With the passage of sweeping reform legislation on a rare Christmas Eve session of the Senate, the long debate over health care reform has now reached its final stage. But as much as Senate Democrats and the White House will celebrate their historic achievement this holiday season, they still have genuine obstacles to overcome before they can get a bill to President Obama's desk in the New Year.
The key question now becomes whether the two houses of Congress can reconcile their differences and still come up with a bill that can get 60 votes in the Senate, the number needed to overcome a filibuster, and 218, a majority, in the House. Leaders of the two chambers are still working out how they will go about doing this. One option may be to forego the more prolonged and formal process of a conference committee, which would have to bring more negotiators including Republicans into the room, and instead have the leaders and their key committee chairmen try to hammer out an agreement that would then be submitted to the House and Senate for a final vote.
However they do it, they will be racing against the calendar to maintain the momentum they need to get the bill passed for Obama's waiting signature. All sides still insist that they want the bill to be signed by the State of the Union address, which has not yet been scheduled, but which could take place as early as the third week in January. However, with the two chambers in recess the House until Jan. 12, and the Senate until Jan. 18 it is possible that the negotiations could slip into February. One factor that could delay things is that they will need to seek cost estimates from the Congressional Budget Office on everything they consider, to make sure that the price tag for the final bill remains below $900 billion over the next decade an amount that Obama has insisted upon as the upper limit.
In their broad outlines, the House and Senate versions of reform have much in common, starting with the fact that both are projected to result in more than 30 million additional Americans having some kind of health coverage. Both would establish a new requirement that most people who do not get health insurance from their employer go out and purchase it themselves. All but the smallest businesses would be penalized if they do not provide coverage, but they would also receive new tax breaks if they do. The two bills would set up new insurance marketplaces where individuals and small groups could get a better deal than they do now. They would also provide subsidies to help low- and middle-income people buy that coverage, and would expand Medicaid for the poorest Americans. Finally, the two bills also would ban the insurance industry from engaging in such practices as denying coverage to those who have pre-existing conditions.
However, there are still some major areas of differences that both chambers must resolve. Here are the five most crucial: