As for Speaker of the House Dennis Hastert, R-Ill., the man behind the sinking of Shays-Meehan on a procedural vote on Thursday, Shays had the kindest words of all for him. Shays said, “There’s no one I respect more than Denny Hastert.”

Whether a House speaker thrives on respect or fear, Hastert earned both as a Republican leader on Thursday with his maneuver on Shays-Meehan. He protected the president from what most of the party considered a poisonous choice between a veto and a fundraising nightmare, while playing the kind of hardball politics against Democrats and moderates that many conservatives had whispered he was incapable of. On Thursday, the New York Times attacked his villainy, deriding the procedural hardball he used to defeat Shays-Meehan as “thuggish.” Harsh words from the national paper of record, but a badge of honor for a conservative pol.

It was two short weeks ago that rumors were floating through Washington that Hastert might be quitting the House entirely. At the time, the speaker accepted the blame himself for fueling the speculation by making a careless remark in a television interview. Hastert had compared his political philosophy with the coaching philosophy he developed during his years teaching high school wrestling. The coaching experience, Hastert had asserted, taught him that it’s best to quit at the top of his game.

“Well, I’m not at the top of my game yet,” Hastert said, quashing the retirement rumor. With Thursday’s “success,” that might have changed.

While he’s earned high-fives from conservative colleagues for his handling of Shays-Meehan, there are still political risks associated with Hastert’s tactics. For one, by preempting an up or down vote on the bill, Hastert may have cheated Republicans of a greater victory. With the exception of reform hawk Sen. John McCain, R-Ariz., none of the bill’s primary backers had expressed certainty on Thursday that they had enough votes to prevail. Efforts to steel the nerves of Republican reform backers and placate the concerns of Democrats in the Congressional Black Caucus had achieved only mixed results.

That means that the bill could’ve failed, with at least a handful of Democrats jumping their own party’s ship to kill the legislation, enough to call the bill’s defeat “bipartisan” with a semi-straight face. But the procedural measure was strictly the handiwork of Republicans, and so the GOP may have handed its opponents a freebie in the 2002 elections.

Another risk for Hastert is that his move radicalized reformers in both parties. That was evident in the new tough talk delivered by the normally low-key Shays during his Friday gab with reporters. While Shays refused to strike back for being called “small,” “arrogant,” “naive,” “embarrassing” and “unreasonable” by Armey during Thursday’s debate, he did promise to start fighting fire with fire on the floor.

After a period during which members on both sides of the issue can “take a nice deep breath or two and let cooler heads prevail,” Shays said, he was prepared to play hardball. “I’m going to be more active on my side of the aisle,” he said. “Those of us on the Republican side of the aisle will do anything and everything to ensure that we have a fair debate.”

That means that if Hastert and the GOP leadership continue to stall the bill’s progress, Shays says, he’ll tell anyone who’s listening about just how much money has poisoned politics, drawing from his own experience handling the fundraising demands of Republican Party bosses. While Shays resisted providing details on Friday, he hinted that continued leadership resistance to reform would leave him little choice.

“I am going to be very blunt about what we’re being asked to do,” he said. “I am going to make sure that when we walk over to the [Republican National Committee] to have a big meeting, and they give us a big stack of papers of people to call [for donations], you will have copies of those papers.”

And Shays said that he was willing to embarrass House leaders equally in the chamber and in the press. Citing the 19 Republicans who voted against their party on the Shays-Meehan debate as a potent force in a potentially multi-issue reform coalition, Shays suggested that those representatives and the Democrats could block debate on some other legislation, until GOP leaders gave reform a fair hearing. “This may be more distasteful, but it is certainly a possibility,” Shays said simply.

He might want to talk that strategy over a bit more with some of those rebel Republicans, because they seem less ready than Shays for an inter-GOP battle. Spokespeople for several congressional GOP members who voted with Democrats on the Shays-Meehan rule said that the representatives had no knowledge of a plan to block future votes.

A spokesman for Rep. Sherwood Boehlert, R-N.Y., said that all the backers of Shays-Meehan want a fair debate, but that Boehlert had not considered using vote blocks as a means to achieve that end. “He wants a straight up or down vote on Shays-Meehan,” said Boehlert spokesman Jim Philipps. “He would prefer not to play games.”

And Boehlert was not at all angry with Speaker Hastert over the bill, Philipps said. “He met with the speaker on this very issue, and he told him that on this issue, he would be voting against [Republican leaders],” said Philipps. “There wasn’t undo pressure.”

Likewise, Rep. Michael Castle, R-Del., who also voted down the rule, was satisfied with Hastert’s performance. “Mr. Castle has a very good working relationship with the speaker,” said Castle spokeswoman Elizabeth Brealey.

But the love-in might end for Hastert if Shays and other Republican reform backers go ahead with plans to pry Shays-Meehan loose from the Rules Committee with a discharge motion. Shays insisted that he preferred to aim for a quiet resolution to move the debate forward, one that didn’t humiliate Republican leaders, “so no one’s nose gets out of joint.”

At the same time, however, Shays seemed remarkably cavalier about the prospects of doing battle with party bigwigs. When asked whether he was afraid that his tough talk on campaign finance reform would provoke retaliation from the speaker or any other Republican leaders, Shays didn’t hesitate to respond.

“I don’t care,” he said. “I simply don’t care.”

And the distinguished senator turned out to be right. By day’s end, House Republican leaders had succeeded in killing — or at least rendering comatose — the campaign finance bill offered by Shays and Massachusetts Democrat Marty Meehan. There’s almost zero chance the bill will be reconsidered before the fall, and it could be as late as next year.

The Shays-Meehan bill would virtually ban soft money, the unlimited donations that unions, corporations and individuals make to political parties. It would also ban certain types of political advertising in the final 60 days of a campaign. Its Senate version, McCain-Feingold, passed in early April, but the House has been a much tougher sell, even though roughly the same bill passed the House in 1998 and 1999.

This year, though, with McCain-Feingold passing the Senate, bipartisan campaign finance reform skeptics have begun to coalesce around a rival House bill, sponsored by Rep. Bob Ney, R-Ohio, and Rep. Albert Wynn, D-Md., head of the campaign finance reform task force for the Congressional Black Caucus. But even Ney-Wynn supporters blasted the Republican leadership’s tactics Thursday.

Congressional GOP leaders began the assault on Shays-Meehan in the dead of night, with the House Rules Committee announcing before 2 a.m. that it wanted to break Shays’ adjustments to the bill into 12 separate sections for debate, instead of letting them go to the floor as a single package.

Given that the chamber had scheduled just one day of debate on the measure, Democrats and moderate Republican backers of the bill balked, and voted 228 to 203 against the rule. With that, the GOP leadership declared that — because of the intransigence of the bill’s supporters and sponsors — Shays-Meehan would go back to the Rules Committee, and not emerge again until the grown-up Republican majority damn well felt like it.

“Right now I have no plans to bring this bill up,” said House Speaker Dennis Hastert. Other Republicans merrily announced that they wouldn’t have to deal with Shays-Meehan again until the fall.

That’s the short story of the Shays-Meehan defeat. But this was a long-story day, with the eventual victors climbing the crooked path to their winners’ circle, and the losers getting a chance to cover their mistakes and paint their defeat in righteous indignation.

Republican leaders seemed entirely unprepared for the level of resistance provoked by their midnight chop suey treatment of Shays-Meehan. Rather than finding a willing coalition of anti-reformers and loyal Republicans willing to support the piecemeal debate structure, the maneuver earned the opposition of 19 Republicans and all but one Democrat. Even some of the Shays-Meehan bill’s sworn opponents believed that the Republican leaders had gone too far.

“This is the stupidest rule I have seen in 23 years,” said Rep. Martin Frost, a Texas Democrat who had lobbied his colleagues to defeat Shays-Meehan. On Wednesday, Frost had circulated a letter declaring, “If Shays-Meehan becomes law in its current form, Members of Congress will be divorced from local political activities in their home districts in a way that harms the democratic process, rather than helping it, as many reform proponents would suggest.” On Thursday, he voted with the bill’s supporters to quash the rule.

The bill’s Republican opponents apparently figured out that they had a problem on their hands before the vote, and if they hadn’t come to that conclusion on their own, Shays-Meehan supporters let them know. Early in the afternoon, Shays himself delivered a message to Hastert from the reform squad that the rule would go down to defeat and that the GOP had better back down and let the debate go forward.

Hastert said something like “OK” to Shays’ demand that the bill’s 12 parts be put back together again. But there was a catch. In exchange for repairing the Shays-Meehan fracture, the GOP wanted the bill’s supporters to allow Ney to propose an amendment to their legislation. The catch’s catch: The Shays-Meehan team wouldn’t know what was in the amendment before it hit the floor.

That didn’t fly. House Minority Leader Richard Gephardt said he couldn’t possibly prepare Democrats to debate an amendment sight-unseen, and insisted that the Republicans give him two hours to look over any new measure from Ney. “I don’t know what’s going to happen,” he said as he left the House floor at about 4 in the afternoon, saying that he couldn’t guess what the Republicans would do next. Gephardt saw a basic choice available to the GOP: allow their doomed rule to get defeated on the floor, and then regroup; or go ahead with the compromise, giving the Democrats two hours to get a look at the amendment, and proceed from there.

Meanwhile, congressional Republican supporters of Shays-Meehan threw their weight behind the blind-amendment compromise. “It seems acceptable,” said Rep. Fred Upton, R-Mich., of the deal. McCain ally Rep. Lindsey Graham, R-S.C., told reporters that he believed that the details would be ironed out, and that debate would go forward on Shays-Meehan. “I think it looks pretty good,” he said.

It didn’t look good for long. About an hour later, Republicans flooded back into the chamber with Reynolds thundering that if Shays-Meehan supporters wanted to defeat the 14-section debate proposal, they’d be putting their own beloved bill to sleep for the foreseeable future. But the coalition didn’t back down, and voted down the rule anyway.

After the vote, GOP leaders accused Democrats of intentionally sinking their own bill to avoid an embarrassing defeat, and to preserve the issue for future campaigns. “I know a political day when I see one,” said New York Republican Rep. Thomas Reynolds, accusing the Democrats of turning the vote into “an opportunity to make mischief in the House.” Majority Leader Dick Armey was even more damning, sneering that the Shays-Meehan coalition was “not willing to do the hard work on the legislation” and “obviously not capable of taking [the process] seriously.” Ney suggested that the Democrats defeated the rule in order to escape competition from his bill. “This is a smoke screen to stop campaign finance reform,” he said.

“That’s ludicrous,” Gephardt said after the vote defeating the rule. “Does he really expect anybody to believe that?”

Shays-Meehan supporters in both parties gathered at a late press conference to grimly lick their wounds, shaking their fists at culprits named or unnamed. “This was hardball politics today,” Graham said. “I don’t know who’s to blame.” While Shays himself said that both parties were responsible for the defeat, he saved the harshest words for his fellow Republicans. “The fix was on,” Shays said, adding that the House leaders never intended to deal with the issue fairly. “There was no real dialogue.”

Perhaps because the wreck didn’t happen on his turf, Sen. Russ Feingold, a Wisconsin Democrat and McCain’s reform partner in the Senate, was determined to be sunny in defeat. “It was a great day,” he proclaimed, proudly pointing to the 19 Republicans who jumped ship on the rule vote as evidence that the reform tide was growing. Feingold suggested that he and the other reformers would soon be back, perhaps using their own parliamentary move, a discharge motion, to force the Rules Committee to let Shays-Meehan go.

McCain himself joined Feingold’s call for continued battle, but declined to put a smiley face on the vote. “This is not a happy day,” he said.

Lost in much of the mourning over Shays-Meehan was the question of whether the bill could have survived the up or down vote that its proponents had been begging for. At the funereal press conference, none of the supporters said unequivocally that they had garnered enough votes to ultimately prevail. Gephardt, responding to Republican accusations that he would have preferred a showy defeat to a win on campaign finance reform, said only, “I’ve worked for days to get Democrats prepared to vote for this bill.”

But it wasn’t clear how much that work would have panned out, specifically the minority leader’s aggressive lobbying of the Congressional Black Caucus. Early Thursday afternoon, Gephardt had emerged from a more than hourlong meeting with African-American lawmakers with a pained expression, lowered shoulders and a determined march away from reporters. Caucus member and Shays-Meehan backer Rep. Harold Ford, D-Tenn., conceded that not a single member had switched sides after the discussion.

McCain apparently had more luck on his side of the aisle, spending much of Thursday on the phone, warming the cold feet of Republican members who had supported Shays-Meehan in previous years but were showing signs of wavering. While McCain believes that a discharge motion to move the bill to the floor may yet revive the legislation in the coming weeks, spokeswoman Nancy Ives said that the Arizona senator didn’t want to talk deadlines. “We need to take things one step at a time,” she said, adding that McCain, a visitor to the House, would prefer to stand back from decisions about a possible discharge motion. “Our first choice would be to have the House leadership to bring [it] up,” she said.

As the Republican co-sponsor, Shays would naturally take the lead on the bill’s resurrection, but he seemed near despair over the ugliness surrounding the bill’s tumble. After the vote to stop the Republican rule change — and ultimately stop his bill — Shays walked away from the House floor, arm in arm with his wife, resting his head on her shoulder. His press secretary waved off reporters, asking that Shays be allowed some time alone.

But according to some healthcare watchdogs, the procedure Cheney had could be denied by many HMOs. And in a strange coincidence, the major piece of legislation moving through the Capitol’s corridors right now — a patients’ bill of rights — would make it easier for patients to demand such coverage should their insurance carriers try to block it. It passed the Senate the day before Cheney entered the hospital, but President Bush has vowed to veto it.

Several critics of managed care say that, had Cheney been an ordinary cardiac patient enrolled in an HMO, he would have had to wait or fight or both to receive the ICD that now regulates his cardiac arrhythmia. Cheney has insisted at press conferences that the implant wasn’t a life-or-death matter, but merely “an insurance policy,” an assertion supported by his own doctors.

“I was kind of struck with the fact that Cheney needed it, they approved it, and then he got the implant,” says Dr. Linda Peeno. Once an HMO claims reviewer, Peeno now serves on the ethics committee at the University of Louisville teaching hospital and has testified before Congress about methods some HMOs use to stand between their clients and necessary medical treatment.

“This is exactly the type of technique that the HMOs would treat as not medically necessary because he could live without it,” says Jamie Court, executive director of the Foundation of Taxpayer and Consumer Rights and author of “Making a Killing: HMOs and the Threat to Your Health.”

And Ron Pollack, executive director of the nonprofit healthcare watchdog group Families USA, agrees, insisting that ordinary managed care clients would be encouraged to make do with a course of treatment like medication to correct the irregular heartbeat that Cheney suffers from: “You could bet that regular HMO patients are not likely to receive this procedure because it is expensive.”

Even Dan Stryer, a medical officer at the Agency for Health Care Research and Quality — an agency within the Department of Health and Human Services responsible for providing the federal government with research about treatment outcomes — says it isn’t clear whether the care Cheney received for his condition, non-acute arrhythmia, could be reasonably expected by the average HMO patient.

“There is not a solid standard on this,” Stryer said. “Given Cheney’s symptoms, you’d have a tough time convincing a lot of cardiologists that it was time for a defibrillator.” Not every doctor would call Cheney’s ICD a medical necessity, Stryer said, and that’s what would be necessary for many HMOs to cover it.

Many patients do undergo the procedure, of course. “About 150,000 Americans are walking around with an ICD right now,” points out Dr. Douglas Zipes, president of the American College of Cardiology, who adds that, as director of the cardiology department at Indiana University School of Medicine, he has rarely had problems with reimbursement regardless of the patients’ conditions.

And Mohit Ghose, spokesman for the American Association of Health Plans, an umbrella group for over 1,000 managed care providers, claims that there are both ethical and financial incentives for providers to allow patients to receive the ICD in most cases where their doctors recommended it. “If you can keep people out of the hospital and living their normal lives, that is providing the best care for the best price,” he says.

But there’s enough disagreement about the medical necessity of the ICD that many cardiac patients could end up on the wrong side of the “best care/best price” equation.

Ghose acknowledges that there are standards that could prevent a cardiac arrhythmia patient from receiving an ICD. “Not everyone with a heart condition should have this kind of implant,” Ghose said. He does say that the ICD is within “established parameters of care” for a “high-risk pool” of cardiac patients who could get approval relatively quickly for such a treatment from most health plans (he also says he doesn’t know whether Cheney fits that category or not).

A split decision among doctors often forces patients to enter an HMO’s dispute resolution system, a procedure that Ghose claimed puts the patient’s health, and not profit, first.

It’s this dispute resolution system that the patients’ bill of rights — the one that passed the Senate, and the dueling versions introduced in the House — deals with. And the difference between those bills and the bill the White House supports is whether HMOs should have a role in the resolution, or an independent board should decide if a patient gets a procedure. In the House bill Bush supports, the HMO would play a major role in deciding.

Ghose says patient protection laws in 40 states insure a review of care denials within a 30 to 45 day period. According to Ghose, treatment is denied or delayed in many cases not because of cost, but because “There might be a doctor reviewing the case who thinks that there is a better course of care.”

Critics of the process believe that managed care denial review procedures are frequently used to discourage patients from getting the care they need. “So much of getting care from an HMO is dependent on overcoming a hassle factor,” Pollack said. Peeno recalls that the HMOs she worked under would deny initial claims for major medical equipment for patients because “maybe next year, they’d switch medical plans, and it would be the expense of another provider.”

This problem is addressed by both the Patients’ Bill of Rights approved by the Senate on Friday, and also by the competing legislation currently being offered by House Republicans allied with the White House. While both bills call for rapid review of denials of care by independent review boards, the bill sponsored by Republicans allows for the HMOs themselves to select who would sit on such a board, which critics claim would undermine the integrity of the review.

And sometimes the patients don’t even know that a certain procedure is available. Frequently, Peeno says, HMOs manage to discourage expensive procedures early in the process. She argues that some managed care officials will set caps on how much they will reimburse doctors for patient care regardless of the severity of the conditions of individual patients.

As a consequence, doctors would lose money on patients who require greater supervision, a problem that would be compounded by referrals to specialists, like the cardiologists who recommended Cheney’s procedure. Consequently, Peeno asserts, doctors might refrain from even informing a patient of an expensive treatment option unless the patient’s life depended on it.

So patients who don’t have independent knowledge of their range of treatment options could be missing out on the advanced medical technology that Cheney has benefited from without ever knowing it, though Pollack believes that ordinary HMO clients have begun to get wise. “People have gotten used to the fact that they have to be the squeaky wheel to get the grease,” he says.

But for now, Pollack thinks that the vice president’s belief that he’s not getting special treatment is just a fantasy: “While everybody wishes the vice president well, you know that ordinary Americans would not be able to receive this kind of care.”

If the test revealed that — and Cheney said that it likely would — he would be admitted to George Washington University hospital to have an implantable cardioverter defibrillator (ICD) inserted in his chest.

But Cheney is famous for understatement. His two previous episodes were marked by White House spin and subterfuge. So is Cheney being upfront about his treatment and prospects for recovery?

For the most part, yes. But he may have underplayed the seriousness of the surgery by saying, “It is basically an outpatient procedure.”

When asked if the ICD implant was normally an outpatient procedure, Dr. J. Thomas Bigger, a Columbia University cardiologist, flatly replied no. “It’s not the procedure that’s big, it’s the disease that’s big,” said Bigger, who served as a spokesman for Democratic presidential candidate Bill Bradley last year when it was revealed that the former New Jersey senator suffered from heart palpitations.

While Bigger acknowledged that “different [medical] centers have different ways of doing it,” he said that he would never send a patient home the same day he performed an implant because he would want to make sure that the heart rhythm stayed stable after the procedure was completed. “It mainly has to do with being sure that everything is secure,” he said. “There’s no point in taking any chances with it.”

Dr. Richard Stein, chief of cardiology at the Brooklyn Hospital Center and a spokesman for the American Heart Association, also claimed that an ICD implant would normally require a patient to stay in the hospital for the night. “Sure, you could go home if you had a doctor and nurse going with you, someone who could stay up and monitor whether anything went wrong,” Stein said.

With White House physicians available around the clock, a doctor probably wouldn’t demand that Cheney spend the night in a hospital. “It’s kind of like the pope,” Stein said. “If he says he wants to go home, you can’t really stop him.”

However, Douglas Zipes, president of the American College of Cardiology, allowed that the procedure “could be outpatient or inpatient,” depending on a patient’s health.

Otherwise, the information coming from the White House appears generally solid. Though he emphasized that he was not privy to details of Cheney’s condition, Stein said that the chances of something going wrong with the procedure or of the vice president’s being incapacitated were very, very small. “It’s really a low-risk procedure,” Stein said.

And Bigger couldn’t stop praising the effectiveness of the ICD. “It’s 99.9 percent perfect,” he said. “It’s good as gold.”

At Friday’s press conference, Cheney assured reporters that the problem was medically minor, but said that he wanted the press and public to be well informed, largely to guard against the confusion that has surrounded his previous cardiovascular issues. “We’ve had enough experience now that sometimes misinformation does arise, and there’s intense speculation, and everybody sort of goes into a high hover,” he said.

Cheney’s concern about the speculation is well grounded, but he neatly stepped around the fact that much of the misinformation surrounding his past heart trouble has come from the Bush team itself. Starting with Cheney’s selection as the vice presidential nominee, the Bush campaign gave only a well-edited version of his medical status, a considerable cause for concern given that Cheney had suffered three heart attacks before turning 50.

Then, amid November’s Florida recount skirmishes, Cheney checked himself in to George Washington University Hospital complaining of chest pains. On the morning of Nov. 22, everyone from the GWU doctors to then-candidate Bush himself insisted that Cheney had not had a heart attack. “He was feeling chest pains, and turns out that subsequent tests, blood tests and the initial EKG showed that he had no heart attack,” Bush said. By the end of the day, Cheney’s doctor had revised his earlier statement, and acknowledged that Cheney had suffered a “very slight heart attack.”

The cardiac spin team apparently stayed on the job, and in March, when the vice president underwent a heart catheterization as a “precautionary measure,” Zipes told Salon that the White House’s explanation didn’t jibe with his experience. “No, you’re not going to do [a heart catheterization] on a precautionary basis,” he said, explaining that it would be incorrect to use that term to describe an invasive surgical procedure employed to help prevent a heart attack in a patient. At that time, Zipes also faulted the Bush team for failing to tell the whole story, and said, “I am concerned that they weren’t forthright about what was going on.”

He reiterated that point during the hearing, saying that ignoring ideology has led to more “gotcha politics” in the confirmation process, with senators and interest groups digging for dirt in nominees’ writings, financial records and personal lives to camouflage differences over issues like abortion and gun control. He argued that such practices increase public cynicism about the nomination process. “Let’s make our confirmation process more honest, more clear and hopefully more legitimate in the eye of the American people,” he said.

But Republicans at the hearing made it known that they believed fairness was the last thing Schumer and other Democrats were looking for in the confirmation process, and that Democrats were instead laying the groundwork for a full-bodied “Borking” of Bush’s nominees.

When Schumer said “ideology,” Republicans heard “litmus test,” and Sen. Mitch McConnell, R-Ky., helpfully offered what he feared were some of the liberal tenets that nominees would have to accept in order to win confirmation. In McConnell’s view, Bush nominees would have to support “partial-birth abortion,” “judicial activism” and “racial preferences.” Nominees would also be required, he said, to promise to “restrict First Amendment rights of political speech and association” — code for supporting campaign reform limits.

With 107 judgeships needing to be filled by the Bush administration, Republicans are warily watching the Democrats’ positioning. A GOP source close to the Judiciary Committee said that three of the president’s first batch of nominees are likely to be targeted by Democrats: