November 13, 2009 8:00 AM

Potholes mark the road to health reform

By DENA BUNIS
COLUMNIST
THE ORANGE COUNTY REGISTER
dbunis@ocregister.com

It's hard to know where to start when it comes to the political and policy pitfalls that can derail President Barack Obama's chances for health reform.

The Senate is poised to start debate on its bill within days. But we have still to see the details of the final bill Majority Leader Harry Reid will use as his opening play in this effort. Anyone who is participating in this drama would do well to get refundable tickets for any holiday travel.

(photo) As supporters of both sides of the health care debate issue passed on a Newport Beach street corner, Randy Lush of Newport Beach, left, made his position known to the approximately 90 public option health reform backers who rallied outside the office of Rep. John Campbell, R-Newport Beach on Thursday

Here's a look at the key flashpoints that supporters of health reform will have to look out for and that critics hope will scuttle this whole deal.

Abortion

This has the potential to blow up the debate even though it's a tangential element in the nearly trillion dollar health care overhaul.

At issue is whether pro-choice and anti-abortion rights Democrats can come to a meeting of the minds. The House-passed bill continues a more than two-decade practice of not using direct federal funds for abortion – as in the case of Medicaid funds. But it goes further than that. It says insurance plans in the new government health insurance exchange could not cover abortions. These exchanges are designed for people who don't have any other access to health coverage.

In the whole scheme of things, coverage for this one procedure is not going to make or break the vast majority of Americans. First, experts say that the majority of women who get abortions pay for it themselves and don't make insurance claims. Second, as with MediCal in California, a state can choose to enact provisions that pay for poor women to get abortions. And third, Planned Parenthood and other such organizations routinely help women afford abortions.

But as with many such issues, this is a political slippery slope. If indirect federal funding for abortions is curtailed, supporters worry that other assaults on this legal right will follow. Will abortion be excluded as an expense that can be included in the items people use to deduct medical expenses from their income taxes? Will federal assistance to hospitals that provide abortion services be disallowed? Can you see where this is headed?

Sen. Bob Casey of Pennsylvania, the most visible anti-abortion rights Democrat has said he is fine with the Senate versions that basically preserve the status quo. But Sen. Ben Nelson of Nebraska told a television reporter after the House vote that he liked the House language and wanted it in the Senate bill.

But in a conversation I had with Sen. Barbara Boxer this past week she said she believes Nelson is softening; that as long as he is convinced no federal funds are going to directly pay for abortions that he won't vote no on the whole bill based on that issue.

So Reid needs to find a way to thread this needle, not just to get the 60 votes he needs in the Senate but to make sure that whatever deal he makes on this issue will get approved in the House, where the majority of members are not pro-abortion rights.

Immigration

Immigration has more of a potential to take up time and make for some uncomfortable votes on amendments than to scuttle the bill. Lawmakers on all sides of this debate have pretty much agreed that illegal immigrants should not get any federal subsidies to help them afford health insurance.

What's still at issue is whether undocumented people should be allowed to go into the government exchange and buy insurance with their own money. The Senate Finance Committee version includes such a provision. The other Senate committee bills do not. Neither does the House-passed bill.

In a way this is a little like the abortion debate. It's the difference between banning a direct government subsidy and giving illegal immigrants indirect access to a plan essentially coordinated through the government.

The Finance Committee language has the blessing of the White House, which made it clear to immigration advocates several months ago that the administration was throwing illegal immigrants over the side so as not to kill health reform.

After Rep. Joe Wilson's famous "you lie" comments during President Barack Obama's health reform joint session speech, there was an added push to get something strong on this issue into the bill.

One senator to watch during the debate on this is Bob Menendez, a Democrat of New Jersey. If anyone it going to try to soften the Finance Committee language on immigration it's him.

At the other end of the spectrum, there could be a move to exclude legal immigrants from federal subsidies for the first five years they have legal status. Under current law, there is such exclusion for the Medicaid program.

There also was one for the State Children's Health Insurance Program but that was lifted earlier this year. Sen. Jon Kyl, R-Ariz., tried to get such a five-year waiting period amendment in the Finance Committee bill but failed. He could bring it up again on the Senate floor.

Sen. Joe Lieberman

This Democrat turned Independent could gum up the works for the majority.

Lieberman announced last weekend that he would not agree to bring any health bill to a final vote if it includes a public option.

That could be crucial because in order to end debate and move to a final vote, Reid needs every one of the 58 Democrats plus the two Independents - Lieberman and Vermont Sen. Bernie Sanders.

The debate over the public option has been muted for the past couple of weeks because there was never any doubt that the House bill would include one.

Reid plans on bringing the bill to the floor with the so-called "opt out" public option. That would allow states to say no to a public option. It's doubtful he has the votes to get that passed. What is looking more likely is the so-called "trigger.'' That would provide for a public option to kick in only in those states where the private sector did not provide an affordable health insurance plan for consumers in the government exchange.

The trigger option has the support of the one possible Republican vote in the Senate — Olympia Snowe of Maine.

The question is whether Lieberman would go for the trigger and not hold up a final vote if that's the public option element included in the bill after all the amendments are done.

The calendar

Obama has consistently said he wants a bill on his desk before year's end. Of course he also said he wanted something done by the August recess. Deadlines in this town don't mean very much.

But there is reason for supporters to worry about the calendar. The further into 2010 this effort goes, the less likely for success because the closer it is to the elections. Opponents are hoping for just that. The longer the debate goes, the more time they have to mobilize public opposition to put pressure on the third of the senators who are up for re-election next year.

The way it looks now, the Senate is likely to just be getting into serious debating when it will get interrupted for the Thanksgiving holiday. After that, there are only three weeks before the Christmas break. Assistant Majority Leader Dick Durbin has already speculated that the best the Senate can do before year's end is get its bill out of the chamber.

After that, there needs to be a meeting of the minds between the House bill and the Senate version. That could be the biggest pothole of all that lawmakers need to avoid.

We'll be watching.


Bunis is the Register's Washington bureau chief

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