Even if House and Senate leaders manage to get the health care bills through their chambers, they will still face a contentious conference committee.
Those negotiations will aim to produce one final bill that must be passed anew in each chamber. But every tweak or amendment could destabilize the carefully constructed majorities in each chamber.
Among the issues already looming as potential poison pills.
Co-ops versus a public plan
Senate reform authors are seriously considering creating a co-op program, rather than a government-run insurance plan, that could help provide consumers with a lower-cost alternative to private insurance.
It’s an option that appeals to Republicans and moderate Democrats, who want to limit government’s encroachment into the private market. The option would also be less expensive than a government-run program.
While some Senate liberals are considering the idea — with a host of strings, of course — House progressives are vowing to walk away from the legislation if the government program isn’t a part of the final bill.
The doctor fix
House moderates are insisting on inclusion of a $245 billion provision that would boost and stabilize Medicare reimbursement rates for doctors.
It’s an issue that can resonate strongly in House districts, particularly rural ones, where a local doctor’s opinion can have big sway in the community.
But some senators, already struggling to raise the nearly $1 trillion to pay for the reform program, are considering punting on the issue rather than finding a way to pay for it.
Hanging in the balance could be vigorous support from the American Medical Association and the nation’s doctors, whose support is considered critical by some lawmakers.
The millionaires’ tax
House leaders are considering a surtax on the wealthy to help pay for the program. Although originally aimed at families earning more than $350,000, House Speaker Nancy Pelosi is signaling a willingness to boost the cutoff to those earning a million or more.
But the millionaire tax appears to be a nonstarter in the Senate. Its exclusion in conference could blow a hole in the House financing plan and force conferees to come up with new funding or carve away pieces of the House plan that rely on it.
Currently, the House plan costs about $1.2 trillion, compared with Senate legislation that is expected to hover around $1 trillion.
Both chambers would mandate that individuals get insurance and that most employers provide coverage to their workers.
But the penalties for businesses that fail to comply with the law differ substantially.
A bill passed by the Senate Health, Education, Labor and Pensions Committee would require any business that doesn’t provide coverage and employs 25 or more workers to pay a penalty of $750 per full-time employee. The House mandate would apply to businesses with payrolls of $250,000 or more with a phased-in payroll tax penalty. At the top tier would be businesses with payrolls of more than $400,000. The top penalty for failing to provide insurance would be an 8 percent payroll tax, which could amount to thousands of dollars per worker.