Senate Majority Leader Harry Reid began private meetings Wednesday with fellow Democrats and the White House to merge his chamber's two health care overhaul bills into a single plan that could win a filibuster-proof majority in the Senate.
Work on combining the Senate's Finance and health committees' bills was supposed to be, in theory at least, the less contentious part of this new phase of overhaul negotiations. But the question of what will hit the Senate floor for debate in less than two weeks remains large and open.
Reid's task is complicated by the fact that although Senate Democrats enjoy a 60-vote, filibuster-proof majority, it is a fragile caucus that includes a handful of moderates whose votes on President Obama's signature domestic initiative are not a given.
And already at least one of Reid's fellow Senate Democrats, New York's Charles Schumer, is agitating for a final bill that includes a public insurance option — something missing from the measure passed this week by the more conservative Senate Finance Committee.
"In one sense, the debate begins all over again," says Bob Moffit, director of health policy studies at the conservative Heritage Foundation.
The long-awaited $829 billion proposal approved Tuesday by the Senate Finance Committee with a single Republican vote "concludes one big chapter of the health care debate," Moffit says. "But you're not going to see that bill again."
Opposition Pumps Up The Volume
Schumer wasn't the only one stirring the pot in the wake of Tuesday's vote.
Interest groups have ratcheted up their message machines this week — from insurers denouncing the Finance Committee proposal for failing to require that all Americans obtain coverage to unions balking at proposed taxes on generous benefit packages.
So Reid, with a tough re-election battle back home in Nevada and a looming showdown with House Speaker Nancy Pelosi over her chamber's competing legislation, has to devise a strategy that not only melds the Finance Committee's bill with the more liberal offering from the health committee but still gives the president a win.
There are a few certainties: There is little doubt that the ultimate Senate bill will include changes that prohibit insurers from denying coverage to Americans with pre-existing health conditions or canceling coverage when a policyholder gets sick.
And both Senate bills contain similar provisions for creating state-based insurance exchanges — or pools — that can be used by poor and low-income individuals and families, and small businesses, to purchase more affordable coverage.
The Finance Committee's plan to expand Medicaid coverage to more poor Americans is also expected to make the final bill, though details on how to pay for it — and for many other bill provisions — have yet to be worked out.
But the Finance Committee bill is the only proposal that does not include a government-run plan, and it does not require employers of a certain size to offer coverage to its employees.
"Do you impose an employer mandate that unions want, but employers will fight to the death?" Moffit asks. "Do you include a public plan that moderate Democrats don't want? Do you impose an individual mandate?"
Those big, fundamental questions are unanswered, says Michael Tanner, a senior fellow at Cato Institute. "There are real problems yet to be resolved," he says. "This is not even halfway there."
Different Mandates, Different Parameters
The Senate Finance Committee bill would require that most individuals obtain insurance, but its proposed phased-in penalties for failure to comply are nominal and would do little, critics argue, to encourage insurance purchase.
It proposes that penalties of $200 per adult begin in 2014 and reach $750 by 2017. The Senate health committee has proposed a penalty of up to $750 a person, with no phase-in period.
The insurance industry had banked on a vastly increased pool of potential clients under a mandated-coverage plan. Now the industry is attacking the Finance Committee's proposal as guaranteeing an increase in the cost of premiums.
Also at odds are the competing Senate committee proposals for employer mandates, which have emerged as one of the stickiest issues Reid faces.
The Finance Committee would require that businesses with more than 50 employees foot the bill for government insurance subsidies for which their workers may qualify. The health committee bill demands that employers pay for part of the cost of worker coverage or face a penalty. Both bills include exemptions for small employers.
A merged Senate bill will very likely include both an individual and employer mandate, but just who will be exempted is expected to be one of the issues dominating closed-door sessions over the coming days.
Meeting Obama's Objectives Without A Public Option
Schumer may be pushing hard again for a public option to be included in the final Senate bill, but Obama suggested Tuesday that the Finance Committee bill — sans public option — brought Congress closer to achieving the president's core objectives: dramatically expanding the number of Americans covered by insurance, and bending the cost curve.
Len Nichols, director of the health policy program at the nonpartisan New America Foundation, said there has been "fertile thought" around an alternative to a full-blown public option.
That alternative, he says, could be some kind of a melding of so-called trigger proposals advocated by both Democratic Sen. Tom Carper of Delaware and Sen. Olympia Snowe of Maine, the only Republican on the Finance Committee to vote for the proposed overhaul plan.
Under a trigger plan, a public insurance option would kick in if a state fails to meet federal insurance coverage goals.
"I would not be surprised at all to see that emerge" from the Senate's bill-merging discussions, Nichols says.
"Some kind of trigger is the best way to square the circle," he says. "It shows the right that there's no government takeover going on here, and moderate Democrats can get onboard."
But on Capitol Hill Wednesday, Reid said he wanted to note where he stands at the start of bill negotiations.
"I believe in a public option," he said, adding, pointedly: "Remember: I said I do."
A Win For Obama?
And that may be the path to what Obama could define as success on his signature domestic issue.
Even with a plan emerging that would contain an alternative to a full-blown public insurance option, and with considerably watered-down mandates for individuals to buy insurance and employers to pay for at least some coverage costs, the White House would most likely declare victory.
"The reason this is historic has almost nothing to do with the specifics," Nichols says, "but [with] the commitment now on the part of five congressional committees to make health insurance and health care affordable for all Americans — and to simultaneously bend the cost curve."
"We've never gotten this far before," he said.
But, for overhaul opponents, the game has only begun — and it will play out in the home districts of members of Congress facing re-election in 2010.
"If this is defeated, it will be defeated at the grass-roots level," says John Goodman, president and CEO of the National Center for Policy Analysis, which has gathered the signatures of more than 1.3 million who oppose the "nationalization" of health care.
"There is," Goodman says, "a real intense battle going on out there."