Fearing a backlash, Democrats worked to smooth the impact of sweeping health care legislation on working-class families Thursday as they pushed President Barack Obama's top domestic priority toward a crucial Senate advance.
The most far-reaching overhaul in a generation aims to protect millions who have unreliable coverage or none at all and to curb insurance company abuses.
Agreement by the Senate Finance Committee is now all but certain for the legislation, which would bar insurance companies from denying coverage or charging higher premiums on the basis of pre-existing medical conditions. It also includes federal subsidies to make insurance available to millions who lack it, and it takes steps to slow the skyrocketing growth in health care costs nationwide.
The panel's verdict was sealed after months of private and public struggle, although no final vote was expected until next week. That formality — Democrats hold a 13-10 committee majority — will clear the way for the full Senate to begin debating the measure at mid-month.
Supporters said the overhaul's cost was in the range that Obama has set, about $900 billion over a decade, and would not raise federal deficits.
The House is considering companion legislation on an issue that dwarfs all others in Congress and is causing supporters and opponents to spend more than $1 million a day on television advertising to sway the outcome.
Allowing state negotiations
After days spent largely turning aside Republican calls for changes in the bill, Senate Democrats coalesced behind two of their own that could alter the legislation in significant ways.
One, backed by Sen. Maria Cantwell, D-Wash., would allow states to negotiate with insurers to arrange coverage for people with incomes slightly higher than the cutoff for Medicaid, the government health care program for the poor. That change was approved.
A second, still pending, would exempt millions from a requirement to purchase insurance that is currently in the bill. As it stands, individuals and families would be required to buy coverage as long as it cost no more than 10 percent of their income, and would have to pay a penalty if they refused.
The Cantwell proposal is based on a system in Washington state that she said results in lower-cost, high-quality coverage, generally delivered through managed care, as the state uses its purchasing power in negotiations with insurers.
Republicans questioned whether the impact would be to raise insurance premiums for others, and said they were fearful the result would be to reduce health care options.
Cantwell said the first concern was unfounded, and added Washington currently has as many as four choices for residents currently covered by the state program.
"If your governor and your legislators don't want to negotiate on behalf of their citizens, that's their political problem." she responded to critics.
The provision passed, 12-11, on a near party-line vote.
It is designed to allow coverage for individuals and families between 133 percent of poverty and 200 percent of poverty. For individuals, that means incomes between $14,403 annually and $21,660. For families of four, the eligibility would be $29,326 to $44,100. Aides said 30 million or more of the nation's uninsured are in that income range.
Warnings of a backlash
As for the penalty for people who decline to buy insurance, Republicans and even some Democrats have warned of a potential backlash without changes.
Sen. Charles Schumer, D-N.Y., proposed lowering the threshold for requiring coverage to 8 percent of income, a level that he acknowledged would result in an estimated 2 million additional individuals and families staying uninsured in comparison with the original bill.
For those still covered by the requirement, Schumer also proposed reducing the penalty for failure to comply.
"These are people solidly in the middle class," he said.
Currently, those ignoring the purchase requirement would pay a maximum penalty of $750 for individuals and $1,900 for families.
Under Schumer's change, no penalty would apply until 2014, when the maximum would be $475 for individuals and $950 for families. The amounts would rise the following year.
Republicans expressed some interest in supporting the changes, but Sen. Olympia Snowe urged a delay in the vote.
"It's not about punishing people. It's about getting it right on affordability," said the Maine Republican.
Sen. Max Baucus, D-Mont., chairman of the committee, agreed — an unspoken acknowledgment of Snowe's influential position as the only Republican in Congress viewed as a potential supporter of the legislation.
Across the Capitol, Democratic leaders in the House met privately with moderate members of the rank-and-file, with liberals, and then with first-termers as they struggled to achieve a consensus on legislation to bring to the floor. Majority Leader Steny Hoyer announced at midday it would probably be at least two more weeks before House legislation was ready.
Under the bills in both houses, most insurance policies would be required to cover preventive care as well as treatment for illnesses, surgery, vision, dental and mental health care.
In general, the legislation is designed to encourage employers to retain coverage they now provide, and workers to remain enrolled. Policies would be available — for those who have coverage and those who don't — through so-called insurance exchanges.
For the first time, individuals would be under the requirement to purchase insurance or face penalties. To help the lower-income buy insurance and prod small businesses to offer it, federal subsidies would be available on a sliding scale to defray the cost of premiums.
The costs would be borne through a variety of taxes on health care providers, as well as hundreds of billions of dollars in cuts in projected Medicare and Medicaid spending.