With the House having approved its version of a healthcare reform bill on Saturday, Democrats in Congress are now closer to passing major reform than they've been in decades. That doesn't mean they're truly close, though -- there are still a lot of issues to be ironed out, and a fair number of potential obstacles that could arise to derail the whole process.
The public option remains a major stumbling block, for one thing, and the issue of coverage for abortion, which has been simmering under the radar for some time now, finally exploded with the addition of the Stupak amendment to the House's legislation.
All this can get pretty confusing, even for people paying close attention. So Salon has put together the list below, addressing some of the most common questions out there, from what kinds of restrictions the Stupak amendment places on abortion coverage and whether it will be in the final bill, to the public option's chances and the current timetable for getting a bill signed.
1. What's the deal with the Stupak amendment? Why is it in the bill?
The Stupak amendment, which has been a target for criticism from the left this week, restricts coverage of abortion, expanding an old prohibition on federal funds being used to pay for abortions. A late addition to the House bill, the amendment is in the legislation because, simply put, the bill would have gone down to defeat without it.
Democrats had long maintained that their proposals didn't provide taxpayer money to pay for abortions, but the right had been alleging that wasn't true, and that was enough to scare some moderate members, not to mention energize the pro-life Democrats in the House. The abortion issue had caused a stalemate in the House, and could have led to further delay in getting the bill passed, but Speaker Nancy Pelosi wanted to get it done over the weekend; thanks to the Stupak amendment, she did.
Pelosi has taken a fair amount of heat for agreeing to allow a vote on the amendment, which she knew its supporters would win, but she didn't have much choice. Majority Whip James Clyburn has said that adding the provision won Democratic leaders 10 votes -- the margin of victory when the House approved the bill late Saturday night was just three votes.
2. What does the Stupak amendment mean for me? Will my insurance stop covering abortions?
Well, there's some debate about that. Opponents, like Rep. Nita Lowey, D-N.Y., or Firedoglake's Jon Walker, contend that it would prevent women from purchasing insurance that covers abortion even if they buy that coverage with their own money. Walker, for instance, pointed to a passage in the amendment that says no funds appropriated in the bill could be used to "cover any part of the costs of any health plan that includes coverage of abortion." The amendment itself, however, is pretty clear that what that's referring to are specific individuals' or families' plans, not a plan or provider generally. (That is, Jane Doe's insurance can't include abortion coverage if she's getting government money to help pay for it, but Blue Cross can offer such coverage on plans not available to people receiving that money.)
Still, the amendment will have the effect of separating women into classes: Those who can afford to buy their own insurance without government help will have the choice of a plan that covers elective abortions, while those who need the subsidies won't have the option. They will be able to purchase separate coverage, but that won't be subsidized, and it strikes many opponents of the amendment as a pointless idea, and with good reason -- that would mean people planning for unplanned pregnancies.
3. How much of this abortion stuff is likely to be in the final bill?
That's a very good question. At this point, it seems inevitable that some sort of abortion restriction will be included if and when the legislation makes it to President Obama's desk. It also seems likely that the exact language in the Stupak amendment won't make the cut.
House Democratic leaders, like Clyburn and his deputy, Rep. Debbie Wasserman Schultz, have said they believe the Stupak amendment will be removed from the legislation when the House and Senate iron out the differences between their bills in committee. Separately, Obama has indicated that he thinks the language needs to be changed. Plus, 41 House Democrats have signed a letter to Pelosi in which they promise not to vote for the final bill if it "contains language that restricts women’s right to choose any further than current law." Beyond that, pro-choice groups and activists are extremely angry about the amendment, and are fighting hard against it. And given the pivotal role the movement plays in the Democratic Party, not to mention the party's reliance on winning a majority of women's votes, it's hard to believe there won't be at least some concessions.
There's an "on the other hand" here, though. First of all, Democrats still need those 10 votes in the House. Then, too, there's the Senate, where Majority Leader Harry Reid can't afford to lose any votes if he's going to defeat a Republican filibuster. Sen. Kent Conrad, D-N.D., a potential swing vote, has said he doesn't believe the Senate will pass any bill that doesn't include restrictions on funding for abortion. Another senator who's been on the fence, Nebraska's Ben Nelson, told Salon he thinks the legislation "should have a prohibition on spending federal money on abortions."
4. Did the House get a public option in the bill? What kind?
The House bill would set up a public option as part of the insurance exchange for people who don't have insurance through their jobs. But it wasn't quite as "robust," to use the word lawmakers like to throw around, as progressives were hoping. The House would force the public plan to negotiate rates for services, medicine and procedures with doctors, drug companies and hospitals the same way private insurers do. The price the plan gets would probably depend in part on how many patients wind up buying into it; the Congressional Budget Office has estimated about 8 million people, which might not be enough to give the plan as much bargaining leverage as progressives wanted.
The more robust version of the public option would have tied reimbursement rates to Medicare, which -- because it covers 45 million people -- has the power to force providers to take lower prices. Progressives wanted the public option to pay 5 percent higher than the Medicare price, which could have saved more money. But just about every industry group -- doctors, hospitals, drug makers and insurance companies -- argued that that would just lead to higher prices for private insurance firms, and in the end, the votes weren't there.
5. What about the public option in the Senate?
That's one of the issues holding up the progress of the Senate's version of the healthcare bill. Reid has proposed a public option that states could decide not to offer, hoping to placate the concerns of some conservative Democrats worried that their constituents will oppose any government-run health plan. (Independent Joe Lieberman, of Connecticut, still says the public option is "wrong" and that he won't vote for any bill that includes one.)
Even some of the strongest supporters of a public option admit they may not have the votes to push it through. "We're still trying to find that level at which the caucus will feel that it's being treated fairly, and it won't alienate any member of our caucus to vote against it," Sen. Ben Cardin, D-Md., told Salon Tuesday. "I don't know how the vote comes out on the floor of the Senate -- I just don't know. I don't know whether we have a majority or not that will support a modified public option. I think it's going to be kind of close."
Still, considering the conventional wisdom for most of September and October was that the public option was dead on arrival in the Senate, the fact that Reid decided to push ahead with even the modified public option was a victory for progressives.
6. What happens next? And when might all of this get done?
The Senate is scheduled to have a bill introduced before the Thanksgiving recess, though lawmakers won't actually get around to debating it until they come back on the Monday after the holiday. One senior Democratic aide says the Senate should be able to pass its version of the legislation by the end of the year "for sure," but meeting Obama's goal of getting the final bill to the White House for his signature by New Year's will take "a lot of luck." Sen. Dick Durbin, D-Ill., the second-ranking Democrat after Reid, said Tuesday that that probably won't happen.
If the Senate does pass its bill, then the White House and Congress will have to come up with a way to merge the two versions. That could lead to a whole new round of disputes and negotiations over abortion rights, the public option and the cost. But at this point, the administration would happily take on that set of worries.
It's almost a given at this point: Any time a Congressional Republican's commenting on the Democrats' healthcare reform bills, they'll likely bring up their length. Some will just mention the 2,074 pages in the Senate version, others will tally the amount of dollars spent per word, some will tell you it's longer than "War and Peace." It's a way to suggest that the bill is impenetrable, that Democrats are sneaking big changes into it -- and that it's bound to increase the size of the federal government, not to mention taxes.
Part of what they're saying is true -- the bill is quite long; the House's version is probably the longest produced in the past 10 years. But "War and Peace" is almost twice as wordy, and the Republicans have gotten pretty verbose recently, too.
The Associated Press noted Tuesday that the Senate bill comes in at 318,512 words, while the House's contains 319,145. "War and Peace," by contrast, ranges from 560,000 to 670,000. And when it was taken out of the legislative format and published in the Congressional Record, the Senate version took up only 209 pages.
OpenCongress.org also did some analysis of the measure, especially as compared to other legislation from the past 10 years. Turns out five of the ten longest bills in that period were written by Republicans.
In fact, while the House's healthcare reform proposal was the longest, a bill authored by Rep. Don Young, R-Alaska, was only 68 words behind. A 2005 appropriations bill sponsored by Rep. James Kolbe, R-Ariz., came in fourth at 296,111 words and one of the centerpieces of former President Bush's agenda, the No Child Left Behind Act, was sixth behind the strength of its 274,559 words. Minority Leader John Boehner, now spearheading the message that the Democrats' bills are too hefty, was the sponsor.
Liberals are frustrated these days, and they have reason to be. They helped Democrats win a theoretically filibuster-proof majority in the Senate, and now the part of the reform bill they prize most highly faces death at the hands of members of the Democratic caucus.
A healthcare reform bill that includes a version of the so-called public option -- a new insurance provider run by the government -- passed its first test in the Senate this weekend. It was a bittersweet moment, though, as at the same time, it was becoming increasingly evident that Democrats won't have the 60 votes needed to break a Republican filibuster if the final legislation still includes a public option. Sen. Joe Lieberman, I-Conn., had already declared his intention to support a filibuster if it came to that, and he's been digging himself in further; Sens. Blanche Lincoln of Arkansas, Mary Landrieu of Louisiana and Ben Nelson of Nebraska could well join Lieberman.
Some liberals, though, have a solution in mind, a silver bullet to save the public option. Led principally by the blog Firedoglake, with encouragement from DailyKos and even former Democratic National Committee Chairman Howard Dean, they're calling on Senate Majority Leader Harry Reid to use a heretofore obscure procedure known as budget reconciliation that forecloses the possibility of a filibuster and would theoretically allow him to pass a bill that includes a public option with only 51 votes.
But as with so much in politics, especially when it comes to Senate procedure, things are not nearly so simple. In fact, if Reid did try using reconciliation, he could end up having to remove key parts of the legislation, not to mention hurting his party politically and losing an extra couple of votes in the Senate -- and, having done all that, he might well find out that he still needed 60 votes in order to get a public option approved.
Reid has ruled out the idea for now, saying last week, "I'm not using reconciliation." And other senators, like Sen. Tom Harkin, D-Iowa, agree with their leader, believing the procedure would end up doing more harm than good. An aide to a senior Democrat, who asked for anonymity in order to discuss the issue more freely, told Salon, "This isn't like a two-week delay, or a three-week delay. This fundamentally changes what we have promised to the American people, and it's risky, and I'm not talking about a little bit of fucking risk, I'm talking about a lot of risk ... It puts universal coverage at risk ... [and] risks allowing insurance companies to discriminate against those with preexisting conditions."
And of those pushing for the use of reconciliation, the aide concluded, "A bunch of people that watched 'Schoolhouse Rock' growing up think that they understand how the Senate works, and they don’t."
The problem is that budget reconciliation isn't really supposed to be used to make policy. Instead, as the Congressional Research Service's Robert Keith said in a 2008 report, reconciliation "is a procedure ... by which Congress implements budget resolution policies affecting mainly permanent spending and revenue programs." In the procedure's early years, however, it was used to circumvent the filibuster on provisions unrelated to that purpose. So in the 1980s, then-Minority Leader Robert Byrd led the Senate in a crackdown. What resulted was the Byrd Rule, which prohibits the Senate "from considering extraneous matter as part of a reconciliation bill."
The definition of "extraneous matter" is fairly broad, and subject to interpretation -- during the Bush administration, Republicans passed tax cuts using reconciliation -- but it generally includes any provision that fails one of these six criteria, as listed in Keith's CRS report:
Even if a provision violates one of these rules, it won't automatically be stricken from a bill. In order for that to happen, a senator has to take action, generally by raising a point of order. Then, the chair (the majority leader or a designee) rules on whether to sustain that point of order and remove the offending part of the bill. That may seem like an easy victory in the making -- Reid rules that the public option passes the Byrd Rule's tests, and that's that -- but that's not necessarily the case.
Liberals argue that the public option could survive the Byrd Rule, pointing to tax cuts that Republicans passed using reconciliation during the Bush administration as precedent, and arguing that the public option would pass the tests anyway because it would theoretically decrease the federal deficit.
They may have a point, but it doesn't much matter -- the only thing that does is the opinion of Alan Frumin, the Senate parliamentarian. Technically, Reid isn't required to abide by Frumin's judgment, but according to Robert Dove, who served twice as Senate parliamentarian, he will anyway. "It's not that they have to [listen to the parliamentarian]," Dove told Salon, "but absolutely they do ... The past history is that the view of the parliamentarian becomes the ruling of the chair."
If Reid did rule the public option out of order under the Byrd Rule, the whole point of using reconciliation would be rendered moot. The only way to overturn the chair's ruling in such a case would be with a three-fifths vote of the Senate -- that is, with the same 60 votes the majority leader would need to round up in order to defeat a filibuster. In that eventuality, there's no way Reid could get the supermajority; Lieberman would certainly abandon him, and moderate Democrats might too. Plus, Byrd has already expressed his distaste for the idea of using reconciliation for health reform, and could be expected to vote to support the rule that bears his name.
Dove wouldn't speculate on what Frumin might decide, or give his own view on the matter, but aides from both parties have met with him, and Reid's office made "preliminary inquiries" about the public option, the aide to a senior Democrat told Salon. No one's offering much detail about what Frumin said, but the fact that Reid has taken reconciliation off the table could well have something to do with those meetings.
The public option might not be the only thing dropped from a bill that's pushed through the Senate using the procedure. Republicans would almost certainly object as often as possible to elements in the legislation, and they'd win many of those battles -- maybe even the war. "If you're a Republican, your job in reconciliation is to do two things: One, to put Democrats in an untenable position to have to vote for or against things that are going to bite them in the ass when they run for re-election; but more importantly, your thing is to find provisions where if you snip that out, it's going to bring down the entire bill," the aide to the senior Democrat said.
Ultimately, passing a reform bill with reconciliation is "feasible," Dove says, but the resulting legislation "would not be pretty, and it couldn't contain a lot of things that people want to be in it."
Under legislation approved Monday night by Baltimore's city council, crisis pregnancy centers that do not offer referrals for abortion or birth control would be required to post signs saying as much. It seems like such a reasonable plea for transparency! After all, these types of centers are infamous for engaging in religiously- and politically-motivated deception of pregnant women -- and yet, if the city's mayor signs the measure, it will be the very first law of its kind in the U.S.
Time and again, we've written about how crisis pregnancy centers masquerade as legitimate healthcare facilities and target young, poor and minority women by offering free pregnancy tests and counseling. In reality, these centers, which are often staffed by unqualified volunteers, provide medical misinformation as a means of coercing women into going through with a pregnancy and, in some cases, to give the baby up for adoption (to a good Christian family, natch). Some clinics have been found to delay pregnancy test results so they can first subject patients to graphic anti-abortion imagery and propaganda.
This measure is bolstered by more than crisis pregnancy centers' well-established reputation nationwide: Last year, the NARAL Pro-Choice Fund sent staff members into 11 Maryland centers in particular to pose as potential patients and reported that "every CPC visited provided misleading or, in some cases completely false, information" about abortion and birth control." For good measure, the clinics also threw in "emotionally manipulative counseling" (for example, one worker told an investigator, "You need to come meet your baby before deciding what to do"). Worse yet, many clinics "purposefully schedule sonogram appointments two-three weeks after the initial appointment to ensure that there will be a heartbeat and that the pregnancy is larger than a grain of rice." (If you're short on outrage today, I highly recommend reading the report in its entirety.)
What makes these centers so pernicious is that they calculatedly project "an aura of medical authority," as the NARAL report puts it, when in reality they are largely "amateur-run." This measure aims to chip away at that facade. Frankly, the legislation could go much farther and actually require them to cop to the totality of their dishonesty -- these clinics should be happy they're getting off so easy.
In case anyone was still wondering, Sen. Joe Lieberman, I-Conn., tells the Wall Street Journal in an article published Tuesday that he opposes all possible forms of a public option, and he's going to be "stubborn" about it.
The Journal's Gerald Seib asked Lieberman if he could support some compromise form of the public option -- if not the one currently in the Senate bill, which allows states to opt out, then perhaps the "trigger" plan advanced by Sen. Olympia Snowe, R-Maine? The answer, reportedly, was no to all possibilities. Asked whether any form of a public option would lead to his voting to support a filibuster, Lieberman replied, "correct."
On a related topic, in the Daily Beast, Peter Beinart has an interesting article exploring Lieberman's history and his current stance. Beinart asks why, given his record as a liberal on domestic policy, the senator's staking out the position he is, and has this answer:
For close to a decade, he got nearly perfect scores from the American Public Health Association, which backs a single-payer health-care system, and in lieu of that, the “public option.” Now, all of a sudden, he’s so outraged by a public option that he’s threatening to filibuster any bill that contains it. The arguments he makes on behalf of his new position are remarkably weak: He says the public option will raise costs, even though the Congressional Budget Office has said no such thing, and even though logic suggests that by competing with private insurers, a government plan will actually drive costs down. Some have accused Lieberman of shifting right in order to win backing from the insurance industry in preparation for a 2012 reelection run. But, in fact, he gets relatively little insurance money, and Connecticut politicos mostly think he won’t run.
So why is he doing this? Because he’s bitter. According to former staffers and associates, he was upset by his dismal showing in the 2004 Democratic presidential primary. And he was enraged by the tepid support he got from many party leaders in 2006, when he lost the Democratic primary to an anti-war activist and won reelection as an independent. Gradually, this personal alienation has eaten away at his liberal domestic views. His staff has grown markedly more conservative in recent years, and his closest friends in Congress are now Republicans John McCain and Lindsey Graham. For Lieberman, the personal has become political, and it has pushed him further to the right.
Women have a simple plan for responding to the unpopular new guidelines on breast cancer screenings: ignore them. A Gallup poll shows that 76 percent of women disagree with the recommendation that women hold off on mammograms until age 50, and a whopping 84 percent of those between age 35 and 49 intend to reject the advice entirely. Women are going to get their mammograms when they damn well please.
The telephone poll of 1,136 women suggests that the objection to the U.S. Preventive Services Task Force's guidelines arises from a mistrust of the panel's motivations. Seventy-six percent of women believe the decision was based on cost, not science. That's no surprise considering that the results were released amid a contentious debate about healthcare reform and that the recommendations have been poorly communicated to the public. As Cristine Russell writes in the Atlantic, the panel's intent may have been to deliver the message "that individualized, informed decision making should replace blanket guidelines for universal, routine mammography screening of women in their 40s" -- but it failed spectacularly on that front.
No matter your personal take on the new mammogram guidelines, one thing is certain: There is a critical lack of information on the topic. The Gallup poll found that 40 percent of women believe that a 40-year-old woman has a 20 to 50 percent chance of developing cancer over the next decade, when her actual risk is only 1.4 percent. Clearly, we need to strike a better balance between effective awareness-raising -- like pink ribbon campaigns -- and communicating nuanced medical fact.
The Senate vote on Democrats' healthcare reform bill Saturday night was close -- maybe too close. Majority Leader Harry Reid won an important victory, no doubt, but he had only the 60 votes needed to invoke cloture and move the legislation to the floor, no more. He may not have all 60 when the next cloture motion, the one to break a Republican filibuster and force an up-or-down vote, comes around.
One member of the Senate's Democratic caucus, Sen. Joe Lieberman, I-Conn., has already said he intends to support a filibuster if the bill includes a public option. And he's not the only one saying something like that -- Sens. Blanche Lincoln of Arkansas and Ben Nelson of Nebraska are also talking defection.
That means that unless Reid can work out some sort of deal, he'll need to look for votes elsewhere: specifically, across the aisle. The New York Times reported Monday that he's already done that; along with the White House, he's courting Maine's two senators, Republicans Susan Collins and Olympia Snowe. Both voted with their party on Saturday, but both have also shown signs that they're willing to defect for the right bill. Snowe, for instance, became the only Republican to have voted for any of the Democrats' proposals when she supported the Finance Committee's version of reform legislation.
And Collins is quoted in the Times as saying, "“I have ruled out voting for this bill, but I still very much want to vote for a bill and that is why I am continuing to have discussions. I still cling to the belief that it is possible for a group of us to come together and rewrite the bill in a way that would cause it to have greater support.”
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