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How many Americans will get subsidized medical
coverage - plus who will pay for it - will be front-burner issues
when Congress returns next month to complete President Barack
Obama's health care remake.


      Pocketbook concerns join abortion and whether Uncle Sam should
peddle insurance as the top bones of contention for negotiators who
must resolve difference between the House and Senate bills.


      The negotiations are the last chance for Democrats to shape the
legislation to deliver concrete benefits to Americans skeptical
that it will help control skyrocketing premiums as it expands
coverage to millions more.

      "People will really begin to focus on some of the core issues
that have received less attention," said Rep. Chris Van Hollen,
D-Md., a member of the House leadership. "These are the
bread-and-butter issues that will have the most significant impact
on people's pocketbooks."

      Broadly speaking, both bills would gradually expand coverage,
while banning objectionable insurance industry practices such as
turning down people with health problems. Eventually, all Americans
would be required to carry health insurance, with government
subsidies to make premiums more affordable for many of them.


      Those covered by big employers wouldn't see major changes, but
individuals buying their own policies and small businesses would be
able to shop for competitively priced plans in an insurance
supermarket called an exchange. Medicare cuts and an assortment of
taxes and fees would pay for the bills.


      Democrats are under pressure to reconcile the House and Senate
versions before Obama's first State of the Union speech. Not yet
scheduled, it's usually delivered in late January or early
February. Republicans will wage legislative guerrilla warfare to
delay an agreement.

      There's not much time, and apparently not much give either.


      Senate moderates say they won't vote for a bill that changes the
basic terms they agreed to with Majority Leader Harry Reid.


      Independent Sen. Joe Lieberman of Connecticut and conservative
Sen. Ben Nelson, D-Neb., have drawn a line against reintroducing a
government-run insurance plan to compete with the likes of Aetna
and Wellpoint. The House bill includes it, but Reid, D-Nev., needs
every member of his 60-vote coalition to hold off GOP opponents.

      More difficult to solve is the issue of how to restrict taxpayer
funding for abortions. Abortion opponents disagree among themselves
over the Senate's approach. Abortion rights supporters are
completely against the more restrictive House language and are
divided on how the Senate has handled it.


      Obama will probably have to step in to settle disputes and keep
things moving.


      Democrats have options on how to handle the negotiations. They
could agree to a limited set of changes, allowing each chamber to
pass identically amended bills. Or they could set up a formal
conference committee to resolve differences. Leaders have made no
decision yet. Naming a conference committee would signal that the
issues have proven difficult.

      Yet the longer Democrats argue, the more suspicious the public
becomes about remaking the health care system. "The making of
salami and legislation is not pretty for people to watch," said
Harvard professor Robert Blendon, who tracks public opinion on
health care. "It has left them nervous that the interests of
middle-income people are not being served."


      That's one reason leading Democrats are arguing for a focus on
pocketbook issues in the homestretch.


      "There will be a certain amount of replaying issues that have
been hot-button issues, but I think there will also be a
refocusing, especially on cost," said Senate Budget Committee
Chairman Kent Conrad, D-N.D. "At the end of the day, when all of
us go home, what we hear about is the ever-increasing,
ever-escalating costs."


      There are some signs of that already.

      Last week, Reid pledged on the Senate floor to close the
coverage gap in Medicare prescription benefit - as the House bill
already does. The message was aimed at seniors worried that
Medicare cuts to hospitals and other providers will jeopardize
their care.


      And Conrad said senators may go along with the House timetable
for expanding coverage, which calls for starting subsidies in 2013,
a year earlier than the Senate bill.


      The House bill provides coverage to 36 million, while the Senate
covers 31 million. Lawmakers in the House want the Senate to move
toward their number.


      Another priority will be to make sure the final bill promotes
competition in the health insurance market, which in many states is
dominated by one or two large carriers.

      Though it sounds arcane, a major problem for negotiators is
whether the new insurance supermarket should be state-based, as in
the Senate bill, or national, as the House calls for. Some
advocates say a national approach provides stronger consumer
protection.

      Finally, the issue of who to tax won't be easy.


      Unions are adamantly opposed to the Senate plan, which would
impose a 40 percent tax on high-cost health insurance above $8,500
for an individual plan, $23,000 for families. Organized labor sees
the tax on so-called Cadillac plans as a hit on its members, who
have fought for years for better-than-average coverage. Unions are
a core Democratic constituency and many House Democrats want to
knock out the insurance tax.


      The Obama administration, however, supports such a tax. In a
recent session with reporters, White House economic adviser
Christina Romer called the tax "a very effective cost-growth
containment mechanism," arguing that it will force people into
more efficient plans.

      Rep. Joe Courtney, D-Conn., wasn't buying it. "The most
troublesome component of the Senate bill remains the 40 percent
excise tax on high-cost health care premiums," he said. More than
190 House Democrats agree. Instead, they want to tax upper-income
earners.

Gallery

How many Americans will get subsidized medical
coverage - plus who will pay for it - will be front-burner issues
when Congress returns next month to complete President Barack
Obama's health care remake.


House and Senate look to final health care talks

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