By Shailagh Murray
Washington Post Staff Writer
Tuesday, November 17, 2009
When the Senate begins floor debate on a health-care reform package this week, the outcome is almost certain to rest on decisions made by a handful of moderate Democrats.
None of those Democrats is feeling the heat as intensely as Sen. Blanche Lincoln (Ark.), who has become emblematic of the improbable distance that health-care reform has traveled, and how far it still must go before becoming law.
Her vote and that of two other Democrats expressing serious reservations about the legislation -- Sens. Ben Nelson (Neb.) and Mary Landrieu (La.) -- will determine whether it will garner the 60 needed to break an all-but-certain Republican filibuster.
There are 60 members of the Democratic caucus but one, independent Sen. Joseph I. Lieberman (Conn.), has threatened to join a GOP filibuster if the final bill contains a government insurance plan, or "public option." With only a single Republican, Sen. Olympia J. Snowe of Maine, even considering backing the final product on the floor, the trio of Democratic centrists could make or break the reform effort.
And of those three, only Lincoln must face voters next year.
Hundreds of thousands of Lincoln's constituents are low-income and lack insurance, the very kind of voters expected to benefit under the Senate bill. Lincoln, a second-term senator, helped write some of the legislation's key provisions as a member of the Finance Committee, and her sometimes uncomfortable role near the center of the debate could cost her in culturally conservative Arkansas. Despite the potential benefits for many in her state, polls show her support weakening, and constituents are expressing doubts about the proposed overhaul.
The low-profile centrist is being pressed by both sides. Democratic activists are incensed that she has turned against the public option, an idea she once supported. Republicans are casting her cautious approach to the health-care debate in starkly political terms, saying that she is unwilling to put local interests above those of a president who lost the state by a resounding 20 percentage points.
"I want to be a check and balance on Barack Obama's extreme agenda," state Sen. Gilbert Baker, a front-runner for the GOP nomination, told reporters last week.
An Arkansas Poll published Nov. 5 found that Lincoln's job-approval rating had dropped to 43 percent, from 54 percent a year ago. At least seven Republicans are vying to challenge her bid for a third term; Baker raised $500,000 in his first month as a candidate. And if she does not embrace the party line on the health issue, Lincoln could also face a Democratic primary challenger, along with a Green Party opponent in the general election.
"In some ways, there's not a good vote on this," said Sen. Mark Pryor (D), Arkansas's junior senator, who coasted to reelection last year. "You're going to have detractors on either side, no matter what you do. So I think in the end you have to what you think is right. And I think that's what we're all going to have to do."
The first test for Lincoln could come as early as Friday, when the Senate will vote on whether to bring the bill to the floor. Lincoln told party leaders she would study the final product before committing either way.
"What people want is for us to take our time and not rush into something that we haven't thought completely through," she said, shrugging off the pressure as she hurried back to her office after a Senate vote last week.
Although Pryor supports the reform effort, another prominent Arkansan, Rep. Mike Ross (D), voted against the House bill.
"Most people support the need for health-insurance reform; they just think we can do it for less," Ross said. "They really, as I do, support more choices. They're just skeptical of a bill that takes 2,000 pages to accomplish that."
Ross was reluctant to offer Lincoln advice, but acknowledged her predicament. "She represents the whole state. I just represent one-fourth of the state. I'd just be guessing." But he added: "I think people fear the unintended consequences in a bill this massive."
Democratic leaders expect Lincoln to stick with them on key procedural votes, but are less confident about winning her support on critical amendments -- particularly on the contentious public option.
Lincoln's record on a government insurance plan has drawn detractors on both sides. In July, she wrote in the Arkansas Democrat-Gazette: "Individuals should be able to choose from a range of quality health insurance plans. Options should include private plans as well as a quality, affordable public plan or non-profit plan that can accomplish the same goals as those of a public plan."
By Sept. 1, she had changed her mind. "I would not support a solely government-funded public option," Lincoln said at an event in Little Rock. "We can't afford that."
In recent weeks, she also has raised concerns about both potential compromise approaches -- one that would allow states to "opt out" of a public plan that Senate Majority Leader Harry M. Reid (D-Nev.) is expected to include in the Senate bill, and a proposal by Snowe, the only Republican still at the negotiating table, to create a public option as a fallback if private insurers do not offer reasonable rates.
In the process, Lincoln has riled liberal groups including MoveOn.org, which is targeting her with radio ads, direct mail and rallies outside two of her Arkansas offices. Perhaps more ominously, MoveOn -- working with the liberal group Democracy for America -- has amassed $3.5 million in pledges to fund primary challenges against any Democratic senator who sides with Republicans to block an up-or-down vote on a bill with a public option.
"We think it's really important for her to see there are negative political consequences to being on the wrong side of this issue," said Ilyse Hogue, MoveOn's campaign director. "There's no arguing she's in a conservative state, but she's going to face a tough election no matter what, and she can't do it without the base. These are the activists, the people who knock on doors, and she is really running the risk of alienating them."
The National Republican Senatorial Committee is also documenting each of Lincoln's comments on health care to build a case against her. The Republican National Committee released a Web video this week that compares her public-option remarks to Sen. John F. Kerry's "I actually voted for it before I voted against it" line about Iraq war funding.
For GOP leaders, the best strategy for defeating the Senate bill is to sow doubts among vulnerable Democrats, convincing them that Reid is leading them off a political cliff.
"There's a great effort under way here to convince their members to ignore public opinion" on health-care reform, Minority Leader Mitch McConnell (R-Ky.) told reporters last week. "I hope it will not be lost on our Democratic friends where the public is, how the public feels about this measure. They're speaking increasingly loudly that they do not think it ought to pass."
Recent polls suggest that reform is a difficult sell in Lincoln's home state. The Arkansas Poll, conducted in mid-October by the University of Arkansas's Survey Research Center, found that 39 percent of voters support a public option and 48 percent oppose the idea. And respondents split about evenly on the question of whether reform would improve or hurt their quality of care.
"It's hard to draw firm conclusions," said Arkansas Poll Director Janine Parry. "People are dissatisfied, but they haven't signed on with an alternative." Lincoln, said Parry, appears to be "right with her constituents -- convinced that we need to do something, and not convinced it's this."
Senior Senate aides said Lincoln helped to shape measures aimed at reducing the cost of such procedures as MRIs and at better coordinating care among doctors, hospitals and nursing homes. And she was the primary sponsor, along with Snowe, of a provision aimed at giving small businesses more health-care choices for employees.
According to the Kaiser Family Foundation, of the nearly 473,000 Arkansas residents who lacked coverage as of 2008, virtually all would be eligible for federal assistance under the Senate bill -- either through Medicaid or through tax credits that would subsidize the purchase of private plans.
"There's a lot in the bill that will be good for Arkansas," Pryor said. "But there are a lot of people in our state who are against this bill. Some have very legitimate concerns and ask very good questions. But also some is based on bad information. We have to try to talk to those people."
If Lincoln supports the Senate bill, she will have to sell it to constituents before they see many of the legislation's benefits. But she says she is well aware of the challenge. "I have no doubt that I'll be held accountable on this," she said. "We're going to be held accountable on a lot of things."