Health Reform Faces Difficult Senate Tests

Broad Disagreements Over Public Option, Cost, and Policies

Medically Reviewed by Louise Chang, MD on November 09, 2009
From the WebMD Archives

Nov. 9, 2009 -- The health overhaul bill that passed the House of Representatives late Saturday night contains lots of reforms to the medical system. But many of them are likely to change substantially before they are ever signed into law.

The Senate is also working on a health bill, and, while it is similar in many ways to the bill passed by the House of Representatives, some of the differences are fundamental. It is also an open question whether Democrats in the Senate will be able to reach a compromise at all on President Barack Obama’s top domestic priority.

The $1.2 trillion House bill tries to make insurance more accessible by creating a national insurance marketplace, called an "exchange," where private plans can offer coverage to individuals and small businesses who can’t find it elsewhere. The coverage on the exchange has to meet government-mandated coverage minimums.

In addition, the House approved a government-run public option plan that would compete with private plans on the national exchange. Government analysts predicted the public plan in the House bill would attract about 6 million members. Analysts also warned it could have higher premiums because those members may tend to be older and sicker than average.

The House bill also includes:

  • A mandate requiring individuals to carry health insurance starting in 2013. Those who don’t buy coverage would have to pay a fine unless they can show financial hardship or religious objections.
  • A mandate requiring employers to purchase at least basic insurance coverage for their workers. Employers with a total payroll under $500,000 are exempt from the requirement. Businesses that don’t buy coverage would have to pay fees into a coverage pool.
  • Subsidies to help people buy coverage. The bill expands the Medicaid health insurance program for the poor to cover more people, and also offers tax credits and cash assistance to help millions of individuals and families buy coverage. The subsidies are on a sliding scale: Individuals making up to about $43,000 per year and families making up to about $88,000 would qualify for assistance. Those subsidies and credits are only available to U.S. citizens and legal residents.
  • Limits on insurance companies. Insurers would no longer be able to deny coverage based on pre-existing conditions and would not be able to drop policy holders who get sick (a policy called “rescission”). Insurers could still charge older policy holders higher premiums, however.
  • Requirements that insurance plans cover preventive health care services.
  • Prohibitions preventing any private plan offering insurance on the exchange from covering abortions. Customers wanting coverage for abortions would have to buy a separate rider.

The bill squeaked by in the House Saturday in a 220-215 vote.

“For all of my friends in the press who’ve been assaulting me in the hallways asking if we had the votes, the answer, is ‘yes,’” House Majority Leader Steny Hoyer said following passage of the bill Saturday night.

The answer was "yes," but only barely. Thirty-nine Democrats voted against the bill, while just one Republican supported it.

That could forecast a very difficult road for health reform legislation in the Senate.

Most of the difficulty is around the public option plan. Senate Majority Leader Harry Reid has said he intends to include a public option in a bill headed for the floor in the coming weeks. But Sen. Olympia Snowe, R-Maine, the only Republican to back a health overhaul in the Finance Committee, has since pledged to oppose it if it includes any form of public option.

Meanwhile, several moderate Democrats have expressed their displeasure with the public option. Sen. Joe Lieberman, a Connecticut Independent who usually votes with Democrats, last weekend repeated his pledge to oppose any bill that contained the policy. Other, more liberal Democrats have pledged to back a bill only if it does include a strong public option.

The Senate Finance Committee also backed away from the House’s idea of requiring employers to cover their workers. Instead, it embraced a policy requiring most individuals to purchase coverage, with subsidies and tax credits to help lower and moderate income people cover the cost.

The House and Senate also disagree on the overall cost of the package. The House’s bill is estimated to cost $1.2 trillion over 10 years, while the Senate bill is expected to cost around $900 billion. Both bills do not add to the deficit over that time, according to the Congressional Budget Office.

Finally, the senators have backed the idea of taxing high-cost health plans as a way to help discourage excess medical spending and as a way to raise money to pay for the plan. The House approved a surtax on wealthier individuals making more than $500,000 and families making $1 million.

“I’m concerned that they get their 60 votes to pass a bill and start negotiating with us,” Rep. Henry Waxman,D-Calif., said of the Senate on Saturday night following the House vote. “But that’s their job now, and we’ve done ours."

Show Sources


Affordable Health Care for Americans Act, H.R. 3962.

Congressional Budget Office.

Rep. Steny Hoyer, House Majority Leader.

Rep. Henry Waxman,D-Calif., chairman, House Energy and Commerce Committee.

Henry J. Kaiser Family Foundation: "Side-by-Side Comparison of Major Health Reform Proposals."

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