The Health Battles That Won't Die: Lieberman, Taxes, Abortion and (Oh, Yeah!) the House

Senate Majority Leader Harry Reid showed just how ugly legislating can get on Monday night, when he called the members of his exhausted, fractured caucus together for an emergency meeting to discuss health reform.

Once inside the large room in the Capitol, he gave them a reality check and a choice.

First, the reality check: The only people keeping the Democrats from passing health care reform were other Democrats.

Sen. Joe Lieberman, an independent who caucuses with the Democrats, had announced the day before that he would filibuster the bill if it contained a Medicare expansion, while a dozen others had sent Reid a letter with less ominous, but still serious, concerns about the idea. Sen. Ben Nelson had not found abortion language to his liking and Sen. Claire McCaskill warned that a high price tag on the measure would send the effort "back to the drawing board."

Reid counseled his members not to let the perfect be the enemy of the good and then gave them their choice: Accept a scaled-back, if watered-down, version of health care reform or let their signature issue die for the second time since 1993.

By all accounts, most accepted Reid's offer in principle, even if it pained them to do so.

"We're going to get this thing done, that's what's important," Sen. John Kerry (D-Mass.) said as he walked swiftly past reporters leaving the meeting. "There's going to be a good bill," promised Sen. Sherrod Brown (D-Ohio), one of the most progressive members of the group.

According to sources familiar with the meeting, the bill that Brown, Kerry and other senators were presented would scrap the government-run "public option" insurance, as well the concept of letting uninsured consumers between 55 and 65 to buy into Medicare. Instead, the bill would expand the power of the Office of Personnel Management to oversee a new, nationwide health care exchange, where people could purchase insurance from private companies and non-profits. It would also extend elements of the federal children's insurance program to mollify liberals' concerns about insurance affordability for children and parents in the short term.

"I wouldn't describe it as a meeting where a definitive conclusion was reached," said Sen. Bob Casey (D-Pa.) of the results of the caucus. "I know everyone wants to know about the vote count, but we're all still working on it. We're going to get there."

Sen. Jay Rockefeller (D-W.V.) authored the public option that Reid removed, but he said he would not think of voting against the measure. "We're not going to get all that we want, but we're going to get so much more than we have," he said. When asked if Lieberman hadn't gotten what he wanted over the objections of the larger caucus, Rockefeller said firmly, "Nobody gets all they want. Nobody."

The good news for Reid and his fellow Democrats is that the meeting seemed to produce some progress toward a resolution as the full caucus prepared to meet with the president at the White House tomorrow. The bad news is that Democrats still have several obstacles within their own party, in both the House and the Senate, before anyone will be able to declare victory. They are:

1. Taxes. The Democratically led House pays for the bulk of health reform through an income tax increase on households making more than $500,000 per year. The Senate opted instead for a Medicare payroll tax increase for income over $250,000, as well as an "excise tax" on expensive heath plans. A senior House staffer described the different tax structures as fundamentally opposed to each other and the single largest issue preventing easy agreement in a House-Senate conference committee.

2. Abortion. Sen. Ben Nelson (D-Neb.) has yet to say he'll vote for the Democrats' health proposals, but he has called the issue of federal subsidies for abortion almost non-negotiable. "You can't split the difference," he told the Washington Post recently. With staunchly pro-choice Sen. Barbara Boxer (D-Calif.) on the other side of the issue, it's hard to see middle ground on this one.

3. Immigration. The Hispanic Caucus in the House carved out a provision to allow illegal immigrants to access the bill's heath exchanges (where consumers would be able to comparison-shop for insurance), as long as they use their own money to purchase coverage. The Senate designed a much stricter bill that prevents undocumented workers from accessing the exchanges at all, no matter how they pay for it. The Senate Finance Committee added that provision to the bill after Rep. Joe Wilson (R-S.C.) called President Obama a liar for saying during his speech to a joint session of Congress that proposals by Democrats would not cover illegal immigrants. It's an idea that is unlikely to be stripped from the bill in an election year.

4. Cost. The House rang up a tab several billion dollars higher than the Senate with its reform bill, mostly because it would give much more generous subsidies to people who cannot afford the insurance that the measure will mandate them to obtain. With the debt spiraling ever higher, Senate deficit hawks are in no mood to spend more money than they absolutely have to.

5. And finally, Joe Lieberman. The independent from Connecticut gave Democrats a raging case of heartburn on Sunday when he said he'd filibuster any bill with a Medicare expansion, even though he had once endorsed the concept. If his colleagues assumed his support was guaranteed with their concessions Monday night, they should think again. Minutes after Lieberman walked out of the meeting, he stopped to talk to reporters about the newest iteration of health reform, specifically altered to win his support. When he was asked if he could now assure Democrats he will vote with them, he paused and said, "It's heading in that direction, but it ain't over 'til it's over."