Heilemann on Health Care: A Christmas Miracle in the Senate, and a Hair-Raising New Year for the House

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Reenter the perspicacity and prowess of Pelosi.
Reenter the perspicacity and prowess of Pelosi. Photo: Getty Images

Assuming that everything goes as planned, the United States Senate will ring in Christmas Eve by passing its version of health-care reform — and then trot out of the chamber, one imagines, singing “God Rest Ye Merry Gentlemen.” No one will be merrier, of course, than Harry Reid, the much-maligned Senate majority leader who somehow managed, against all odds, to rustle up the requisite 60 votes and induce the increasingly and systematically farkakte upper chamber to, you know, do its job.

Yet for all the justifiable celebrations of this achievement, it’s fast becoming clear — as it should have always been — that Democrats are still a long way from home free when it comes to the final enactment of health-care reform into law. That ironing out of the differences between the House and Senate incarnations of the bill is going to be no easy thing. And that, when the process begins again in the New Year, the focus of the story is going to shift: from the resilience and resourcefulness of Reid to the perspicacity and prowess of Pelosi.

To get a sense of the degree of difficulty facing the speaker, begin by considering the narrowness of the vote by which the House passed its version of the bill in November: 220–215. Then realize that, on January 3, Florida Democratic congressman Bob Wexler will resign — and that Louisiana Republican Joseph Cao, the one GOP member who voted for the House bill, has reportedly said he won’t be the deciding vote in favor of final passage. That means the effective baseline Pelosi is working with is 218–216. She truly has no margin for error.

Then consider three widely circulated letters from Democratic House members to Pelosi in the past few months: One in which 60 representatives stated they would not support a health-care bill (like the Senate’s) with no public option; one in which 41 pledged to vote against any bill “that contains language that restricts women’s right to choose any further than current law” (as the House bill did with the inclusion of the Stupak amendment and the Senate’s arguably does with its softer Ben Nelson–approved language); and one in which 188 stated their opposition to taxing high-cost employer-provided “Cadillac” health-care packages (as the Senate bill does).

“There’s lots of overlap [between the signatories], to be sure,” a liberal congressman tells me via e-mail. “But the point is that there are several dozen members who signed three letters saying they were ‘no’ if caddy plan or Stupak were in [the bill] or the P.O. was out.”

The problem for Pelosi is that the progressive members of her caucus long expected the House-Senate conference to be a place where the bill would be nudged back toward the left. But now, the consensus among swing senators — including Nelson, Joe Lieberman, and Kent Conrad — is that any significant movement in that direction would unravel the series of deals and compromises that Reid needed to employ to get to 60.

For Pelosi, the core of her task will boil down to getting House liberals to swallow hard, put down their spears, and take the plunge — on the dead-simple theory that passing a flawed bill is politically more palatable than the consequences of killing it.

For all the sound and fury over the public option this past year, it strikes me that Pelosi will have the easiest time getting the left to surrender on that issue; the votes simply aren’t there in the Senate. And though union pressure on the Cadillac tax is intense, Pelosi should be able to buy off the opposition by raising the floor on the values of the plans — from the $23,000 a year for families and $8,500 for individuals in the Senate bill — that are hit with the proposed 40 percent levy.

Abortion, however, is likely to prove a much tougher circle to square. On one side, there are the pro-choice forces, which aren’t much happier with the Nelson language in the Senate bill than they were with the Stupak amendment. On the other, there are Stupak and ten other pro-life Democrats who voted for the House bill but earlier wrote a letter to Pelosi saying they "cannot support any health care reform proposal unless it explicitly excludes abortion from the scope of any government-defined or subsidized health insurance plan" — which the Senate bill does not. Last weekend, Stupak deemed the Nelson language “unacceptable.”

The idea that Pelosi will wind up backing Stupak is close to unthinkable; not only would the potential losses on the left be too great, but it would never pass muster with pro-choicers in the Senate such as Barbara Boxer. The greater likelihood is that choicers will knuckle under and accept the Nelson language (which has Boxer’s imprimatur) and Pelosi will make up for the lost votes of the Stupak faction by picking up some of the 39 Democrats who voted against the House measure. Largely conservative, this bloc was put off mainly by the inclusion of the public option, but with it now off the table — and with other “cornhusker kickback”–esque goodies available to be tossed their way — just enough of them might be persuaded to vote "aye" this time.

Or maybe not — I mean, who knows? Certainly not Pelosi, who, like Reid, has been flying by wire on health care from the start, without a map or a compass or any tried-and-tested navigating tools. The air show the two leaders have put on over the past year has been hair-raising for all involved. And while their performances so far have been more adroit than anyone would have predicted, what lies ahead may prove even harder: guiding the bill to a Sully-style landing while juggling chainsaws in the cockpit.