Hillarysworld

You Think the Senate Passing Health Reform Settles Everything? Think Again: Our Guide to The Road Ahead

By Daniel Stone and Sarah Kliff

After months of contentious debate and last-minute bartering, the Senate wrote its intent in ink early Thursday morning with the final vote on a health-care-reform package. Once debate was cut off Wednesday evening, Democrats needed only a 51-vote majority to pass the final measure. But they got 60, with late holdouts Joe Lieberman and Ben Nelson approving the final measure and its accompanying amendments. The staunch 40-member Republican caucus became 39; Sen. Jim Bunning of Kentucky was the lone senator not to vote.

Emotions had been palpable on the Hill over the past week, and nevermore so than Thursday morning, the last in a string of early morning and late night votes since Sunday. Democrats milled about the chamber patting backs and offering congratulations, while most Republicans left the chamber quickly. But whether popping the champagne or throwing one back in angst, members of both parties might want to drink quickly; any elation or sorrow is sure to be short lived. Just because the Senate passed a reform package doesn’t make it law. Before any bill is sent for the president’s signature, Senate and House leaders must convene to reconcile each chamber’s bill. They will draft a final law,a House-Senate stew that everyone can (begrudgingly) swallow.

And that’s the problem. Agreement has been in short supply mostly between the two parties. But now the agreement becomes an imperative for the two houses, both controlled by Democrats. Compromising won’t be as simple as splitting the difference. Some issues matter more to swing voters in the House, and others will be nonnegotiable in the Senate.“This is a road strewn with improvised explosive devices that can beset off by angry people on both sides,” says Henry Aaron, a health-care-policy expert and senior fellow at the Brookings Institution. So what will the final bill look like? Here's a guide to how the contentious issues are likely to be worked out:

Abortion: Abortion funding could be a deal breaker for both sides. The House took a more restrictive stance on abortion with the Stupak amendment, without which the House bill wouldn’t have passed. But language proposed in the Senate by Ben Nelson presents a compromise between both sides of the issue. It doesn’t go as far as Stupak, which would bar public plans from covering abortion but does make abortion coverage much more cumbersome for insurance companies. Nelson walked back his threat to filibuster without Stupak language. Stupak has said he'll stall any diluting of his original language─a logical yet far-reaching attempt at leverage. But there are no filibusters in the House, so it's reasonable to think that if the entire package came down to abortion, Stupak would settle on the Nelson compromise, albeit grumbling.

Immigrant coverage: Just like abortion, immigration is another contentious social issue that came into play. The Senate bill denies illegal residents coverage, even if they can pay for it themselves. But the House bill, which qualifies immigrants for coverage but not with any federal money, is a softer approach. Including immigrants in the bounds of the legislation while making them ineligible for funding from John and Joan Taxpayer is a compromise likely to win the day. At stake are the votes of the House Hispanic Caucus, a potent 20-member voting bloc—made all the more powerful by the fact that the original margin of victory in the House was just five votes.

Affordability: There is a huge gap in affordability between the House and Senate Bills. In some income brackets, it’s as big a difference as spending 6.6 percent of your income (under the House version) on health care costs, versus 18.7 percent (in the Senate proposal). There’s also the difference in the Medicaid expansion: in the House, it would go up to 150 percent of the federal poverty level, but only to 133 percent in the Senate. With all numbers, it might be easiest to average the two, thereby annoying everyone equally. But when changing numbers even slightly to accommodate more people into Medicaid, the cost of reform can balloon dramatically. The Senate’s price, estimated by the CBO, is currently $184 billion less than in the House, so keeping the overall cost down will be in everyone’s interest.

Public option: After Joe Lieberman torpedoed the public option this month, it was as good as dead. But maybe not entirely. “It’s liable to sit up and move around a bit,” says Aaron, who wrote in September about kissing any public option goodbye. The House bill contains the basic idea─a nonprofit insurance option funded in part by the government─but that’s frankly too bad because the Senate has zero wiggle room on the matter. (Senators can't make new demands in exchange for their support; conferees can only work in within the bounds of two bills, not introduce new ideas). Might House leaders figure out some fancy footwork to make sure millions more Americans are covered with help from the government? Perhaps. But if it goes too far, you’ll hear about it from Joe Lieberman.

The mandate: Requiring all Americans to buy insurance or face a fine made sense when there was a government-sponsored public option. But the fact that the Senate took it out poses a unique problem for House liberals. “There will be huge pressure from the left to drop the mandate entirely because there won’t be a government insurance option, which means no choice,” says James Capretta, a fellow on health care at the Ethics and Public Policy Center. In other words, no government-sponsored alternative means that Congress will require all Americans purchase health care from private, profit-driven companies–the same private companies whose practices have led to a need for reform. But the mandate will stay in. “The Obama administration will fall on its sword to make sure the mandate stays in,” says Capretta. Without it, the entire bill would begin to unravel.

Funding: Social issues aside, both parties speak the language of money, and figuring out how to fund it might be the toughest agreement to come to. House leaders want to tax rich people, but the Senate wants to glean most of the funding from only those with high-end (or "Cadillac") health plans. Both ideas are grotesquely unpopular in conservative circles, but the Senate version less so. Keeping the wealth distribution in the realm of health care makes more sense than taxing everyone over a certain income. Plus, it gives an option to those with cushy health plans to trade down if they want to avoid taxes.

These points and dozens of smaller ones will take up days, if not weeks, of closed-door deliberations. Beyond just an exclusive club of congressional leaders, President Obama has said that White House staff, and even he, will “roll up their sleeves” to participate in the negotiations. Finding a way to twist both bills to make enough people happy will be a tall order. But the alternative for Obama and Democratic leaders may be even worse: accepting that the year of debates leading up to this morning’s celebration was entirely for naught.