Neither a record two-foot snowfall in Washington nor the gloom of night kept the Senate from voting 60-40 Monday after 1 a.m. on the first procedural vote to move ahead the Senate's healthcare reform bill.
The vote puts the Senate in position to have a final vote on the bill by Christmas Eve—and provides both sides time to debate the new 384-page manager's amendment released by Senate Majority Leader Harry Reid (D-NV) on Saturday morning.
Not surprisingly, gone is any public insurance option and an option to permit uninsured individuals ages 55-64 to buy into Medicare. Included is the provision proposed earlier this month in which multi-state private insurance plans would be offered under contract with the federal Office of Personnel Management, with at least one of the plans being a nonprofit entity.
But the issue that is likely to trigger major discussions this week is whether certain states are getting preferential treatment in the bill to ensure votes. On Sunday, Republicans were quick to point out that provisions were included in the bill for at least one state—Nebraska—and several others whereby the federal government would agree to pay for additional Medicaid costs incurred when newly insured enrolled. Nebraska is the home state of Sen. Ben Nelson, a Democrat who had considered not voting with his party in part because of the abortion language in the bill.
Senate Minority Leader Mitch McConnell (R-KY) said on Sunday that "when you decide to do something one-party only and you have 60 votes, you're open for business." He added: "It creates a smelly proposition. It exposes every one of those 60 to extract some special deal for them at the expense of everyone else in the country."
Sen. Kent Conrad (D-ND), speaking on Fox News Sunday, downplayed the controversy, saying that his "state gets a special deal" and "virtually every state gets some kind of differential treatment based on their situation." He added that North Dakota and "the other frontier states" under the bill will "get an increase in their Medicare levels of reimbursement because we're the lowest states in the country—and that doesn't offend me at all. It's, in fact, fair."
Among other provisions included in the manager's amendment are:
Medical loss ratios. Large group market plans must spend at least 85% of their premium revenues on clinical services and quality activities; for the individual and small group market, the ratio is 80%.
Excessive rate increases. A health insurer's participation in the state exchanges will depend on its performance.
Expansion of delivery system reforms. The secretary of Health and Human Services would have authority to expand successful Medicare programs, such as payment bundling and other value based purchasing projects, and could incorporate private sector payment models into the Medicare accountable care organization program.
Pre-existing condition exclusions for children. Health insurers will be immediately prohibited from excluding coverage for children with pre existing conditions.
Testing new tort models. States will be eligible for grants to test alternatives to civil tort litigation that emphasize patient safety, disclosure of healthcare errors, and early resolution of disputes.
Medicare tax. The Medicare payroll tax increase would be increased to 0.9%, from 0.5% that was proposed earlier, for individuals earning more than $200,000 or families making more than $250,000.
Cosmetic surgery tax. The so-called "Bo tax," is being dropped in favor of a 10% tax on indoor tanning salons.
The next vote on the Senate bill is scheduled for Tuesday morning. The bill is unlikely to garner any Republican votes.
Sen. Olympia Snowe (R-ME), who voted for the Senate Finance Committee bill, said Sunday on "Face the Nation" that "we're treating it as if it's the legislative appropriations at the end of the year. It's like the last train leaving the station; we're going to dump everything in there."
She said the current bill is "more expansive" than the Finance Committee bill--including for instance a new provision of long-term care insurance. "It...is a whole new entitlement that frankly will turn in the red five years after the benefits begin."