Health Care: Running Out of Options

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After looking at all their other options–drafting a smaller health care bill, or passing the most popular parts piecemeal–Democratic leaders in the House and Senate have come down to the realization that they’ve got one play left on health care: Get the House to pass the Senate bill, with the assurance of a set of revisions to be included in a companion measure passed under the budget reconciliation process, to circumvent the Senate’s 60-vote majority requirement.

The key word here is “assurance.” And right now, it is far from clear how nervous House members could get the guarantees they need.

That is likely to be the main issue when House Democrats caucus tonight at 7 p.m. As Speaker Nancy Pelosi announced last week, there is simply no way she can find the votes to pass the Senate bill as is. But her members might, if they knew that there would be some fixes. Among those changes: They don’t want the Senate bill’s “Cadillac tax” on high-priced insurance policies; they want the bill stripped of sweetheart deals like Ben Nelson’s “Cornhusker Kickback;” they would like a national health insurance exchange, not the state ones in the Senate bill.

The only way to get any of those through the Senate is by the use of the reconciliation process. So the thinking now is to come up with what one top aide to the House Democratic leadership describes as “simultaneous tracks” for the Senate bill and the companion reconciliation bill.

But leaders have yet to figure out how that would work. Trust between the two chambers is frayed, and not likely to grow as more and more Senate Democrats come out against using reconciliation to get a health bill to President Obama’s desk. Already, we are seeing the defections of moderates such as Nelson, Indiana’s Evan Bayh, and Arkansas’ Blanche Lincoln. Budget Committee Chairman Kent Conrad is no sure thing; nor is independent Joe Lieberman. Meanwhile, Republicans are certain to drag out the bill as long as they can.

And then there is the larger question of what the political consequences might be of a procedural win in the wake of last week’s Massachusetts elections. Republican Senator-elect Scott Brown told me the morning after the election: “I think they’ll pay for it dearly in 2010. I think people will be outraged, regardless of party, if they let that happen.”

What Democratic leaders argue, however, is that the consequence of not passing a bill would be even worse. It would leave their party crippled and limping into the 2010 election with nothing to show for a year’s worth of effort on the issue. Further, passing a bill would allow them to quit talking about the ugly process of dealmaking, and remind voters of the actual features of the bill–many of which remain popular.

So what’s the betting at this point? It’s probably overstating the case to say that Democratic leaders are optimistic. But I’m still sensing that the determination to do something is there.

UPDATE: Health care experts weigh in:

We have come further than we have ever come before. While the House and Senate bills differ on specific points, they are built on the same framework and common elements–eliminating health status underwriting and insurance abuses, creating functioning insurance markets, offering affordability credits to those who cannot afford health insurance, requiring that all Americans act responsibly and purchase health insurance if they are able to do so, expanding Medicaid to cover all poor Americans, reforming Medicare payment to encourage quality and control costs, strengthening the primary care workforce, and encouraging prevention and wellness.

Key differences between the bills, such as the scope of the tax on high-cost plans and the allocation of premium subsidies, should be negotiated through the reconciliation process. Key elements of a reconciliation compromise enjoy broad support in both houses. Other discrepancies between the House and Senate bills can be addressed through other means.