The Senate continues to debate health care reform with passage of the Democrats’ health care bill expected by Christmas Eve. Key differences between the two bills — in the areas of abortion, financing and a government-run “public plan” health insurance option — would need to be resolved in a House-Senate conference deal, and approved by both chambers before reaching President Obama’s desk.
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LAURIE MCGINLEY: Good day. I am Laurie McGinley with Kaiser Health News, and this is Health on the Hill. Today, we are talking with Mary Agnes Carey with Kaiser Health News about all the recent developments in Congress. So, Mary Agnes, it looks as though Mr. Reid finally has himself a bill, just before Christmas, just as you predicted. How did he pull that off?
MARY AGNES CAREY: Well, he had to reach agreements with a lot of senators but in particular Ben Nelson, a Democratic Moderate of Nebraska, was a key player here. He had very strong concerns about the abortion issue.
They reached a funding compromise, which basically secured Senator Nelson’s vote, but of course in any big piece of legislation, someone like Harry Reid, the majority leader in that position has to do a lot of work with other members to get their support and they have a lot of targeted provisions.
Some that have gotten a lot of attention include additional Medicaid funding for Nebraska. Now that funding would include, there is going to be an extension of Medicaid coverage and so the federal government would pick up the entire coverage of that new population, the extended population, forever for Nebraska under the agreement.
Vermont got some extra Medicaid money. Massachusetts got some extra Medicaid money. There are other provisions scattered through the Bills to get support but Senator Reid has been very open about when you have a bill this big and comprehensive that you have to almost, you have to target certain provisions to Senators and Senators go and try to get these provisions for their states. So this is all part of the negotiations that will continue even past, if there is a Senate passage which people expect there will be.
LAURIE MCGINLEY: And Republicans of course are calling this a Christmas Tree Bill.
MARY AGNES CAREY: That’s right.
LAURIE MCGINLEY: But they have been known to do similar things in the past.
MARY AGNES CAREY: Right when both majorities, both parties, when they are in the majority have to do these things to get a big bill. Remember, this Health Care Bill is sweeping, it’s comprehensive, it’s a sixth of the economy. It’s one of the toughest things that Congress has ever had to do and so I think you can expect this kind of horse trading all the way to the end.
LAURIE MCGINLEY: So now they go to conference and I guess the question I would ask, because everyone says it has to come out looking very much like the Senate bill because the margin for error is so slight in the Senate, so why do we even need a conference and what is going to happen in the conference?
MARY AGNES CAREY: Well there are two chambers, the House and the Senate, and of course the House will want to do as much as it can to preserve its Health Care Bill. This will be the delicate balance.
House Democrats will feel that of course they want to have their Bill preserved as much as possible, but as we have already heard from, we’ve talked about Ben Nelson of Nebraska, Joe Lieberman, an Independent from Connecticut has said if the final package, these two Senators have said if the final package isn’t close to the Senate package that they won’t be able to support it.
So there is a lot of concern if the Senate Bill, if the final conference package rather isn’t close to the Senate Bill that it won’t pass the Senate and if nothing passes then it won’t matter whether the House or the Senate, what’s in the Bills because there won’t be a final Health Care Bill. So this is where Nancy Pelosi, who is Speaker of the House, Harry Reid, who is the majority leader of the Senate, have to negotiate to try to get the provisions in that final package that will win final support in both chambers.
LAURIE MCGINLEY: What are some of the biggest differences between the two Bills?
MARY AGNES CAREY: Well, there is financing for one. For example, in the Senate Bill, a key part of financing is an increase in the Medicare payroll tax for the highest wage earners. Here we are talking about individuals making $200,000 or higher, or couples $250,000 or higher.
In the Senate Bill, there is also a tax on what is deemed high cost health insurance plans and here we are talking about family policies that are around $23,000, individuals around $8,500, there are some exceptions for police, fire fighters and high risk professions.
Go to the House side, a major finance provision there is on a tax on high wage earners in the sense of tax of all the income, $500,000, rather an advance of these thresholds, in excess of the thresholds, higher than $500,000 for individuals or $1 million for couples.
That doesn’t seem to have any appeal, that tax, House tax in the Senate, and in the House the tax on the high cost health insurance plans doesn’t seem to have a lot of appeal so that will be a key fighting point. Abortion is different. There is a compromise reached with Senator Nelson, the House has far more restrictive abortion language. That will be an issue.
LAURIE MCGINLEY: Will that be the final issue, do you think, abortion? Is that going to be the hardest issue to negotiate?
MARY AGNES CAREY: I think it will be one of the hardest because both sides have such strong passionate feelings. Abortion rights opponents feel that language in the Senate Bill goes well beyond the Hyde language and again this would prohibit federal funding for abortions, except in the cases of rape, incest, or to save the life of a mother.
So they will fight very much to see any expansion beyond that or language they feel that goes beyond that, they want to stop it. Conversely, abortion rights proponents want to preserve what they feel are individual rights to spend your own money to get abortion services, so this will be one of the defining issues in this debate. It has been and it will continue to be.
LAURIE MCGINLEY: And are we assuming then there will be yet a third abortion provision essentially written by the conferees?
MARY AGNES CAREY: There could be, yes very much so, but again let’s remember that balance. Bart Stupak, who is a Democrat of Michigan, in the House is pushing very much for his language which is far more restrictive, no abortion services offered in a public plan or in exchanges where people can get subsidies and he will very much push for that.
And again in the Senate we have a difference where you would allow states as they currently do under current law could pass laws saying abortion can be allowed in the exchange but if you buy a health plan that has abortion services, you would have to write two separate checks to keep that firewall. Ben Nelson feels that’s a strong firewall but abortion rights opponents do not.
LAURIE MCGINLEY: What about the public plan, that sounds as though it’s really dead for now, that it’s going to be very hard for the House to prevail on that.
MARY AGNES CAREY: Right, it will be. Now in the Senate what they have done as a compromise is have the Office of Personnel Management that oversees the federal health insurance employees’ health plan, have them negotiate national plans, one of which must be a not for profit plan, to offer to people. Now, public plan proponents will not like this. They won’t feel it’s strong enough, but again as we are talking about if you’ve got to get close to that Senate language for passage, the thought is that is where public plan issue will end up closer to the Senate language that has the OPM involved.
LAURIE MCGINLEY: Then there’s another tier of issues where the House and Senate Bills both have similar provisions but there are, even in those cases, there is enough of a difference to create some problems. Tell us a little bit about some of those.
MARY AGNES CAREY: They both provide subsidies, for example, to folks up to 400-percent of the poverty level to be able to buy health insurance. The House does it differently than the Senate. The House subsidies are perceived to be more generous. This could be an issue in conference where the Senate makes some compromises and tries to have some differences in the funding there.
On the Medicaid expansion, both Bills do that. The House does it to 150-percent of the poverty level; the Senate does to about 133-percent of the poverty level, so we will have to work that out. The Senate has a different formula than the House in the sense of helping states to cover the cost of that expansion.
The Governors are very concerned about additional costs to them. That will have to be resolved. And on the exchanges, both plans would offer this idea of an exchange, a menu of choices for insurance you can purchase. The Senate has the states play a strong role in the exchanges in the House there. It’s a national exchange, so they are going to have to resolve how they work that out.
LAURIE MCGINLEY: It’s interesting when you look at the different opinion, obviously, from a political standpoint that the Democrats and the Republicans have. The Democrats seem to have accepted this theory that has been pushed by Rahm Emanuel and Bill Clinton that they will pay heavily at the polls next year if they don’t pass health care reform, and the Republicans think that the Democrats are making a titanic political mistake, what do you think about those warring views of this legislation?
MARY AGNES CAREY: Well, I think that I can see where they are both coming from, as you say. You know, Rahm Emanuel, former member of the House, now key in the White House, and former President Bill Clinton are saying look folks, we have been down this road before.
If you don’t pass it now, it’s not going to happen for a long time and that they campaigned for, it’s why they have the majorities in Congress, you know, the proponents, Democratic proponents of this will say this is why we were elected to do this, and if we don’t do it, we are going to be hurt in the midterm elections in 2010 and in the Presidential Election as well.
I think there is also an awareness from many Democrats of just the pure logistics of getting to this point, all the hearings, all the back and forth, let’s remember we had five committees of jurisdiction pass this Bill in the House and the Senate and they are trying to merge them, how tough this process is.
So I think the Democrats feel many of them, they need to deliver and they need to do it now, but Republicans think that this is a big political miscalculation of the Democrats. They are pointing continuously in the debate on the Senate which is ongoing and they have done this in the House and will continue.
They say the Bill is too expensive, it will cut Medicare too deeply, it won’t do enough for people who currently have insurance, it will raise their premiums. They are throwing all sorts of charges out there, and so while they are fighting the Bill vehemently, especially in the Senate and want to stop it, I think they think Democrats will pay for this as far as their candidacy in the mid-terms and at the Presidential Election.
LAURIE MCGINLEY: Do you think the final vote on this is in fact going to go to Christmas Eve or does there seem to be any indication that it might occur earlier?
MARY AGNES CAREY: Well, there is some discussion that perhaps we wouldn’t. We will have to see how it plays out but I think now we have had a few procedural votes that show that Senate Democrats have got the 60 votes to pass this, so you may have some decision on the Republican side of the aisle that perhaps they don’t need to have that final vote as late as Christmas Eve. We are talking now in the 7 to 10 p.m. window. There are going to be some meetings on Capitol Hill today, some discussions among the Republicans, and so we will see where they are later today.
LAURIE MCGINLEY: Great, Mary Agnes, thank you very much.
MARY AGNES CAREY: You are welcome.
LAURIE MCGINLEY: This is Health on the Hill. Thank you for joining us and Happy Holidays.