The fate of President Barack Obama's top domestic priority — a remake of the U.S. health care system — now rests in the hands of a pivotal but deeply divided Senate committee.
Members of the Senate Finance Committee plan to start voting Tuesday on their version of a health care reform bill.
Democrats on the committee are disappointed with the bill proposed by the chairman, Sen. Max Baucus of Montana. Republicans see a chance to deliver a stunning blow to Obama that could cripple his presidency.
The stakes are so high because this isn't just another committee.
The 23-member committee is a microcosm of the Senate, the narrow gate through which legislation to cover the nearly 50 million uninsured Americans and try to control medical costs has to pass. If the committee can't produce, then the ability of Obama and the Democrats to pass a bill this year will be in serious question.
"If it can't get through the Finance Committee, the mountain that has to be climbed is a much higher mountain, and I don't know whether they'll have the ability to climb that mountain," said Christine Ferguson, a Senate Republican health aide during the Bill Clinton-era health care debate. Now a George Washington University professor, Ferguson was part of an unsuccessful effort to find a bipartisan deal.
Chairman has no Democratic support
Baucus, an optimist by nature, says he has the votes. "Oh, yeah — no doubt," he says.
But last week the chairman stood alone as he explained and defended his 10-year, $856-billion plan.
No Democrats joined him in front of the media — not even Sens. Kent Conrad of North Dakota and Jeff Bingaman of New Mexico, who spent months working with Baucus trying to find a compromise both political parties could support.
The second-ranking committee Democrat, Sen. Jay Rockefeller of West Virginia, promptly announced he couldn't vote for the bill without major changes. Senators have readied more than 560 amendments.
The Baucus plan would require all Americans to carry health insurance or pay a stiff fine. It would provide subsidies to many middle-class households and expand government health programs for the poor. Insurers could not deny coverage based on someone's personal health history.
The plan would be paid for with cuts in spending on Medicare and Medicaid — the government-run programs that provide health care coverage to the elderly and poor — as well as a heavy tax on high-cost health insurance plans. Baucus would not create a government plan to compete with private insurers. And workers at larger companies that offer coverage wouldn't see big changes.
‘This has to work for families’
While business and health industry groups generally have said good things about the proposal, core Democratic constituencies are angry.
Labor unions see the insurance tax as a direct threat to hard-won benefits. Liberals are outraged by the absence of a government insurance plan. There's widespread concern that Baucus' subsidies are too meager and will stick hard-pressed households with thousands of dollars in new insurance bills.
"At the end of the day, this has to work for families," said Democratic Sen. Debbie Stabenow of Michigan, a committee member. "The trade-off can't be that a middle-class family won't be able to afford the insurance in this bill."
Wave of amendments expected
Baucus can't ignore such concerns. With 13 Democrats and 10 Republicans on the committee, he doesn't have much room to maneuver for votes. At best, he may be able to win over one Republican, the moderate Sen. Olympia Snowe of Maine.
The committee staff tentatively has scheduled three days of work on the bill, but that may not be enough to handle the deluge of amendments.
Many Democratic amendments are geared to improving subsidies to make coverage more affordable and scaling back or replacing the 35 percent tax on high-cost health insurance plans. Also on their list: adding the public government-run plan favored by liberals, as well as a requirement that employers offer coverage.
Rockefeller is proposing to cap itemized deductions for the wealthiest taxpayers as an alternative to the insurance tax. He also wants to strike the nonprofit insurance co-ops that Baucus has proposed in lieu of a government plan.
Republicans say they're coordinating their amendments to highlight what Sen. John Ensign of Nevada calls "fundamental differences" with Democrats.
The top committee Republican, Sen. Chuck Grassley of Iowa, said Baucus' insurance requirement and fines as high as $3,800 for going without coverage amount to "a penalty against middle-class Americans."
Republicans will try to bar funds for abortions and tighten rules to prevent benefits from going to illegal immigrants, although Baucus says his bill already does both. And they're pushing for a bolder approach on limiting medical malpractice lawsuits.
Pass now, work out issues later?
Many committee members would like the bill that emerges to be significantly different from the plan Baucus placed before them.
But they're up against a hard barrier on costs. Obama has said he wants legislation that costs about $900 billion over 10 years. The Baucus plan is right under that level. Sweeten the subsidies too much and the cost could zoom above $1 trillion.
That's why Democratic leaders and major interest groups backing a health care overhaul are urging the committee to pass a bill now — and try to work out problems later.
Action by the committee is the first of four big steps before any legislation can be signed into law.
Next, Senate Majority Leader Harry Reid of Nevada would "meld" the Finance Committee bill with a more liberal measure from the Senate Health, Education, Labor and Pensions Committee. Then, the House and Senate would each pass its own version of legislation. Finally, a negotiating committee with representatives from each chamber would have to reconcile the two bills.
"The important thing is to keep moving the process forward, and to keep the big goals in mind, even if there are concerns about the specifics," said John Rother, the top policy strategist for AARP, a lobbying group for older Americans.