Points Of Tension: A Guide To The Senate Health Care Debate


Reid3This afternoon at around 2 or 3pm, Senate Majority Leader Harry Reid (D-NV) and Minority Leader Mitch McConnell (R-KY) will kick off the Senate’s long-awaited health care reform debate with dueling opening speeches and one amendment from each side. Even if lawmakers do not take a day off until Christmas, the Senate will have just 25 days to pass a bill before year’s end, an ambitious goal, considering that Reid has yet to secure the support of moderates Sens. Mary Landrieu (D-LA), Ben Nelson (D-NE), Blanche Lincoln (D-AR), Evan Bayh (D-IN) and Joe Lieberman (I-CT).

Republicans who have publicly stated that they want to kill the bill, will still offer myriad amendments to “improve” it. “We would like to start over,” Senator Jon Kyl (R-AZ) said on “Fox News Sunday.” “There’s no way to fix this bill.” But “fix” it they shall, or at least try to. Any amendment will require 60 votes, and the GOP’s so-called message amendments or ‘poison pills’ on immigration or abortion could both stall debate and force Democrats to cast a series of votes to weaken the bill. Sen. Tom Coburn (R-OK), “perhaps the most prolific amendment writer in the Senate,” “has hundreds of amendment ideas and is looking forward to a full and open debate,” his spokesperson said.

The Senate is expected to debate the bill for 3-4 weeks, after which Reid hopes to attract 60 votes to end debate and ultimately vote to pass the bill before the Christmas vacation. If he succeeds, a conference committee made up of members from the Senate and the House will then reconcile the differences between the House and Senate bills and produce a final report that each chamber will have to approve without amendments early next year. The President could then sign reform legislation before or shortly after the State of the Union.

Here is a guide for what to expect:


Current Language:
– The legislation establishes a national public health insurance plan and gives states the option to pass a law and opt-out by 2014.

Possible Amendments:
– Sen. Tom Carper’s (D-DE) proposal to trigger a national board that will sell insurance in states where private plans don’t offer affordable options. Sen. Chuck Schumer (D-NY) may offer a similar compromise that satisfies moderate Democrats opposed to the public plan.

– Sen. Olympia Snowe’s (R-ME) proposal to trigger a public option in each state where private plans don’t offer affordable options.

– Sen. Jay Rockefeller (D-WV) will likely offer an amendment to strengthen the public plan by allowing it to reimburse providers at Medicare-like rates and giving it access to the Medicare provider network.

– A Democrat may offer a provision that would trigger a robust public option that uses Medicare-like reimbursement rates if national health expenditures increase too rapidly.

– Republicans will likely offer a series of amendments to take the public option out of the health care bill.


– Lieberman, Lincoln, and Nelson have promised to vote against the final health care bill if it includes a public plan, while several Democratic Senators (like Sen. Jay Rockefeller) consider the public option essential to reform. The House Progressive Caucus has also promised to veto any bill that does not include a public option. Reid will have to craft a compromise that pleases both camps and could resolve the issue in a last minute manager’s amendment.


Current Language:
– Federal dollars can only be used to pay for abortions when the pregnancy threatens the life of the mother or results from rape or incest; private premiums must be used to pay for any other type of abortion, including those for health reasons. Each plan in Exchange will decide whether to cover additional abortion services and at least one plan in each market must offer abortion services and one plan must not. In the public option, the Secretary can cover abortion only if the procedure is financed with private funds.

Possible Amendments:
– Sen. Orrin Hatch (R-UT) is expected to offer an amendment to insert tough abortion restrictions in the bill. During the HELP Committee’s mark-up Hatch offered an amendment requiring that “no funds authorized or appropriated under this Mark may be used to pay for any abortion or to cover any part of the costs of any health plan that includes coverage of abortion.” Under Hatch’s amendment, women who purchase comprehensive private insurance packages — that include abortion services — would have to pay for the entire cost of the package (even if they qualify for subsidies) and obtain a separate rider for abortion coverage.

– Other Republicans may offer similar amendments, in an effort to insert Stupak-like language into the Senate bill.

– While the United Conference of Catholic Bishops is still looking for a Senator to introduce Stupak-like abortion language into the Senate bill, Democrats seem convinced that Republicans don’t have 60 votes to change the current abortion compromise. Pro-life Sen. Bob Casey (D-PA), who has suggested that he is satisfied with the existing abortion language, will be pressured to vote for tougher abortion restrictions and is expected to introduce amendments to prevent unwanted pregnancies.


Current Language:
– Undocumented immigrants are ineligible for government subsidies and cannot purchase coverage within the Exchange. Legal immigrants could qualify for tax credits outside of the 5-year waiting period. The Senate bill requires all applicants’ name, social security number, and date of birth to be verified with Social Security Administration (SSA) data. The information of immigrants is checked against DHS data to verify they are lawfully present in the US.

Possible Amendments:
– Republicans are expected to introduce amendments that would bolster the verification process and reinstate the five year waiting period for legal immigrants to receive tax credits. During the Senate Finance Committee’s mark-up, Sen. Chuck Grassley (R-IA) introduced an amendment to require an applicant to present a government-issued photo ID at the time of application for Medicaid or CHIP benefits. Sen. Mike Enzi (R-WY) wanted to require applicants for health insurance tax credits to supply a valid SSN of spouse and qualifying child in the individual’s tax filing unit even if spouse/child is not applying for a tax credit.

– Sen. Robert Menendez (D-NJ) may offer an amendment to allow undocumented immigrants to purchase insurance in the Exchange with their own money.


– Senators will not have 60 votes to change the immigration compromise, but may insert language to allow undocumented immigrants to purchase coverage with private premiums in conference committee. In the House, the 23 members of the House Hispanic Caucus have pledged to vote against any bill that bars undocumented Americans from purchasing insurance from the exchanges.


Current Language:
– The bill levies a 40% excise tax on insurers that sell policies above $8,500 (individuals) and $23,000 (families), increases the payroll tax by .5% (increases to 1.95%) on individuals who earn more than $200,000 and families earning more than $250,000 a year, taxes insurers, pharmaceuticals, and medicare devices and cuts $491 billion from Medicare and Medicaid.

Possible Amendments:
– Democrats may offer amendments to eliminate or increase the threshold for the excise tax.

– Republicans will undoubtedly portray any taxes as increases on middle class families and paint the Medicare cuts as ‘cutting care’ to seniors.

– While lawmakers may not have 60 votes to eliminate the provisions concerning Medicare savings or industry taxes, Reid may feel pressured to tweak the excise tax on Cadillac plans. Union leaders have termed the excise tax “a tax on the middle class since many labor groups will see some of their members affected by it. In addition, labor-friendly lawmakers have said it would break President Barack Obama’s campaign pledge to not tax those making less than $250,000 annually.” Meanwhile, moderate Democrats and most economists see the tax as one of the best ways to lower health care spending over the long term.


Current Language:
Large employers are not required to provide coverage to their employees but businesses would have to pay a fee if their workers receive subsidies through the exchanges. Employers would pay $3,000 per every employee who receives a subsidy in the Exchange, or $750 for every employee (not just the subsidized worker).

Possible Amendments:
– Progressive Democrats have portrayed the free rider as a discriminatory policy that disadvantages lower-income workers and minorities and Rockefeller or Kerry could offer an amendment that requires large employers to provide health insurance to their workers.

– Republicans view the current language as a tax on small businesses and will argue that a full-blown employer mandate would lead to job loss and lower wages. They are expected to introduce amendments that would eliminate the existing employer provisions.


It’s unlikely that Senators will have 60 votes to change the language. The issue may become a sticking point in conference when lawmakers will have to reconcile the free rider provision with the House’s employer mandate.