The Senate vs. the House on healthcare reform

A guide to the key differences between the two bills

Published November 21, 2009 1:01AM (EST)

Earlier this week, Senate Democrats finally unveiled their healthcare reform legislation. Despite all the squabbling that's gone on over the public option the bill does, like its House counterpart, contain a plan for a government-run insurance provider. However, there are a number of important differences between the two proposals. Assuming Senator Majority Leader Harry Reid musters together the 60 votes necessary to get his version through the Senate, there are going to be a number of points that negotiators will need to work out in committee. Here are some of the most important differences between the bills.


Public Option: Will states be allowed to “opt out”?

Both bills include the creation of a government-run insurance provider to compete with private insurers. However, the Senate version would allow states to opt out of the public plan.

Abortion: The Stupak Legacy

To garner much-needed support from anti-abortion Democrats, House Speaker Nancy Pelosi (D-CA) allowed them to attach the infamous Stupak-Pitts amendment to her chamber's version of the bill. The provision would bar women who are receiving federal subsidies for their insurance from purchasing plans that cover elective abortions. It would also bar the public plan from offering abortion coverage. The Senate version takes a more moderate approach: Those receiving federal subsidies could buy insurance that covers abortion -- but insurers would have to place federal money in separate accounts and could only use private dollars to cover the procedure. The public plan could also offer abortion coverage, as long as it segregated federal subsidies in the same way.

Cost: The difference a year makes

According to the Congressional Budget Office, the House bill would cost about $1.052 trillion and reduce the deficit by $138 billion. The CBO predicts that the Senate bill would cost $849 billion, while cutting $130 billion from the deficit. This difference is largely due to the fact that many major provisions in the Senate proposal would not go into effect until 2014 -- a year later than in the House bill.

Coverage: Universal? Not quite

For decades, the Democrats talked of providing universal healthcare. These bills come closer, but neither quite reaches that goal. Both, however, will significantly reduce the number of uninsured. Today, 83 percent of non-elderly legal residents have health insurance. (The elderly are covered by Medicare.) Under the House bill, 96 percent of that population would be covered by 2016. The Senate's legislation would expand coverage to 94 percent. Still, about 18 million people would remain uninsured under the House's proposal, as would about 23 million in the Senate's.


Paying the bills: What gets taxed

Under the House bill, much of the money to pay for the reforms would be raised through a 5.4 percent surtax on high-income people -- that is, individuals making more than $500,000 a year or couples with annual incomes in excess of $1 million. The Senate version, on the other hand, would impose a different series of new taxes including: A 40 percent tax on “Cadillac health plans” (employer-sponsored group plans with premiums of over $8,500 for individuals or over $23,000 for families); the introduction of annual fees for health care companies; an increase in Medicare payroll taxes from 1.45 percent to 1.95 percent for those earning more than $250,000 a year and the implementation of the so-called "Botox tax," which is a five percent tax on elective cosmetic medical procedures.

Employer mandates: Do companies need to offer health insurance?

The House bill stipulates that employers with payrolls of more than $500,000 must offer health coverage or pay a federal tax. The Senate version does not explicitly require employers to provide coverage; however, companies with 50 or more full-time employees would have to pay a penalty of $750 per employee if they fail to offer coverage and if any of their employees obtain federally subsidized care via the new health insurance exchanges.

Friday, Senate Democratic leaders agreed to include the Wyden amendment in their healthcare proposal. Under this provision, employers would have one of two options. Companies could offer their employees a single plan and give all eligible workers the option of accepting a voucher to independently purchase their own insurance. Alternatively, an employer could offer two or more health care plans, provided that at least one has a premium that costs no more than the average premium of the two least expensive health plans in the local exchange. The House bill includes no comparable language.

Individual mandates: Penalties for remaining uninsured

Both bills require most Americans to maintain a minimum level of health insurance. However, the penalties for not doing so are much stiffer in the House bill: Those who failed to acquire insurance would pay a tax equal to 2.5 percent of their gross income of over $9,350 for individuals or $18,700 for couples. Under Reid’s legislation, the penalties would start at $95 per person in 2014 and gradually go up to $750 a head in 2016.

Insurance Exchanges: State-based or national

Both bills would create some sort of health insurance exchange, a marketplace where individuals and small companies can shop for insurance and compare benefits and prices. The exchanges would put individuals into large risk pools, which are intended to provide them with leverage to purchase insurance at a lower cost. The House bill would create a national exchange, although states could petition to run their own exchanges as well. Under the Senate proposal, states would form their own exchanges. This, however, could prove problematic, as it is unclear whether state exchanges would be able to attract a sufficient number of enrollees to push for lower premiums.

Illegal Immigrants

The House bill would allow illegal immigrants to buy insurance from the exchanges, but would not allow them to obtain federal subsidies. The Senate version prohibits illegal immigrants from purchasing insurance from these exchanges, even if they could pay for their own coverage in full. This could have the effect of preventing illegal immigrants from buying individual insurance altogether.

By Emily Holleman

Emily Holleman is the editor of Open Salon.

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Healthcare Reform U.s. House Of Representatives U.s. Senate War Room