Pelosi on Health Care: “We have to get this done.”

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House Speaker Nancy Pelosi is sounding very determined–and surprisingly upbeat–about the prospects for a comprehensive health care bill in the wake of last week’s Senate election in Massachusetts, which cost the Democrats their 60-vote, fillibuster-proof majority.

“You can always find a way. You can always find a way,” Pelosi told a group of about a dozen journalists this afternoon. “We have to get this done for the American people—one way or the other. … We need to get this done. Process I don’t care about. But we need to get this done.”

Of course, Pelosi does care about process. And no one is more effective at making the process work. As Pelosi talked, it was pretty clear that she has already developed at least the broad tactical outlines of how she intends to get health care legislation to President Obama’s desk:

As I wrote yesterday, that health care legislation would be delivered to Obama in two parts: (1) the legislation that passed the Senate on Christmas Eve and (2) a set of revisions, which would skirt a Senate filibuster by passing under the budget reconciliation process, which requires only 51 votes.

Pelosi continues to insist that the Senate bill, in its current version, could not pass her chamber. But with a separate bill, passed under reconciliation (which Pelosi prefers to call “majority vote”), she predicted, “it’s a whole different ball game … We’ll be able to come up with something that sufficiently addresses the concerns of the House members.”

Among those concerns:

1. The so-called “Cadillac Tax” on high-priced insurance policies: Pelosi says the deal that the White House reached with labor might be “a good start.” But her preference, she said, would be to just get rid of the tax entirely. “Our members still don’t like the excise tax,” Pelosi said. “They don’t like half of it; they don’t like any of it.”

However, that tax is one of the few provisions in the bill that economists say could have a major effect on bringing down health care costs, and President Obama has already said he wants it in there. So this is not something that either the Senate or the White House is likely to give up entirely.

2. Affordability: The House is likely to demand more subisidies to help people buy insurance.

3. Stripping out special deals like the Cornhusker Kickback.

The House is also eager to see a restructuring of other parts of the bill, but it is not clear that this could be done under the limitations of the reconciliation rules. Reconciliation can be used for provisions that have a direct effect on the federal deficit, but not for writing new policies, such as a repeal of the insurance industry’s antitrust exemption. Aides say, for instance, they have yet to figure out how to restructure the Senate bill’s health insurance exchanges, and make them national rather than state-based. As a result, Pelosi is also talking about a “separate track”–additional pieces of legislation to make these kinds of revisions.

Interestingly, she downplayed some of the hot-button issues that had dominated so much of the debate last year. Abortion, she said, “is not the subject of our conversations at this time.” And she dismissed any suggestion that the public option might be resurrected. “You can’t do that,” she said.

She made it clear that House members are not going to vote for the Senate bill without getting a guarantee first of the revisions. As Greg Sargent noted today, there are questions as to how they could do that. How do you amend a bill that hasn’t passed? But a top Pelosi aide I talked to told me that this is entirely doable. Here’s how the sequencing could work: The House and Senate would pass the reconciliation legislation first, then the House would pass the Senate version of the health care bill. But the Senate health bill would be sent to Obama’s desk first, and signed into law. The President would then sign the reconciliation bill, revising the original health care bill.

Yeah, I know. That’s all pretty convoluted. And this whole process could take both Congress and the President into pretty uncharted procedural territory. It is fair to wonder whether the whole thing could blow up in the Democrats’ faces politically, given the increasing unpopularity of the entire health care endeavor. But Pelosi insists the consequences of inaction would be worse. Once they get through this messy and ugly process, she says, Democrats can start reminding voters of what they like about the substance of the bill. “You can bake the pie, or you can sell the pie,” she says. “It’s hard to do both at the same time. … Our members will be very well equipped to talk about what they voted for and why.”

And as for the process of even getting to that point. “Everything is a heavy lift here,” she said. “We like heavy lifts. This is what we thrive on around here.”

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