Still a long way to go before health bill becomes law

WASHINGTON -- Now comes the hard part of crafting a new health care system -- hard not just because a lot of corporate, consumer and political interests want to be satisfied, but because the next steps will proceed in secret.

White House Chief of Staff Rahm Emanuel, Health and Human Services Secretary Kathleen Sebelius and other top Obama administration officials huddled for about an hour Wednesday afternoon with Senate Democratic leaders, trying to fashion a plan that can get the 60 votes needed to overcome procedural hurdles in the Senate.

Democratic leaders of the House of Representatives have been meeting privately with their caucus members for weeks, seeking enough common ground to bring legislation to a vote.

The Senate aims to begin debate the week of Oct. 26, but the House is unlikely to start floor consideration of its bill before early November. If the two versions win approval in each chamber, compromise negotiations will combine them into a single measure that must again win majorities in the House and Senate. Final votes are unlikely before December.

Along the way, several political mazes must be navigated.

The Senate's two health bill-writing committees, Finance and Health, differ sharply on whether to create a government alternative to private insurers, or "public option." (Finance said no; Health said yes.) The House and Senate are at odds over how to pay for changes: The House wants higher income taxes on the wealthy, while the Senate prefers higher taxes on insurers.

Adding to the drama is the secrecy: The White House-Senate session took place behind closed doors in Senate Majority Leader Harry Reid's Capitol office, and few clues were available about the talks' progress, let alone specifics.

Republicans have already started pounding away at the secrecy.

"The real bill is currently being written behind closed doors in the dark corners of the Capitol," lamented Sen. Orrin Hatch, R-Utah, usually one of the GOP senators to whom Democrats turn when they want compromise.

The key to any bill's success are the centrists. In the Senate, that means wooing eight to 10 moderate Democrats and two Republicans, Maine's Susan Collins and Olympia Snowe, who was the only Republican to back the Finance Committee bill.

Collins signaled Wednesday that she's open to compromise, but had concerns about the Finance Committee bill. She was "disappointed" that it didn't trim costs further, and "troubled" about its Medicare changes.

In addition, said Collins, the measure "falls short of the goal of providing access to more affordable health care to all Americans."

Centrist Democrats voiced other concerns.

Sen. Blanche Lincoln, D-Ark., insisted that the federal budget deficit not be increased, as the House bill would do. Sen. Ben Nelson, D-Neb., would like near-universal coverage, and saw the Finance bill as not going far enough. In the House, many lawmakers from rural areas want assurance that small businesses won't be unduly burdened by the cost of providing insurance.

Here are some key questions that lawmakers must answer before they can be optimistic about legislative success:

-- Can a public option win congressional approval? President Barack Obama, Democratic congressional leaders and most Democratic lawmakers want a government-run plan. So does their party's base.

A group of 27 labor unions ran full-page newspaper ads Wednesday calling the Finance Committee bill "deeply flawed," and endorsing the public option.

Moderates, however, are unenthusiastic.

The Finance Committee endorsed co-ops, or member-run, nonprofit companies that would negotiate with providers.

Among the compromises being discussed: allowing states to set up their own public plans or enabling a nationwide government-run system to be created if private insurers fail to meet certain standards.

While the House is expected to back the public option, the Senate is more of a battleground. Asked what he'd support, Senate Majority Whip Richard Durbin of Illinois said, "I'm going to keep an open mind about all this."

-- Who should pay higher taxes? The House Ways and Means Committee would begin imposing higher tax rates on adjusted gross incomes of more than $280,000 for singles and $350,000 for couples.

Moderate Senate Democrats see such taxes as particularly onerous to small business. They prefer a 40 percent excise tax on most high-end insurance policies.

Any new tax has to come from the health care sector, and it has to make health care less expensive, said Sen. Thomas Carper, D-Del., a Finance Committee member. The House's income-tax surcharge, he said, does neither.

House Democrats, though, are wary of an insurance tax. Last week, with labor's backing, 157 Democrats signed a letter opposing it.

The insurance industry's trade group also expressed concern about the Finance Committee's tax provisions. The measure "imposes hundreds of billions of dollars in new health care taxes and provides an incentive for people to wait until they are sick to purchase coverage," said Karen Ignagni, the president of America's Health Insurance Plans, a health insurance industry group.

-- Are enough people covered? The Finance bill would cover about 94 percent of all eligible Americans, the nonpartisan Congressional Budget Office says. The House plans would cover an estimated 97 percent, largely because it would provide more financial help for lower-income people. Currently, about 83 percent have insurance.

Liberals want near-universal coverage, and are willing to spend whatever it takes to meet that goal.

"I fundamentally believe that if we place a mandate on families to purchase coverage, we have to ensure that that coverage is truly affordable," said Sen. Robert Menendez, D-N.J.

The CBO estimates that the Finance version would reduce the federal deficit by $81 billion over 10 years, while the House bill would increase deficits by $239 billion over the same period.

Moderate Democrats have said that they're not going to stand for that.

"It's not perfect. We all know that. But the (Finance measure) is a great step in the right direction," said Lincoln of Arkansas, emphasizing that it met her "principle" of deficit reduction.

There are no easy choices, said Durbin of Illinois. Asked if lawmakers agree on anything, he chuckled. "Prevention and wellness," he said.

ON THE WEB

Fact sheet on House income tax proposal

Congressional Budget Office analysis of House health care plan

Text of Finance Committee measure

CBO analysis of Finance Committee bill

Side by side comparison of health care bills

House Republican health care proposal

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