Senators Continue Work on Health-Care Bill, but Obstacles Remain

By Shailagh Murray and Paul Kane
Washington Post Staff Writers
Thursday, September 10, 2009 6:23 PM

Senators are proposing changes to a draft health-care bill offered this week by Senate Finance Chairman Max Baucus (D-Mont.), but their work has made plain that deep divisions remain among the lawmakers a week before they are due to make their bill official.

Nevertheless, those involved in the Finance Committee negotiations remain hopeful that a bipartisan deal may yet materialize from the talks . The three Republican negotiators have offered the longest lists of changes, but most individual suggestions were relatively narrow, leaving the basic framework of Baucus's proposal intact.

But the group still appears to be struggling with how to settle the basic questions of how much health coverage should uninsured people be required to obtain, and how much the government should help to pay for it. This nettlesome challenge has dominated discussions among the negotiators -- the so-called Gang of Six -- for at least two months.

As they continued their talks, congressional Democrats on Thursday began their push to unify their ranks behind President Obama's outline for health-care legislation, hours after the president laid out that plan in a speech that was met with loud protests from some Republican lawmakers.

House Democrats held a meeting of their top vote-counters in the morning, and followed with a pair of key meetings later Thursday. One gathered a group of centrist Democrats who have been opposed to a key plank of the legislation, and the other was with party liberals who have been the loudest proponents of that proposal, known as the "public option," a government-funded insurance program that has served as the biggest fault line in the debate so far.

In addition, Vice President Biden came to the Capitol on Thursday to meet with the Congressional Black Caucus, which has joined the liberal call for a "robust public option."

Biden predicted Thursday that Congress would complete a health-care reform bill "before Thanksgiving." He added in an interview on NBC's "Today" show that Obama is "willing to sign a bill, any bill, by whatever mechanism, that in fact guarantees that there is a choice for people that is affordable."

The Senate, meanwhile, paused to pay tribute to the chamber's leading proponent of the health-care legislation, the late Sen. Edward M. Kennedy (D-Mass.), who died last month after a 15-month battle with brain cancer and whose memory Obama invoked Wednesday night.

All three Republicans involved in the Finance Committee talks want to change current medical malpractice laws. The two conservatives at the table, Sens. Mike Enzi (Wyo.) and Charles Grassley (Iowa), also want explicit language that prohibits federal funding, including subsidies for private insurance, from paying for abortions, and bars the extension of benefits to illegal immigrants. They proposed a five-year waiting period for legal immigrants to receive insurance subsidies.

Sen. Olympia Snowe (Maine), the moderate Republican in the group, proposed one major change, allowing insurers to offer national plans and to participate in state-based insurance exchanges. The Baucus proposal would permit states to form "health-care-choice compacts," allowing for the purchase of non-group health insurance across state lines.

Snowe also proposed new provisions, including a recalculation of the affordability of employer coverage, that would increase the overall price of the Baucus plan to about $900 billion over 10 years.

Enzi requested several changes to Baucus's proposed Medicaid expansion, a step aimed at easing the cost burden on states. Enzi wants a requirement that the federal government pay 100 percent of expansion costs, in order to avoid imposing an unfunded mandate on states. He would also lower the income threshold at which individuals can choose between Medicaid and private insurance.

Grassley and Enzi both favor a smaller package that costs less and scales back required coverage. Grassley also urged Baucus to drop numerous fees that would be assessed across the health-care industry, including on insurers, medical device manufacturers and clinical laboratories.

Sen. Kent Conrad (D-N.D.) offered just two proposed changes, including the addition of a temporary federal reinsurance program. It would reimburse insurers in the non-group market, along with companies in the small group market with fewer than 100 employees, for the cost of very sick beneficiaries. Under the Conrad program, the government would pick up 75 percent of medical claims above $50,000 in one year, for any worker or retiree, or their dependents.

Conrad's reinsurance program would operate in the individual and small group markets in 2011 and 2012, until health insurance market reforms and exchange subsidies take effect in 2013. The idea is to ease the transition, but also to force insurers to lower premium costs for everyone.

If the Finance Committee's talks unfolds smoothly, the committee would approve the legislation -- with or without Republican support -- by the end of the month. But if the negotiations end without a bipartisan agreement, Democratic leaders will be forced to contemplate procedural maneuvers to bring reform legislation to the floor on a party-line vote.

At that point, Reid would take over, melding the Finance bill with the legislation produced by the Senate health committee and bringing the massive package to the Senate floor for debate. Senators would then have the opportunity to test support for controversial ideas such as the public option, malpractice protections and an individual insurance mandate.

Baucus said he would continue to negotiate with the three Republicans until his deadline of Sept. 17. "A bipartisan bill is much more durable, much more sustainable," he said.

Inside the Senate chamber, members took to the floor Thursday to hail Kennedy's efforts at bipartisan legislation over his nearly 47 years in the Senate. The tone among Senate Republicans echoed their attitude in the House on Wednesday night, when most either remained silent or gave nods of approval and applause at lines in Obama's speech they supported. That contrasted with House Republicans who shouted catcalls as Obama spoke, most notably Rep. Joe Wilson (R-S.C.). He later called the White House to apologize for shouting that Obama was lying about how the Democratic legislation treats illegal immigrants.

Wilson stuck by his contention Thursday that the president was wrong to say that illegal immigrants would not be covered. A nonpartisan evaluation by the Congressional Research Service, he said, "has indicated that indeed the bills that are before Congress would include illegal aliens, and I think that this is wrong."

But he told reporters that his outburst was "spontaneous."

Obama said Thursday after a meeting of his Cabinet that he appreciated Wilson's apology. "We all make mistakes," the president said.

Democrats made an effort to prevent discussion of Wilson's actions from drowning out a substantive debate on health care. "It was stunning," House Speaker Nancy Pelosi (D-Calif.) said Thursday at her weekly press briefing, but she called for no further recourse. "It's time for us to talk about health care and not Mr. Wilson."

The organizations with the most at stake in health-care reform -- the health-care industry and related interest groups -- say that they remain open to the idea of big changes in the availability, financing and regulation of health insurance, as Obama called for Wednesday night.

Leaders of the American Medical Association, America's Health Insurance Plans, the Pharmaceutical Research and Manufacturers Association and AARP all agreed that Congress must push through a health-care overhaul this year.

But Democrats still have a long way to go in terms of building party unity toward that goal.

Liberals sat silently when Obama cited "constructive ideas" that could take the place of a government insurance plan, but cheered wildly when he vowed to hold insurance companies "accountable." Afterward, many congressional liberals said that, rather than paying attention to Obama's olive branch to party centrists, they were pleased to hear Obama's praise for the public option. "I thought in every way he supported the public option," Sen. Sherrod Brown (D-Ohio) said.

As Congress proceeds, the template Obama provided will help to guide Democratic leaders through the minefield that lies ahead. The president even widened the cast of potential supporters by endorsing provisions that are popular among Republicans, including pilot programs to test whether medical malpractice reform could lower health-care costs and an expansion of special-risk pools that allow people with preexisting conditions to buy insurance.

And yet the road to a White House signing ceremony remains difficult terrain. In both the House and Senate, Democratic leaders must combine several bills, factoring in Obama's priorities but also the proclivities of internal factions. The middle road is usually the path of least resistance, especially in the Senate -- but already Baucus, the only Democratic chairman seeking to forge a bipartisan consensus, has sparked a liberal backlash by tweaking certain provisions to satisfy moderate Democrats, along with the three Republicans helping to draft his bill.

Because the House has more authoritarian rules than the Senate, Pelosi can reshape the pending House bill with input from a dozen or more key lawmakers, including those from competing ideological caucuses.

Once the House leadership thinks it has a bill that can garner at least 218 votes, the minimum for a simple majority, the legislation will be dropped into the House Rules Committee, the body that will formally draw up a bill and dictate how the debate will unfold. Democratic sources said the House bill could come to the floor late this month. Reid's tentative goal is to produce a Senate bill by Oct. 15.

Staff writers Debbi Wilgoren, William Branigin and David Brown contributed to this report.