WASHINGTON — The Senate Thursday began what promises to be a bitter, lengthy battle over the future of health care in America, and taxes, abortion, affordability and federal deficits emerged as key flashpoints.
Senate Democratic leaders expect the first test vote on their new $848 billion, 2,074-page health care overhaul bill will come on Saturday evening. Although Democrats are likely to get the 60 votes they need to move forward with the debate, the outcome is uncertain.
Should the measure pass that initial test, lawmakers made it clear Thursday that they're ready for weeks of political warfare.
Democrats framed their mission in heroic terms.
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"This is about the woman with high cholesterol, or the man with heart disease, or the child with hay fever who can't get help," said Senate Majority Leader Harry Reid, D-Nev. "That's why we're stopping insurance companies from deciding they'd simply rather not give health care to the sick."
Republicans countered that the Senate bill would create more bureaucracy and run up the federal debt, and would hardly make health care more affordable.
"We don't need a 2,000 page bill," Sen. Lamar Alexander, R-Tenn., the Republican conference chairman. "We need to take it step by step in the right direction to cut health care costs."
The bill would require most legal U.S. residents to obtain health coverage and create insurance exchanges, or marketplaces, where people could shop for policies and rates. It would create a new federal insurance alternative, or public option, for most people who can't get private insurance. The nonpartisan Congressional Budget Office estimates that 94 percent of the public would obtain coverage by 2019, up from the current 83 percent.
Insurers would have to accept all applicants and couldn't deny coverage because of pre-existing conditions. States could opt out of the public system.
The funding would come from a projected 10-year, $491 billion savings from Medicare, Medicaid and other federal health care programs, as well as a series of tax increases. Among them are a 40 percent excise tax for most insurance policies costing more than $8,500 for singles and $23,000 for families, and a 0.5 percentage point increase in Medicare payroll tax on high earners.
The higher tax, now 1.45 percent, would be imposed on singles with wages of more than $200,000 and couples making more than $250,000.
In the weeks ahead, though, senators plan to offer amendments on almost every piece of the bill, and coalitions will shift. Thursday, some of the key questions surrounding the bill and its future included:
_ Can a compromise be reached on abortion? The House of Representatives agreed to tough restrictions on access to abortion, but the Senate bill has language preferred by abortion rights supporters.
Some Republican abortion foes are insisting that Saturday's procedural vote should be seen as a test of abortion sentiment.
"This is a critical pro-life vote," said Sen. Mike Johanns, R-Neb.
His Nebraska colleague, Democrat Ben Nelson, also an abortion foe, disagreed. "It's not," he said. "It's a simple vote on whether to go forward with debate or not."
_ Will the bill make coverage more affordable? If enough senators are uncomfortable with the answer, the entire effort could collapse.
Supporters argue that competition among insurers, as well as allowing the government to negotiate public plan reimbursement rates with doctors, hospitals and others, should lower costs.
"For the first time, (this bill) will allow Americans to be involved in a buyers' market to buy insurance," said Sen. Christopher Dodd, D-Conn.
The CBO analysis warned that the public plan would result in "premiums that were somewhat higher than the average premiums for the private plans in the exchanges." One reason, it said, is that the government option would "attract a less healthy pool of enrollees."
Many senators want to study the bill more.
Sen. Bernard Sanders, I-Vt., said that while he plans to vote with Democrats on Saturday, he wants the measure strengthened to make sure it "will be affordable for working families and the middle class.''
_ Will senators feel comfortable with the deficit projections? CBO estimated that the Senate bill would reduce the deficit by $130 billion during the next decade.
Republicans scoffed, pointing out that's less than the record $176.4 billion deficit logged in October alone.
_ Will senators accept tax increases? Republicans have for years resisted most big tax increases and won political success for doing so. The bill's excise and Medicare taxes alone would generate $203 billion over 10 years, CBO said. There also would be a series of smaller taxes, such as a new 5 percent tax on elective cosmetic surgery, starting next year.
Democrats argued that the taxes are "user fees" of sorts, a way of having the wealthy pay for coverage for lower-income people. Republicans aren't buying it.
"It's chock-full of new taxes and higher health care costs that would threaten jobs, weaken our economy, punish families and small businesses trying to make ends meet," said Sen. Mike Enzi, R-Wyo., the top Republican on the Senate Health Committee.
_ Are there 60 votes for the public option? Not at the moment. At least three Democrats, and Connecticut Independent Joseph Lieberman, have said they're opposed.
One Republican, Maine's Olympia Snowe, has indicated a willingness to consider such a plan. However, Snowe wants it with a "trigger," meaning the plan only goes into effect if private insurers fail to meet certain standards.
The Senate Finance Committee rejected the public option. Instead, it approved having Washington aid states or regions in setting up co-ops, or nonprofit member-run insurance providers. The new bill would provide for creation of co-ops.
Sen. Jay Rockefeller, D-W.Va., said he would "probably" push for a more "robust" version of the public option, like the one adopted by the House.
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