committee also exposed sharp divisions among Democrats about the extent of government involvement in health insurance and how to pay for any changes, while Republicans are all but universally opposed to the Democrats' terms.
Shortly after this week's final Finance vote, Senate Democratic leaders, with White House help, will combine the Finance measure with a more liberal bill that the Senate Health Committee approved over the summer. The full Senate is expected to start debating it on Oct. 13.
Senate Finance is only one of five committees, including three in the House of Representatives, that rejected creating a government-run insurance plan, or public option, as an alternative to private health insurance. Finance Committee members also had no interest in the kind of income tax surcharge on the wealthy that House Democratic leaders have endorsed.
Moderate Democrats wouldn't even consider such a tax. "I couldn't support what the House did," Sen. Blanche Lincoln, D-Ark., said flatly.
All this suggests that Democrats still have some big decisions to make as they craft final legislation, with conclusive floor votes not likely before late November or December.
The committees' work made it clear that the ultimate bill must meet three basic criteria: Coverage has to be affordable, easily available and paid for, so federal deficits don't expand. There may also be a fourth standard to meet if anything is to pass: Constituents may have to understand and be comfortable with the proposed new system, or lawmakers facing midterm elections in 2010 may not dare vote for it.
The House and Senate will consider different versions of the legislation. Both chambers are expected to begin debate later this month. Because House rules make it easier for the leadership to control debate, deliberations there should take only a few days.
In the 100-member Senate, however, where 60 votes are needed to overcome procedural hurdles, virtually every issue is sure to be subject to roll call votes, and the process could consume several weeks.
Under a rules change that permits the health care bill to be processed under what's known as "budget reconciliation," 51 votes will be enough to settle issues on the measure after Oct. 15. Details of how that would work remain murky, however, and Democratic leaders are reluctant to use that procedure, fearing that they'd be attacked for muscling through a profound change with a dubious bending of the rules, which could expose them to retaliation at the polls.
The most closely watched issue in the weeks ahead is likely to be the fate of the public option. Supporters will argue that a government plan, which Obama backs and which is expected to win House approval, will make coverage less expensive and easier to get.
Such a plan, said Sen. Jay Rockefeller, D-W.Va., "would simply guarantee that there is at least one health insurance plan in the exchange ... that ordinary Americans can afford and can count on to have more moderate premiums and yet the same benefits or perhaps more."
Senate Republicans, and some Democrats, are concerned that their constituents will see this not as an alternative to private insurance, but as an expensive first step toward a government takeover of the health care system.
"It would be a disaster," said Sen. Orrin Hatch, R-Utah. "The American people will lose an awful lot of control over their health care needs."
Senators are weighing other options. "We've gotten locked in a really sterile debate that says the only alternatives are what we've got now or public option. Those are not the only alternatives," said Sen. Kent Conrad, D-N.D.
The Finance Committee draft includes co-ops, or nonprofit member-run companies organized on a state, local or regional basis to purchase insurance, an idea that Conrad championed. In addition, Sen. Thomas Carper, D-Del., is floating a proposal to allow states to create their own public options. Snowe has proposed allowing public options only if state health-insurance markets prove uncompetitive.
What's important, Carper said, is that lawmakers can go home and explain, in simple terms, not only how coverage will be more easily available, but also that it's "affordable enough for middle-class people in most places."
Among concerns still unresolved for the final bill: Will the Finance Committee's excise tax on high-end insurance policies be passed along to middle-class consumers? Will tax credits for families who earn less than $88,000 annually be enough to assure affordability? Are penalties for not buying coverage too much of a burden on the middle class?
"People will be barely emerging from this economic recession ... they're wondering how they're going to make it, and we're talking about onerous penalties?" Snowe asked.
Debates over a host of other incendiary issues also loom: abortion, coverage for illegal immigrants, Medicare reimbursement and more. The Finance Committee rejected proposals to make it easier for federal agencies to verify the immigration status of applicants for insurance through co-ops, and to bar federal and state governments from requiring physicians to perform abortions.
In each case, the votes were 13-10, suggesting lengthy floor debates ahead.
"These are all legitimate questions," said Senate Majority Whip Richard Durbin, D-Ill., "and nothing will be resolved until we really get into the bill."
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