A top-to-bottom remake of the U.S. health care system along the lines sought by President Barack Obama moved a step closer to reality Tuesday as the Senate Finance Committee approved a 10-year, $829 billion plan that would extend coverage to millions more Americans and seek to hold down spiraling health costs over the long term.
The Finance Committee was the last of five House and Senate panels with jurisdiction on the issue to act on health overhaul legislation. Here's what happens next:
IN THE SENATE
Majority Leader Harry Reid, D-Nev., must merge the Finance Committee bill with a more liberal version passed by the Health, Education, Labor and Pensions Committee, the panel formerly led by the late Sen. Edward M. Kennedy, D-Mass.
Reid will do the work in closed-door sessions with Senate Finance Chairman Max Baucus, D-Mont., and Sen. Chris Dodd, D-Conn., who presided over the health committee in Kennedy's absence. Key White House aides including Chief of Staff Rahm Emanuel will be in close consultation.
Reid will face numerous crosscurrents as he aims to produce a bill that can attract 60 votes in the 100-member Senate, the number needed to overcome a Republican filibuster. A key question is whether he includes any version of a provision to allow the government to sell insurance in competition with the private market, something that's supported by liberals but viewed skeptically by some moderate Democrats, and uniformly opposed by Republicans.
The Finance bill does not include such a so-called public plan, while the health committee's bill does.
Democrats control 60 Senate votes, but they can't be certain of support from moderates such as Joe Lieberman of Connecticut and Ben Nelson of Nebraska. So Reid will be courting moderate Sen. Olympia Snowe of Maine, who was the lone Republican to vote for the Senate Finance Committee bill, if not others in the GOP.
Under the Senate's arcane procedures, if 60 votes appear out of reach Democrats have the option of pursuing a parliamentary maneuver called "budget reconciliation" that would allow them to pass the health care bill with a simple 51-vote majority. That would likely result in a weaker bill since non-budgetary items could be ruled out of order.
Reid is aiming to finish the merger process in time to begin debate the week of Oct. 26. The debate could take weeks with numerous amendments by lawmakers from both parties and several procedural votes before a vote on final passage.
IN THE HOUSE
Speaker Nancy Pelosi, D-Calif., and other Democratic leaders have been working for weeks to combine bills approved by three committees over the summer. Pelosi has been struggling to satisfy the concerns of moderate and fiscally conservative Democrats in her caucus _ who include some of the most politically vulnerable lawmakers in the 2010 midterm elections _ without alienating liberals.
Disputes have centered on the shape of a new government insurance plan that would compete with the private market, Pelosi's plan to pay for the bill by taxing high-income Americans and regional disparities in Medicare reimbursements. Disagreements also center on language preventing federal funds for abortions and keeping illegal immigrants from getting government-funded coverage.
The health overhaul bill in the House is not expected to win a single Republican vote. There are 256 Democrats in the 435-member House so Pelosi could lose 38 Democrats and still attract the 218 votes necessary to pass the legislation by the simple majority required in the House (although there are currently two vacancies).
Pelosi is aiming to begin floor debate later this month.
IN THE WHITE HOUSE
After a series of missed deadlines, Obama is now aiming to sign a health overhaul bill by year's end.
Obama left much of the bill-writing work to lawmakers, though top aides were closely involve along the way. The president will have a critical role to play in the days ahead. Most importantly he'll act as cajoler in chief, reaching out to wavering lawmakers to shore up their support, and using his bully pulpit to try to rally public sentiment.
Obama has been holding regular meetings and phone calls with Democratic senators, both liberal and moderate. He had a meeting Tuesday afternoon with Sen. Evan Bayh, D-Ind., one of the moderates whose votes could be critical.
Obama's top lieutenants _ Emanuel and Nancy-Ann DeParle, head of the White House Office for Health Reform _ are helping to referee disputes on final bill language in the House and Senate.
IN THE LOBBY SHOPS
Industry players, some of whom had been working behind the scenes with key White House and congressional players to blunt the effect of the health overhaul on their businesses, are stepping up their lobbying efforts against key aspects of the health legislation as it becomes clear how costly it will be for them.
This is especially true of large insurers, who have balked at new fees, taxes and requirements the measure would slap on them, particularly since they fear that their primary incentive for backing the overhaul _ that it would bring them millions of new customers _ has been weakened considerably.
Drug makers are still fighting to keep intact a deal they cut with the administration and top Democrats earlier this year to limit their costs, and have worked with their champions in the Senate to beat back several efforts that would have opened them to billions more in expenses.
A wide array of specialized health interests, such as medical device makers and clinical laboratories, are also struggling to fend off new fees they would have to pay to finance the measure. They're targeting senators who represent states that house companies that would be hardest hit.
The business lobby, which has mostly remained quiet on the measure until now, is gearing up to oppose it, worried about opening a wide variety of companies to increased health costs and regulations.
The Finance Committee bill is also coming under attack from the left. About 30 unions planned to run a full-page ad in newspapers Wednesday announcing their opposition to the legislation because it lacks a publicly run insurance plan and would tax high-value insurance plans, which they fear could affect union workers. Sponsors included the AFL-CIO and the Communications Workers of America.
The liberal group MoveOn.org also announced plans for a weeklong cable TV ad featuring a former insurance company executive denouncing the Finance Committee bill as a giveaway to the insurance industry.