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Senate and House in search of health-care compromise

Pelosi and Senate Majority Leader Harry M. Reid (D-Nev.) plan to talk next week about how to move forward, with the most likely course being informal negotiations rather than a formal conference committee. That would give negotiators more flexibility to come up with new policies in service of a compromise and eliminate some complicated procedural obstacles.

Negotiators from both chambers could rewrite the Senate bill and send it to the House for a vote. The Senate then would give it final approval. Pelosi has asked key House chairmen to return to Washington in the first week in January to launch that effort, with the full House due back a week later. The Senate is out until Jan. 19, leaving little time to push through a final bill.

Senate Republicans have vowed to fight the Senate bill with every parliamentary weapon they can muster. Over the past week, they have forced the Senate to work virtually round the clock, holding votes at odd hours, to finish the Senate bill by Christmas. Late Wednesday afternoon, the Senate voted 60 to 39 to turn back the third and final Republican filibuster attempt.

"We stand on the doorstep of history," Reid said afterward.

Clearly exhausted, Reid told reporters to expect further details on reconciling the two bills "after I go home to Searchlight," his desert home town in Nevada. "But for the time being," he said, "I'm going to focus on this bill passing in the morning. And for a few days after that, frankly, I am going to just sit back and watch my rabbits eat my cactus."

With Thursday's vote, both chambers of Congress will have given preliminary approval to health packages that share remarkably similar visions of reform, despite the remaining differences. Both seek to extend coverage to millions of Americans, in part by establishing insurance exchanges operated by government officials who would be empowered to monitor price increases and the quality of coverage, and to negotiate with insurers. That job would fall to each state in the Senate bill and to the federal government in the House bill.

Both bills also call for the biggest expansion of Medicaid since its creation, guaranteeing public insurance to everyone in the nation under a certain income level, regardless of family status. The House bill is more generous, offering Medicaid eligibility to anyone who earns less than 150 percent of the federal poverty level (a little more than $16,000 a year for an individual), compared with a 133 percent cap in the Senate bill.

Both bills would create a system of insurance subsidies for people who earn less than 400 percent of the federal poverty level (about $88,000 for a family of four) to limit the share of income they would have to spend on premiums. The House bill is more generous to people at the lower end of the scale, while the Senate would offer more assistance at the upper end, capping premium costs at 9.8 percent of income compared with 12 percent in the House bill.

The House bill would cover more people, as many as 36 million, according to congressional budget analysts, compared with 31 million under the Senate bill. But it would cost more than $1 trillion over the next decade, compared with the Senate's $871 billion package.

Many health policy experts are urging the House to press for its national version of the exchange, arguing that state officials would be less likely to enforce new insurance regulations and seek out the best deals for consumers.

"There are hundreds of thousands of decisions that need to be made as these things are being put into place that affect access and costs in a very significant way," said Linda Blumberg of the Urban Institute. "There's a lot at stake here, and we need to be defaulting on the side of uniformity."

The national exchange may also have a political advantage, by appealing to frustrated supporters of the government-run insurance option, who believe they have sacrificed too much.

"It's the last big bone for the liberal camp to build up a more significant role for the federal government, to have a structure to build on for the future," Altman said.

Staff writer Shailagh Murray contributed to this report.

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