For anyone who has lost track of where we are on the health-care bill, here is a brief summary. Three different House committees have reported out health-care bills. All three contain mechanisms for setting up a public plan, but it would be limited to various groups of people, and would not kick in immediately. All the bills contain a mandate for individuals to buy health insurance or pay a fine and all three provide for government subsidies for poor people who can't afford insurance. The bills differ on many details and the three chairmen, George Miller (D-CA), Charlie Rangel (D-NY), and Henry Waxman (D-CA), are currently working with the White House and Nancy Pelosi to come to one bill which would be brought to the floor of the House for possible amendments and a vote. The Progressive Caucus says it will not support a bill without a public option and the Blue Dog Caucus says it will not support a bill with a public option. Both caucuses are large enough to defeat the bill. Horse trading and sausage making are going to be on display shortly.
Over in the Senate, the HELP committee, formerly chaired by the late Sen. Ted Kennedy (D-MA) and currently chaired by Sen. Tom Harkin (D-IA), has already reported out a bill that includes a public option. The Senate Finance Committee, chaired by Sen. Max Baucus (D-MT), has produced a 223-page bill but not passed it yet. It has something for everyone. Liberals like the fact that it increases the Medicaid limit up to 133% of the poverty line and allows small businesses with up to 50 workers to join "exchanges" on which private insurance companies would offer competitive plans to gain new customers. Furthermore, the 50-worker limit would increase over time, allowing bigger companies to join in.
Conservatives like the fact that there is no government-run public option but does have individual mandates, forcing everyone in the country to buy private insurance, a huge windfall for the insurance industry. They also like the absence of any mandate on companies to provide insurance for their workers, although companies will have to pay a fine for any workers getting government assistance to pay for health care. This provision might deter companies from hiring poor people.
A major source of revenue in the Baucus bill is a 35% excise tax on gold-plated insurance plans. Baucus and every health economist in the country thinks this is a great idea (because gold-plated plans encourage frivolous use of scarce health-care resources), but everyone else opposes this provision. However, scotching it leaves a huge gap in the financing that must be filled.
Next week the Baucus bill will be marked up, meaning that all 23 members of the committee get to propose amendments which are then voted up or down. Here is a list of the committee's members. With the potential exception of Sen. Olympia Snowe (R-ME), all 10 Republicans on the committee basically don't want any bill and will try to weaken or scuttle it. The 13 Democrats want a bill, but they are scattered all over the ideological spectrum, from Sen. Chuck Schumer (D-NY) on the left to Sen. Blanche Lincoln (D-AR) on the right. Sen. Jay Rockefeller (D-WV) has already said he will vote no on the Baucus bill as it is currently written. He gave Ezra Klein a good interview about heath care as well. Sen. Maria Cantwell (D-WA) has joined Rockefeller and said she will also vote no unless a public option is added. Without Rockefeller and Cantwell, Baucus doesn't have enough votes unless he can get Snowe to vote yes. But according to Rockefeller, the Republican leadership is bringing down the hammer on Snowe to vote no. But she is from a blue state and not up for reelection until 2012, so they have limited ability to pressure her. Also, Schumer is generally to the left of Rockefeller and Cantwell and if they don't like the bill, he probably likes it even less.
It is hard to guess what will come out of mark-up next week. A total of 543 amendments were submitted before yesterday's deadline. Rockefeller submitted one to create a government-run plan. Sen. Ron Wyden (D-OR) wants employers to offer a choice of at least two plans. Other amendments deal with the numerology: how poor do you have to be to get a subsidy, how much should Medicare pay doctors, and so on. Chances are a bill will emerge because everyone knows this is not the final step. Once the bill clears the committee, it has to be merged with the HELP bill, which means that Baucus and Harkin will have to duke it out, with majority leader Harry Reid and the White House watching very closely. Then the merged bill will go for a vote to the full Senate.
By then, Massachusetts will probably have a second senator, so the Democrats will have 60 votes and could invoke cloture to shut off debate if they all stick together. It is possible that Snowe will play an outsized role here. If she votes for the final bill, this may give cover to conservative Democrats like Sen. Ben Nelson (D-NE) and Sen. Mary Landrieu (D-LA) to vote for it, so it may pass using normal procedures. Needless to say, this situation gives Snowe enormous leverage to have the bill shaped the way she wants it, which is sure to displease Senate liberals.
If Snowe does not like the final bill and votes no, some conservative Democrats may join her in voting no. Then the Democrats would have to use the budget reconciliation procedure to get the bill through. This requires only 50 votes plus the Vice President, but the Senate parliamentarian, Alan Frumin, could rule that the bill does not qualify for reconciliation. However, the Senate could overrule him and even fire him, replacing him with a more accomodating parliamentarian. This is precisely what happened with the Bush tax cut bill of 2001. Then-parliamentarian Robert Dove ruled against the Republicans so majority leader Trent Lott fired him and installed Frumin.
A wild card in all this is the health of Sen. Robert Byrd (D-WV), who might not be able to make it to the Senate to vote. If he felt his absence was dooming health care, though, he could resign and let Gov. Joe Manchin (D-WV) appoint a new Democrat in his place. Byrd is not the resigning type, however. If he is technically alive, he'll probably vote.
Once the Senate has passed a bill, the real fun starts. The House and Senate bills will have to be merged into a single bill that can pass both chambers. A key issue here is who gets appointed to the conference committee. The Democrats will have the majority, but a committee featuring Baucus and Waxman could become a real food fight, as they are miles apart ideologically. If and when a report emerges from the conference, it goes back to both chambers for approval. Conference reports are subject to filibuster in the Senate unless there are 60 votes for cloture or the bill is part of the budget reconciliation process. At that point pressure will be immense on everyone and there is no telling what might happen.
