President Obama’s most recent plan is for the House to adopt the Senate’s bill, and then for both chambers to use the reconciliation process to approve a measure smoothing over the substantial differences between the original House and Senate versions. The reconciliation process, typically used for budget bills, would prevent Republicans from launching a filibuster now that Senate Democrats have lost their 60-vote majority.
Despite surfacing discussions of being one vote away, an article in the Wall Street Journal by Michael Barone argues that, as of today, Speaker Pelosi does not have enough votes to pass the bill. The House has repeatedly “brushed aside” calls by the White House for a vote before March 18, when the President leaves for Asia, assumedly because House Democratic leaders know they do not yet have enough votes to pass a bill, according to Mr. Barone. Of the 220 House members who supported the legislation last fall, the single Republican supporter will now vote no, one Democrat supporter passed away and two other Democratic supporters have since resigned. This gives Democrats exactly 216 votes if all remaining Democrats who supported the House bill approve the Senate bill, which would be a challenging feat for Speaker Pelosi, according to Mr. Barone.
Key provisions in the Senate bill that have been particularly divisive for House Democrats include abortion coverage for enrollees of government-funded health plans and provisions assumedly included in the Senate bill to gain votes from specific senators, such as the so-called Nebraska deal, which would use federal funds to cover the cost of newly eligible Medicaid enrollees in Nebraska. Several House members seem to be apprehensive of passing the Senate bill without assurance that the reconciliation process would be used to change certain provisions within the Senate bill. On the abortion side, Rep. Bart Stupak (D-Mich.) seems to be leading the charge, pushing for more conservative language that would bar individuals receiving federal subsidies to purchase any health plan that includes elective abortion coverage. The Senate Bill allows individuals to purchase plans to include abortion coverage, but would require individuals to make two monthly premium payments, paying separately for abortion coverage, according to a report by the New York Times. Rep. Stupak has said that the abortion issue could jeopardize up to 12 votes in the House, according to the same New York Times’ report, but in a recent show of support to the President, he did state that he believed the issue could be solved. Speaker Pelosi recently said that the abortion issue would not derail her efforts and that the bill does not represent a change in access to abortion, according to a report by the Washington Post.
2. As federal efforts to pass comprehensive legislation more forward, so do state efforts to render the efforts ineffective. Last week Virginia became the first state to pass legislation that will prohibit health insurance mandates and makes clear that no individual can be required to obtain coverage. Virginia is one of 36 state legislatures that have taken steps to limit, alter or oppose comprehensive reform by the federal government, according to the National Council of State Legislatures. In addition to Virginia, Idaho and Utah have advanced bills to alter state law in a way that would block at least some of the goals of federal reform. The 25 other states are seeking to amend their state constitutions to limit federal reforms. In most, but not all cases, these states are considering adding language to their constitutions to protect citizens from being required to purchase health insurance coverage. Arizona was the first state where both the House and Senate approved such changes to the constitution, and the measure will face a state-wide vote on the November ballot.
In addition to state legislatures, several state attorneys general have also considered legal action to challenge the constitutionality of a federal comprehensive reform bill that includes coverage mandates. The Senate bill, if passed by the House, faces additional scrutiny as 13 state attorneys general have already publicly questioned the constitutionality of the bill’s “Cornhusker Kickback” provision. Legal scholars, however, contend that overturning a law on the basis of constitutionality is very difficult as courts usually defer to legislative bodies when determining constitutionality claims.
3. Lawmakers concerned with bill’s cost. The White House has estimated the cost of the reconciled plan proposed by President Obama at $950 billion over 10 years but claims that the bill would ultimately reduce the federal deficit by $100 billion.
According to a recent piece by New York Times‘ economic columnist David Leonhardt, the bill “relies on accounting gimmicks” to cover its $950 billion price tag. These “gimmicks” include calculating the 10-year cost from 2010-2020, even though coverage will not be expanded until 2014, delaying the costs associated with covering 31 million additional Americans until then, according to Mr. Leonhardt. The cost estimates also assume that Congress will not use the legislative process to change any of the taxes or payment cuts included in the bill to be phased in over the next 10 years, which seems unlikely given the potentially drastic cuts and political clout of physician and healthcare organizations like the AMA and the AHA in the legislative processes. While cost concerns might not be enough to stop reform efforts in its tracks, they are certainly concerning to financially minded lawmakers on both sides of party lines, including centrist Democrats.
