Building the health care vote: A kaleidoscope of compromises

WASHINGTON — When crunch time came on President Barack Obama’s health care initiative, the pressure on Democratic holdouts came from almost everywhere — from Air Force One and the House Speaker’s suite, from blaring television ads and anxious constituents.

But for Rep. Dale Kildee, the last word came in a Catholic rectory, during a quiet morning hour of meditation and counsel that ended with a priest laying both hands on the Michigan Democrat’s head in a blessing.

For Kildee, who spent six years in seminary as a youth, support for the bill was contingent on it banning federal funding for abortion. He studied the text. He absorbed criticism for waffling. He consulted like-minded colleagues. But he was not sure what to do until he took the question to his priest who, despite other church leaders’ opposition, told him the bill was true to his anti-abortion commitment.

“We are on good grounds to support the bill,” Kildee said after the pastoral meeting.

In the run-up to Sunday’s climactic vote, abortion was just one issue and Kildee was just one of the last dozen or so House Democrats who did not reach their decisions until the final week. But Kildee’s experience underscores a striking fact about how these pivotal decisions were finally made.

For all of the stereotypes about how Washington works — about Lyndon Johnson-style arm twisting and horse trading — what moved many of these lawmakers was not so much back-room threats and promises. Rather, it was substantive changes in the legislation, from minute parochial details to large matters of conscience.

To get the final votes they needed from the widely diverse Democratic caucus, party leaders kept tweaking and changing the massive legislation to make specific provisions acceptable to individual members — always mindful that each change could win one vote but lose another.

It was like trying to twist a kaleidoscope but control what the new picture would look like.

From the beginning of the epic debate more than a year ago, the vast majority of House Democrats have been strong supporters of a far-reaching health care overhaul. But as the final decision came in sight this week,a significant number — among backbenchers, abortion opponents, labor allies and liberals — still had not made the journey to ‘yes’ from ‘no’ or ‘maybe.’

And in most cases, House Speaker Nancy Pelosi, D-Calif., and her lieutenants had little leverage outside the bill itself, with each concession to win a holdout carrying the unnerving possibility of unraveling all that had gone before.

Spending curbs that helped win over fiscal conservatives alienated liberals; shifting Medicare funding to one region penalized others; the abortion compromise that prevailed in the Senate endangered the bill in the House.

For none of the holdouts was it an simple journey. And each had to follow a different path.

Here are the stories of three of them:

Rep. Dan Maffei, who won a swing district upstate New York in 2008, had voted for the House bill last year but was dismayed by the more conservative Senate version — which became the only path to healthcare legislation once Democrats lost their filibuster-proof supermajority in the Senate.

His labor backers were bitterly opposed to the tax on “Cadillac” plans. Changes in Medicaid, the state-federal health program for the poor, would penalize New York. And medical device manufacturers, a major employer in his district, were fighting a tax on their industry.

Maffei migrated from ‘no’ to ‘maybe’ after Obama proposed scaling back the Cadillac tax. When the reconciliation bill to “fix” the Senate measure was written, some $2 billion was added back for New York on Medicaid. The medical device tax was postponed.

He talked to Phil Schiliro, Obama’s chief lobbyist and a friend from before the 2008 elections when the two were senior congressional aides. With that history, Maffei felt free to complain about the administration’s hands-off strategy of leaving the legislation to Congress until the end.

“They needed to be more involved much sooner,” said Maffei, who welcomed Obama’s decision this month to put off a planned trip to Asia.

When Obama called, he sold Maffei on the idea that defeat of the health care bill would be such a setback that many of the nation’s other priorities would fester, untouched, for years to come.

Maffei gave his word to the president, flew home, and announced his position in East Syracuse. “While the reform process isn’t pretty, we’ve debated this bill long enough,” he said. “In fact, we’ve talked about reforming health care for decades. Doing nothing is no longer an option.”

His Republican opponent’s response: Do something. Just not so much.

“Health care reform is needed,” said Ann Marie Buerkle, who criticized Maffei for announcing his support before the final text of the 2,400-page bill was made public. “Everyone agrees to that. What is not needed is this overall, sweeping health care reform.”

The Senate’s movement to the right on health care may have caused Maffei heartburn, but it was good news for Gordon, a 26-year veteran of the House who was among 39 Democrats who had voted against the House bill last November.

Gordon, a longtime member of the Blue Dog Coalition, had made his name as a fiscal conservative from a state that has been trending Republican. And like many Blue Dogs, he complained that the House bill did not do enough to restrain growing healthcare costs.

The Senate on Christmas eve passed a bill that cost less, dropped a House income-tax hike on the wealthy and scaled back the provision that many conservatives considered anathema — a new government health insurance program called the “public option.”

After it became clear that the House would have to swallow the Senate bill — with limited changes in a separate bill — Gordon warmed to the legislation. And as Democratic leaders hunted for converts, Gordon was a particularly promising prospect.

Because he had announced he was retiring at the end of this term, he did not have to worry about political blowback from switching his vote.

Still, Gordon lay low until the nonpartisan Congressional Budget Office released its evaluation of the final healthcare package. After the CBO gave the bill a deficit-reduction seal of approval — it found the bill would cut the deficit by $138 billion over the next decade — Gordon flipped.

“Growing health care costs are … straining our economy and increasing our national debt,” Gordon said in announcing his decision to vote for the bill. “Health care expenditures now account for 20 percent of the federal budget. Without reform, that number is projected to double in the next ten years.”

“I have made my decision to help ensure health care is affordable for Middle Tennesseans today and for generations to come,” he said.

There was something else in the bill for his constituents: it permanently restored federal aid to state hospitals that provide substantial charity care. The aid had been cut in the ‘90s when Tennessee embarked on an ultimately unsuccessful effort to dramatically expand its Medicaid program for the poor.

Even though he is not facing a political opponent this fall, Gordon has not found the switch to be easy. He expressed frustration that people believed he switched his vote in exchange for the state hospital aid even though it had been sought by Democrats and Republicans alike in the entire delegation.

And Republicans publically accused Gordon of agreeing to back the healthcare legislation in exchange for an appointment to be NASA administrator. Gordon went to the House floor to refute the charge.

“If it was offered to me, I would not accept,” he said.

Nowhere did Democratic leaders face a more intractable and risky legislative trade off than on abortion, the issue that has bedeviled the debate at every stage. The final bill included Senate language designed to bar the use of federal funds to pay for abortion with the new premium subsidies and in the new insurance exchanges.

But with the U.S. Conference of Bishops saying it did not go far enough, anti-abortion Democrats were pushing for the stricter language included in the House bill by Rep. Bart Stupak, D-Mich.

For Kildee, it was a wrenching quandary. A die-hard liberal who was first elected to Congress in 1976, he had wanted health care reform for decades; his beleaguered hometown of Flint is packed with people who long ago lost their jobs and health coverage.

At the same time, he has a lifelong anti-abortion voting record and a bachelors degree from Sacred Heart Seminary in Detroit. He joined his fellow Michigan Democrat, Stupak, in demanding that his anti-abortion amendment be included in the House health care bill last year.

More recently he came to believe that the Senate’s language could also do the job.

At the first sign of wavering, Kildee was lambasted by conservative activists who aired attack ads on local radio.

Kildee was encouraged to shift by Rep. James Oberstar, another liberal anti-abortion old timer — who in 1976 sat in the back of the House chamber with Rep. Henry Hyde, R-Ill., and scribbled out the original amendment banning federal abortion funding that came to be known as the Hyde amendment.

But the final assurance came from his priest, who was so well versed in the legislation that he could cite page numbers.

“He agreed that this is the correct vote,” Kildee said.