High hurdles remain for health care reform

WASHINGTON — The fierce national debate over health care is entering a new phase, with advocates on all sides focused on a few legislative bottlenecks that will determine the ultimate overhaul of the $2.5 trillion medical care system.

President Barack Obama’s prime-time address to Congress on Wednesday reassured some nervous Democratic lawmakers, and he aligned himself more closely with certain proposals. While Obama’s words seemed to halt and possibly reverse the momentum that conservative groups had gained in August, they did not resolve all the concerns of centrist Democrats who will play pivotal roles, especially in the Senate.

Obama’s speech “was a game-changer when it came to the message,” said Sen. Ben Nelson, D-Neb., one of the moderates. “But it’s not an automatic change on the legislative side.”

Some version of a health care overhaul must squeeze through five key gates this fall if a final package is to become law by year’s end.

Advocates would be shocked if the Democratic-controlled Congress failed to pass some version. At a minimum, they say, it would bar insurers from dropping customers who become sick and require them to cover people already with medical conditions.

But Obama and most congressional Democrats want more:

* granting subsidies to help low-income people buy health insurance;

* requiring nearly all U.S. citizens to have insurance and requiring large employers to contribute;

* creating greater competition for private insurers, possibly through a government-run option;

* imposing more efficiency in Medicare and other programs, where experts say too much money and effort are wasted.

Obama is pressing the case with a rally today in Minneapolis, an appearance Sunday on CBS’ “60 Minutes” and trips in the week ahead to New York, Ohio, Pennsylvania and Maryland.

But the health care issue is mainly in Congress’ lap.

Knotty issues include whether to establish a government-run insurance plan and how to control costs.

Perhaps the easiest early hurdle will be in the House. But even there, divisions between liberal and conservative Democrats worry leaders, and Republican opposition appears absolute. Three House committees have approved portions of a far-reaching health care bill, but it will be changed before it reaches the full House.

In essence, Obama encouraged House leaders to tweak their bill when he embraced several Senate proposals absent from the House version. He also set a 10-year spending target of $900 billion, which may prove hard to meet.

Conservative Democrats may try to remove the government-run insurance option, which is dear to liberals. Still, many lawmakers expect the public option to stay in the House bill.

Things are more complicated in the Senate, where procedural rules make it much harder for the majority party to impose its will. Obama’s remarks revitalized efforts by Senate Finance Committee negotiators to shape a compromise bill that can attract at least one Republican’s support.

The first Senate showdown is expected in about two weeks, when that committee debates and votes on the bill. Liberals may try to add a government-run insurance option, similar to the House’s. More likely to survive are nonprofit insurance cooperatives, designed to compete with private industry and give consumers more choices.

The committee-approved bill will be merged with a second committee’s version and sent to the full Senate, the third legislative choke point. Lawmakers expect emotional debate and numerous bids to amend the measure.

To avoid a bill-killing filibuster by Republicans, supporters must assemble 60 votes in the 100-seat chamber. With Sen. Edward M. Kennedy’s death, Democrats hold 59 seats. Their best hope for a GOP crossover is Sen. Olympia Snowe of Maine, one of the Finance Committee negotiators.

But Snowe may be loath to be the only Republican supporter and the crucial 60th vote. “I’m not going to speculate” on the possibility, she said Friday. “That is very dangerous territory.”

If Snowe balks, the ultimate Senate bill may need a lower price tag or other changes to attract a few other Republicans, such as Ohio’s George Voinovich, who is retiring. Liberals would chafe at such concessions.

Senate Democrats could try a contentious tactic, called “budget reconciliation,” to pass portions of the health care package with simple majorities that are not subject to filibusters. Some liberal groups urge this strategy. Senate insiders consider it unlikely.

With Congress on track to pass substantially different bills, a yet-to-be-appointed House-Senate conference committee will meld them into one. This small group, dominated by Democrats, will wield extraordinary power, including the right to add provisions that neither the House nor Senate passed.

Some lawmakers think the panel could try to split the difference on the public insurance question. A possible compromise would be to replace the House’s public option and the Senate’s cooperatives with a “trigger” or “fallback” public plan, which would take effect only if private insurers fail to meet targets for providing affordable policies.

Snowe backs such a plan, and some lawmakers think it must be included in the bill at some point to win her vote.

In the fifth hurdle for the legislation to clear, the conference committee would send its reconciled bill to the House and Senate for a final yes-or-no vote, with no amendments allowed. House liberals might be furious over various concessions, but Democrats think they would hold their noses and pass the bill.

In the Senate, opponents could try one last filibuster. If so, the bill’s backers would need at least one GOP vote, as before. And they would need all, or virtually all, of the Senate Democrats to agree to let the bill reach the floor, even if some plan to vote against it on final passage, which requires only a simple majority.

House and Senate Democrats might find plenty to complain about in the final bill produced by the conference committee, said Richard Kirsch of the liberal Health Care for America Now. But they will feel tremendous pressure to vote for a long-sought health care overhaul, flaws and all.