Still an option

A comprehensive Senate bill to overhaul the U.S. healthcare system likely will contain the divisive measure known as a public option.

Lawmakers late last week revealed that a small but pivotal group of senior senators are leaning toward a national public health option—a provision that could kill off any hope of Republican support and even isolate a handful of Democrats. The House, too, is focusing some of its efforts on a public option (See story, below).

Senate Majority Leader Harry Reid (D-Nev.), along with Senate Finance Committee Chairman Max Baucus (D-Mont.) and Sen. Christopher Dodd (D-Conn.) have met regularly with HHS Secretary Kathleen Sebelius and other White House higher-ups to meld components of two health reform bills. The group developed a blueprint for a national health plan.

The public option under consideration, according to one senator, would be a national plan that would allow states to ultimately opt out of participation—but only if they meet certain affordability and enrollment standards.

“I think at the end of the day there will be a national plan, probably put together not by the federal government, but by a national board, with seed money from the federal government,” Sen. Thomas Carper (D-Del.) said shortly after leaving a meeting with Senate Finance Committee Democrats.

The plan would be administered by a not-for-profit board, and not HHS, which Carper said is key to gaining the support of centrists. It would also have to adhere to the same rules that govern private plans, he added.

Still, it's not certain that such a measure could corral the 60 votes needed to pass. Sen. Ben Nelson (D-Neb.), a conservative Democrat who represents a potential swing vote, was cagey when asked if he would vote against the measure. “I'm not sure I understand why you want to have a national public option in advance of the states saying there's a need for one,” Nelson said.

Sen. Olympia Snowe of Maine, the only Republican to vote for a health reform package, said she could not support the structure for a national plan. “There's nothing new about my views,” she said. “They've been stated repeatedly.”

Internal discussions among the Senate leaders, which also included White House Chief of Staff Rahm Emanuel, budget chief Peter Orszag and the administration's reform specialist Nancy-Ann DeParle, have also keyed in on other areas, such as strengthening the individual insurance mandate, making plans affordable and finding a workable employer mandate.

Nothing has been set in stone, and the mercurial rules of Congress ensure that there will be a number of opportunities for legislation to be shaped and reshaped again. For instance, reports surfaced that the White House had warmed to a proposal by Snowe that would allow for a public option to kick in if private plans don't reach certain payment, performance and enrollment goals. That option, known as the “fallback” or “trigger” plan, first took shape in June and has been in and out of discussions ever since.

The legislative haranguing almost ensures that the Senate won't have a completed package this week. Further, some lobbyists have begun to say that a bill may not get passed until early 2010 despite a push by the White House to get it done sooner. When asked about the timeline slipping until early next year, Snowe shrugged her shoulders. “It's possible,” she said.

The negotiations played out against the backdrop of one of Reid's most stunning losses. On Oct. 21, the Senate's top Democrat saw a bill that would have zeroed-out the double-digit Medicare payment cuts that physicians face each year as a result of being based on a measure called the sustainable growth rate. The measure garnered only 47 votes when it needed 60 to advance, and saw 13 members of the Democratic Caucus break from their party's leader.

The loss, though expected, surprised many on and off Capitol Hill for the sheer number of votes against it.

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