- The Washington Times - Sunday, October 18, 2009

You may think Democrats and Republicans are at odds over health care. Well, they’ve got nothing on House and Senate Democrats going after each other.

The intraparty disputes may prove the most grueling test of all as Congress tries to write a bill that fulfills President Obama’s goal of extending coverage to millions of Americans and reining in rising medical costs.

The disagreements extend well beyond whether to allow the government to sell insurance in competition with the private market, though fissures over the so-called public plan - preferred in the House and less so in the Senate - have drawn the most attention.

Some of the toughest fights loom over what requirements employers should have to shoulder to see that their workers are covered, and perhaps stickiest of all, how to make coverage affordable and pay for extending it to millions of uninsured.

Senators would tax high-value health insurance plans to pay for covering the uninsured, an approach supporters say would curb health costs because it would lead to employers offering less generous benefits. The more populist House would tax the highest-income people, placing the burden of caring for the neediest Americans on the backs of millionaires.

“I don’t know how you split that difference,” said Rep. Artur Davis, Alabama Democrat, a member of the House Ways and Means Committee. “It’s not just about numbers. These are philosophical differences about how you pay for reform.”

Any showdown between the House and Senate is a ways off, and will happen only if both succeed in passing their own health bills. Democratic leaders in both houses are working to finalize their legislation - a process that is itself fraught with difficulties - in time to hold floor debates within the next several weeks.

Presuming the House and Senate do pass bills, they would go to a conference committee made up of Democratic leaders and key committee chairmen from both chambers. There, with plenty of input from the White House, the most powerful members of Congress would fight it out in private.

Senate Majority Leader Harry Reid, Nevada Democrat, put it mildly last week: “There are different views in the House.”

Democrats are increasingly optimistic about the possibility of success on health legislation, and they’re quick to point out the many areas where the House and Senate legislation overlap.

Both are expected to carry price tags of about $900 billion over 10 years. Both would require almost all Americans to purchase insurance, and contemplate subsidies for lower-income people. Both set up new marketplaces or exchanges where individuals and small businesses could shop for and compare insurance plans. Both put new requirements on insurance companies, barring them from dropping sick people or refusing coverage to people with pre-existing medical conditions.

Even within these commonalities there are differences that will have to be worked out in what are sure to be tough and lengthy negotiations. But the big sticking points are these:

• Government insurance. House Democrats are adamant about allowing the government to sell insurance to people who don’t have affordable care and are too young for Medicare or make too much money for Medicaid. The leading Senate bill contains no such public option, and even if senators ultimately agree to some public plan variant, it’s certain to be much weaker than the House version. House Speaker Nancy Pelosi, California Democrat, has staked out an uncompromising position on the issue.

• Employer responsibility. The House includes a requirement for employers to provide insurance coverage to their employees or pay a penalty. There’s no such mandate in the leading Senate bill. Instead, employers would be required to pay a fee for any employee who obtains coverage with government subsidies. The distinction may seem subtle, but it makes a big difference to business groups and Democrats on both ends of the ideological spectrum.

• Paying for the bill. In recent weeks, the issue of affordability has become central to the health-overhaul debate, in part because it’s a critical concern for Sen. Olympia J. Snowe, Maine Republican, who has considerable leverage as the only Republican in Congress to have voted in favor of Democratic health care legislation. The House offers more generous subsidies to lower-income people than the Senate, and senators have already talked about adjusting their subsidies upward. That’s where the cost of the bill and the different methods used to pay for it in the House and Senate come in.

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