U.S. Republicans are counting on Democratic defectors in the Senate to upend President Barack Obama's goal of extending health-insurance coverage to all Americans, now that the House of Representatives has narrowly passed its own reform bill.
Though Mr. Obama's objective of enacting health reform is now nearer reality, major hurdles remain. Republicans vowed Sunday that no final bill will reach the President's desk, with South Carolina Senator Lindsey Graham calling the House legislation "dead on arrival" in the Senate.
"I hope and pray it doesn't [pass]because it would be a disaster for the economy and health care," Mr. Graham said on the CBS show Face the Nation . "It will be a death blow to private choice."
Republicans and conservative Democrats alike denounced the Affordable Health Care for America Act as a symbol of government intrusion gone awry. But after Mr. Obama's last-minute cajoling - calling on Democrats to "answer the call of history" during a weekend visit to Capitol Hill - enough legislators in the House voted to adopt the bill in a squeaker vote of 220 to 215 during a rare Saturday night session.
It did not come without major compromises, as House Speaker Nancy Pelosi, a fervent defender of abortion rights, yielded to conservative Democrats and included a provision in the bill to prohibit publicly subsidized health insurance from covering abortions.
The abortion issue illustrates just one of the fault lines within the Democratic caucus that Mr. Obama has had to negotiate in order to advance a key plank of his agenda, with members of his own party attacking the bill from both the right and the left - the nearly 2,000-page document becoming a weighty prop without which almost no opponent would be seen on TV.
Despite the last minute deal-making, 39 House Democrats voted against their leadership's own bill. But after decades of false starts, almost no one was underestimating the significance of Mr. Obama's House victory. The idea of a bigger government role in health care has divided Americans the way constitutional reform has confounded Canadians, making change a career-limiting quagmire for Democratic presidents.
"We're not going to get the Canada Health Act," Timothy Jost, a professor of health law at Washington and Lee University in Lexington, Va., quipped in an interview. "But it's very important and historic because we've never gotten this far before."
The $1.1-trillion (U.S) bill promises to extend health-care coverage to 96 per cent of American residents - or 36 million more people - by providing subsidies to lower-income Americans to buy insurance from either a private company or a new government-run plan that would compete with the private sector. Illegal immigrants would not be eligible for subsidies.
Had it not been for the election last week of two more Democrats to the 435-member House, and a vote for the bill by one Republican in a left-leaning New Orleans district, Mr. Obama would likely have seen health-care reform elude him as it had almost every Democratic president of the past century.
It still could. The Senate has yet to vote on its own health-care bill and passage there is far from a slam dunk. Even if a bill gets through the Senate, there will messy negotiations between both chambers of Congress to draft a final bill to send to Mr. Obama for his signature.
Prof. Jost suggested any stalling by Senate Republicans could doom health-care reform for yet another presidency. "If this thing goes much past the beginning of the year, we're going to be into an election year and everyone is going to be getting nervous," he said.
Fears of a taxpayer revolt during next year's mid-term vote, when the entire House is up for re-election, is one reason Republicans in Congress have been joined by conservative Democrats who oppose both the costs and intrusiveness of health-care reform.
The House bill, as well as proposals expected to come before the Senate, would require all Americans or their employers to buy health insurance or face fines. Under the House bill, the $1.1-trillion (U.S.) cost over 10 years of subsidizing health-insurance would be offset by new taxes on Americans earning more than $500,000 (U.S.) and cuts to Medicare, the 44-year old public health care plan for seniors.
The Congressional Budget Office, the agency that costs out government programs, concluded that House bill should not add to the U.S. deficit, which swelled to a record $1.4-trillion (U.S.) in the year ended Sept. 30. That, however, is based on the assumption that Congress will actually move to contain Medicare costs, something it has resisted countless times before.
Even the CBO, in its Oct. 29 report, made note of the intricate financial acrobatics that will be required to cover the cost of extending health care coverage. The House bill proposes to reduce the annual increase in Medicare spending to 6 per cent from 8 per cent just as ranks of American seniors are about to swell as the baby boom generation hits 65.
``Congress lacks the will to impose these deep [Medicare]cuts on a permanent basis," James Capretta, a fellow at the Washington-based Ethics and Public Policy Center, said in an interview.
Ms. Pelosi's concession on abortion makes it all but certain that any final health-care reform package will prohibit the use of government funds to cover the procedure. But in caving, Ms. Pelosi alienated many of her closest allies among left-leaning Democrats.
"If enacted, this amendment will be the greatest restriction of a woman's right to choose in our careers," Colorado Democrat Diana DeGette said. In the end, though, Ms. DeGette voted for the bill.
Mr. Obama likely had something to do with that. As he pleaded with House Democrats to pass the bill, he emphasized the historic nature of health-care reform over the histrionics that have characterized recent debate.
He's won - for now - but there is plenty of hyperbole to overcome before health-care reform is a done deal.