Health Stakes: Pressure Builds on Democrats to Reverse Decades of Failure

White House pressure, union pressure, leadership pressure – no stone is being left unturned this weekend as Democrats move to a final House vote Sunday on the health care overhaul that was central to President Obama's campaign and has consumed much of his first 14 months in office.

The procedural obstacle course faced by the 10-year, $940 billion package is a fitting end to the most suspenseful legislative journey of any bill in recent memory. One member at a time, House Democrats were slowly amassing the 216 votes they need to pass a bill that makes major strides toward the long-held Democratic goal of health coverage for all.

The House Rules Committee met Saturday to approve the rules for a vote expected mid-afternoon Sunday. From there, the bill will move to the Senate, where Republicans have vowed to try to kill it with a barrage of amendments. The Democrats' hope is for the Senate to pass the House product verbatim so it can go straight to Obama's desk – thereby ending a journey that began a century ago when Teddy Roosevelt called for national health insurance.

This is all assuming, of course, that the package makes it through the House in the first place. Democrats were buttonholing the undecided at the Capitol, and Obama was talking to them at the White House. Obama also rallied House Democrats en masse Saturday afternoon at the Capitol visitors center. He told them the health reform package was "the single most important step that we have taken on health care since Medicare."

Unions were ramping up pressure as well, in some districts talking about recruiting primary challenges to Democrats who got elected with their help but plan to vote against reforms they consider vitally important.

"SEIU members expect Congress to pass health care reform. If the U.S. House fails to muster the courage to pass health insurance reform, there will be consequences," Jessica Kutch wrote on the Service Employees International Union blog. The first casualty appears to be Rep. Michael Arcuri, D-N.Y., who has said he'll vote no.

Some of the loudest hue and cry in the past few weeks has been over the process Democrats are using to move the bill through Congress. The main vehicle is a Senate-passed bill with elements that Obama, House members, and many senators want to modify or eliminate. Normally this would be done in a House-Senate conference committee, then voted on by both chambers. But Senate Republicans gained a 41st vote with Scott Brown's election in January, allowing them to kill any conference bill with a filibuster.

The upshot is that the House must approve both the Senate bill and amendments to it, and senators must pass those amendments in a reconciliation process that requires only 51 votes. But House members are so uncomfortable with the Senate bill that they wanted to vote on the amendments and simply "deem" the underlying bill passed -- that is, approve the bill and the fixes with a single vote.

Conservatives threatened a constitutional challenge, although Republicans have used the same technique scores of times, and ridiculed House Democrats over their procedural gymnastics. The socially conservative Family Research Council, for instance, on Friday sent out a Washington Update headlined "Speed Deemin': Dems Race toward Sunday 'Vote.' "

Mary Wilson, president of the League of Women Voters, accused reform opponents of adopting a strategy of "fear, delay and obfuscation." The Constitution clearly says Congress makes its own rules on how to pass bills, she said, and it is "disingenuous to criticize the use of parliamentary procedures that have been employed for decades by the leadership of both parties."

But the criticism and the risks prompted Democrats to change course Saturday. Brendan Daly, a spokesman for Speaker Nancy Pelosi, said there would be separate votes on the Senate bill and the package of fixes House members had sought. "What will Republicans gripe about now?" the Democratic National Committee asked in an e-mail.

So what's actually in the two bills? The sweeping package would start phasing in expanded coverage, consumer protections, business tax credits, and aid to the elderly this year. Some 32 million people without insurance would get coverage in the first 10 years, about half of them through Medicaid. A competitive insurance marketplace, the cornerstone of efforts to offer reasonably priced policies to individuals and small businesses, would open in 2014. Almost all Americans would have to buy policies or face penalties. Lower income people would receive subsidies to make coverage affordable.

Democrats are paying for the bill with higher payroll taxes on the wealthy, an excise tax on very expensive health plans starting in 2018, savings in hospital and drug costs under Medicare, elimination of subsidies to private Medicare Advantage plans that are more expensive than regular Medicare, and a grab-bag of incentives, research, and pilot programs aimed at producing care that's more effective, efficient, and coordinated.

The nonpartisan Congressional Budget Office says the bill will not add to the federal budget deficit; in fact, CBO says, it will reduce the deficit by $138 billion in its first 10 years and by $1.2 trillion in its second decade.

Senate Republican Leader Mitch McConnell summarized the Democrats' health reform package this way Friday on the Senate floor: "Medicare will be deeply cut, insurance premiums and taxes will go up, the federal bureaucracy will grow, and as demand increases, the quality of care in this country will get worse and worse." He said the final product combines "a bill that House Democrats are too embarrassed to vote on," with more than $50 billion in new taxes and $60 billion more "slashed" from Medicare. "It's not reform," he said.

Labor leaders disagreed. They had pushed for a public health insurance option as part of an overall plan and, given the expensive health plans negotiated by various unions, protection from the excise tax. The public option was dropped and the excise tax will end up hitting more people than they would have liked. But unions stuck with the Democrats in the final push. "It's not a perfect bill, but it breaks the logjam" and "takes us a good part of the way" toward meaningful reform, AFL-CIO president Richard Trumka told reporters. He said the bill presents "an opportunity to change history that we can't afford to miss."

Obama, speaking Friday to a young audience at George Mason University in Fairfax, Va., also cast the moment in historic terms. Earlier generations decided that seniors and the poor "should not be forced to go without health care just because they couldn't afford it," he said. "Today it falls to this generation to decide whether we will make that same promise to hardworking middle-class families and small businesses all across America, and to young Americans like yourselves who are just starting out."

The president said cable TV likes to talk about everything but what's in the plan. "What they like to talk about is the politics of the vote," he said. "What does this mean in November? What does it mean to the poll numbers? Is this more of an advantage for Democrats or Republicans? What's it going to mean for Obama? Will his presidency be crippled, or will he be the comeback kid?" He was teasing, but as the final act for health care looms, all of those questions are real.

Note: This story has been updated to reflect new developments.