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The left-vs.-right battles that dominate American politics — and that President Barack Obama has sought desperately to avoid — are about to move center stage in the health care debate.
After months of discussion about once-obscure policy particulars, the debate is reverting to well-trod political terrain over issues that have long divided Democrats and Republicans: whether lawsuits against doctors should be capped, how much care to provide the poor, whether to pay for abortions and whether people who came here illegally should be covered.
The emergence of these now-familiar dividing lines doesn’t bode well for a White House — and a president — that has been eager to avoid the politics of the past and already has had enough trouble selling the idea of reform in broad strokes. In his speech to Congress last week, Obama tried to assuage concerns about abortion and illegal immigration and offered to include new restrictions on medical malpractice lawsuits, extending an olive branch to Republicans that only seemed to reignite a long-standing debate.
The Senate Finance Committee, which is expected to produce a bill this week, has been immersed in discussions on these hot-button issues over the past week as Chairman Max Baucus tries to reach an agreement with a group of two fellow Democrats and three Republicans.
And these fights could very well overshadow debate on matters of health care policy as the rank and file start making more noise about them. Obama himself might also have to wade into the debate once the inevitable deadlocks emerge.
“Most of this stems from the way the president talks about reforming health care,” said Michael Cannon, director of health policy studies at the Cato Institute. “The administration has been trying too hard to project an air of inevitability without getting into specifics.”
Here are the coming flash points:
A proposed increase in this program to provide medical coverage to the poor barely garnered any notice over the summer, when House Democrats approved a $438 billion expansion of Medicaid. Democrats want to raise the threshold for receiving Medicaid to 133 percent of the poverty level.
But it’s not escaping notice any longer. This fight is one that could be waged between the chambers — and with state governments, who pay for part of the coverage. House lawmakers wanted to use federal money to fund the expansion.
Senate negotiators want the states to bear part of the burden in order to reduce the overall costs of the federal tab — an idea that is, not surprisingly, pretty unpopular back in the statehouses, most of which have budgets deep in red ink.
But the fight could go deeper. It could reignite ideological concerns from Republicans and small-government Democrats who have problems with federally funded health care programs — even one with as long a history as Medicaid. And conservative groups will only add more fuel to the fire.
“The federal government shouldn’t be expanding Medicaid. It should be cutting it,” said Cannon.
Baucus said Monday he hopes the final Senate Finance Committee bill will actually be less difficult for states to shoulder than many states originally feared. But that doesn’t mean it won’t be controversial, even within the Finance Committee, where Sen. Olympia Snowe, the Maine Republican who is one of only three Republicans still at the table, has raised concerns about putting too much burden on the states.
South Carolina Rep. Joe Wilson, a genial back-bencher, earned national scorn (and acclaim, in some circles) for calling Obama a liar after the president claimed his health care bill won’t offer any benefits to illegal immigrants.
The now-infamous episode, for which Wilson apologized, renewed a debate that stirs as much angry opposition as any in American politics — making it such a powerful foil for Republicans and other critics of health care reform.
Democrats in the House went out of their way to include a passage in their bill to explicitly bar illegal immigrants from receiving any health care benefits established in the bill.
However, there are pre-existing loopholes that make it difficult to prevent illegal immigrants from receiving emergency-room treatment under Medicaid, and the Congressional Research Service acknowledged that some could share in subsidies to purchase insurance if others in their household already qualify.
The Senate Finance Committee is looking to create a verification system that would bar illegal immigrants from receiving any benefits under these programs. The bipartisan group of six senators is also weighing a five-year delay on benefits for legal immigrants, which Sen. Chuck Grassley (R-Iowa) favors.
The White House position is that illegal immigrants would be barred from buying insurance in the exchange, and the verification system could mirror one currently used for government entitlement programs. Legal immigrants should be able to participate in the exchange, according to the White House.
But immigrant advocates complain that these political arguments miss the point on immigration and health care. “The Senate Republicans and Democrats, the Gang of Six, are just folding in the face of one heckler,” said Ali Noorani, executive director of the National Immigration Forum, an advocacy group for immigrants.
Ira Mehlman, spokesman for the Federation for American Immigration Reform, said the prohibition on illegal immigrants must apply to the exchange and any sort of public option, and the Senate Finance Committee bill should stipulate a verification system.
Medical malpractice reform
Obama appeared to throw Republicans a bone last week when he acknowledged that “defensive medicine may be contributing to unnecessary costs.” He even directed his administration to explore pilot programs to limit unnecessary lawsuits against doctors.
The Senate Gang of Six received legislative language Monday from staff on providing federal funding to the states to experiment with medical malpractice reform programs.
The GOP has been asking the president for months to include some form of malpractice reform in the health care reform bill. But most Republicans were skeptical in the wake of his speech.
The fight typically splits over whether to cap the money a jury can award plaintiffs in a medical malpractice lawsuit. Until he offers more details, or until congressional negotiators reach some agreement, Republicans will continue to view his offer as a rhetorical flourish meant to win more points with voters than corral GOP votes.
“While his demonstration program might be a step in the right direction, the devil is in the details,” said Lisa Rickard, president of the U.S. Chamber Institute for Legal Reform.
In his speech to Congress, Obama said “no federal dollars will be used to fund abortions,” sparking another round of head-scratching about whether the legislation will actually allow federal funding for abortion.
Rep. Lois Capps (D-Calif.) tried to craft an amendment in the House Energy and Commerce Committee that would allow lawmakers to keep the current ban in place without reigniting a bitter fight over abortion rights.
The current law bans federal funds from being spent on abortions, but under the Capps amendment, private insurers that already provide coverage for abortion would still be allowed to offer those services. Her amendment requires every exchange to include at least one plan that offers abortion coverage and at least one that does not.
Reproductive rights groups are fighting hard to at least preserve the Capps amendment.
“At a very minimum, there should not be backsliding for American women for their access to abortion,” said Nancy Northup, president of the Center for Reproductive Rights, who wants the Senate to match the language in the Capps amendement.
On the president’s speech last week: “The rhetoric has been unhelpful.”
Joy Yearout, communications director for the Susan B. Anthony List, a group that opposes abortion rights, said the opponents of abortion are looking for an explicit exclusion of taxpayer funds for abortion. “No matter how many times the president says abortion coverage will not be in the bill, there is no bill, and there is no language. Until we see the language, we can’t assess what it says.”