How many Americans will get subsidized medical coverage — plus who will pay for it — will be front-burner issues when Congress returns next month to complete President Barack Obama's health care remake.
Pocketbook concerns join abortion and whether Uncle Sam should peddle insurance as the top bones of contention for negotiators who must resolve difference between the House and Senate bills.
The negotiations are the last chance for Democrats to shape the legislation to deliver concrete benefits to Americans skeptical that it will help control skyrocketing premiums as it expands coverage to millions more.
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"People will really begin to focus on some of the core issues that have received less attention," said Rep. Chris Van Hollen, D-Md., a member of the House leadership. "These are the bread-and-butter issues that will have the most significant impact on people's pocketbooks."
Broadly speaking, both bills would gradually expand coverage, while banning objectionable insurance industry practices such as turning down people with health problems. Eventually, all Americans would be required to carry health insurance, with government subsidies to make premiums more affordable for many of them.
Those covered by big employers wouldn't see major changes, but individuals buying their own policies and small businesses would be able to shop for competitively priced plans in an insurance supermarket called an exchange. Medicare cuts and an assortment of taxes and fees would pay for the bills.
Democrats are under pressure to reconcile the House and Senate versions before Obama's first State of the Union speech. Not yet scheduled, it's usually delivered in late January or early February. Republicans will wage legislative guerrilla warfare to delay an agreement.
There's not much time, and apparently not much give either.
Senate moderates say they won't vote for a bill that changes the basic terms they agreed to with Majority Leader Harry Reid.
Independent Sen. Joe Lieberman of Connecticut and conservative Sen. Ben Nelson, D-Neb., have drawn a line against reintroducing a government-run insurance plan to compete with the likes of Aetna and Wellpoint. The House bill includes it, but Reid, D-Nev., needs every member of his 60-vote coalition to hold off GOP opponents.
More difficult to solve is the issue of how to restrict taxpayer funding for abortions. Abortion opponents disagree among themselves over the Senate's approach. Abortion rights supporters are completely against the more restrictive House language and are divided on how the Senate has handled it.
Obama will probably have to step in to settle disputes and keep things moving.
Democrats have options on how to handle the negotiations. They could agree to a limited set of changes, allowing each chamber to pass identically amended bills. Or they could set up a formal conference committee to resolve differences. Leaders have made no decision yet. Naming a conference committee would signal that the issues have proven difficult.
Yet the longer Democrats argue, the more suspicious the public becomes about remaking the health care system. "The making of salami and legislation is not pretty for people to watch," said Harvard professor Robert Blendon, who tracks public opinion on health care. "It has left them nervous that the interests of middle-income people are not being served."
That's one reason leading Democrats are arguing for a focus on pocketbook issues in the homestretch.
"There will be a certain amount of replaying issues that have been hot-button issues, but I think there will also be a refocusing, especially on cost," said Senate Budget Committee Chairman Kent Conrad, D-N.D. "At the end of the day, when all of us go home, what we hear about is the ever-increasing, ever-escalating costs."
There are some signs of that already.
Last week, Reid pledged on the Senate floor to close the coverage gap in Medicare prescription benefit — as the House bill already does. The message was aimed at seniors worried that Medicare cuts to hospitals and other providers will jeopardize their care.
And Conrad said senators may go along with the House timetable for expanding coverage, which calls for starting subsidies in 2013, a year earlier than the Senate bill.
The House bill provides coverage to 36 million, while the Senate covers 31 million. Lawmakers in the House want the Senate to move toward their number.
Another priority will be to make sure the final bill promotes competition in the health insurance market, which in many states is dominated by one or two large carriers.
Though it sounds arcane, a major problem for negotiators is whether the new insurance supermarket should be state-based, as in the Senate bill, or national, as the House calls for. Some advocates say a national approach provides stronger consumer protection.
Finally, the issue of who to tax won't be easy.
Unions are adamantly opposed to the Senate plan, which would impose a 40 percent tax on high-cost health insurance above $8,500 for an individual plan, $23,000 for families. Organized labor sees the tax on so-called Cadillac plans as a hit on its members, who have fought for years for better-than-average coverage. Unions are a core Democratic constituency and many House Democrats want to knock out the insurance tax.
The Obama administration, however, supports such a tax. In a recent session with reporters, White House economic adviser Christina Romer called the tax "a very effective cost-growth containment mechanism," arguing that it will force people into more efficient plans.
Rep. Joe Courtney, D-Conn., wasn't buying it. "The most troublesome component of the Senate bill remains the 40 percent excise tax on high-cost health care premiums," he said. More than 190 House Democrats agree. Instead, they want to tax upper-income earners.
Associated Press writers David Espo and Erica Werner contributed to this report.
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