Debate on H.R. 3590, the "Patient Protection and Affordable Care Act" continued this week and is expected to continue over the next two weeks.

As of Friday morning, 92 proposed amendments to the bill had been officially filed, although it is not certain how many of them will actually be voted upon.  So far, two amendments have been formally adopted: 

• An amendment by Sen. Barbara Mikulski (D-Md.) was adopted by a 61-39 vote to ensure coverage and eliminate co-payments and deductibles for certain preventive services for women. The Mikulski amendment requires health insurers to cover evidence-based recommendations supported by the Health Resources and Services Administration in addition to those receiving a rating of "A" or "B" by the U.S. Preventive Services Task Force (USPSTF). 


• An amendment written by Sen. David Vitter (R-La.), which was adopted as part of the Mikulski amendment, provides that the USPSTF recommendations on mammograms issued last month are not considered the most current, so those issued earlier are to be used.

In an effort to forge a compromise that will help win passage of the Senate health care reform bill, Senator Tom Carper (D-Delaware) has been working closely with liberal and conservative Democrats, as well as Sen. Olympia Snowe (R-Maine) to come up with yet another version public option.  It is believed  that the version of the public option currently in the bill does not have enough votes to pass.   As reported in The Hill,

Sensing that his bill may need changes, Reid recently called on Carper and Sens. Charles Schumer (D-N.Y.) and Mary Landrieu (D-La.) to come up with new legislative language on the hot-button issue of the public option.  Carper indicated that significant progress has been made and it is a question of when, not if, the new healthcare plan will be unveiled. Carper initially said an outline of his measure could be issued later this week, but later said it is more likely to emerge next week ....

As the Senate begins debate on its health reform bill, Kaiser Health News dug through the 2,074-page bill and found several special interest provisions that have thus far flown under the radar.  Congress has a long history of adding items that may not be able to get passed on their own to larger comprehensive bills that are more likely to be approved by both houses and the Senate health care reform bill is no exception.  Some of the special interest additions to the bill include the following:

Nursing Mothers Get A Break

Employers would be required to provide an unpaid "reasonable break time for nursing mothers" in the first year after giving birth. Women would be provided a private place, other than a bathroom, to use a breast pump. The provision exempts companies with fewer than 50 workers if the requirement would impose "an undue hardship," a determination left to the employer to make. To encourage businesses, the legislation would give them a tax credit toward the costs of providing a suitable space for women...

Learning To Be An Adult
Being a teenager is tough. The Senate wants to help with a provision allocating $400 million from 2010 to 2015 to help teens make the transition to adulthood.  The money goes to states primarily to set up sex education programs. But the money can also be used for "adult preparation" programs that promote "positive self esteem, relationship dynamics, friendships, dating, romantic involvement, marriage and family interaction...."

Retiree Health Benefits

The Senate bill includes a provision designed to ease out-of-pocket costs for retirees who are under 65 but who still get health insurance from their former employer.  The bill would create a temporary "reinsurance" program under which the government would pick up 80 percent of some high-cost insurance claims filed by retirees...

The AMA wrote a letter to Senate Majority Leader Harry Reid (D-Nev.) Dec. 1 concerning the Senate's proposed health system reform bill. The bill--in the form of a substitute amendment to H.R. 3590, the "Patient Protection and Affordable Care Act"--represents a melding of previous proposals reported by the Senate Committee on Health, Education, Labor, and Pensions and the Senate Finance Committee. In the letter, the AMA does not make a formal statement of support or opposition to the legislation in its current form. Given that Senate floor consideration is expected to last several weeks and the legislation will be amended, the AMA is reserving judgment on final passage of the Senate bill until later in the debate.

The AMA also released today a handy point by point comparison of the Senate and House health care reform bills along with AMA commentary on the major provisions.

Read the letter here and the AMA comparison of the Senate and House health care reform bills here. 

Debate has begun on the Senate's health care bill and the first proposed amendments have been introduced.  As reported in the Washington Post,

The initial amendments offered illustrated the legislation's vast scope and lingering vulnerabilities. The first, co-sponsored by Sens. Barbara A. Mikulski (D-Md.) and Olympia J. Snowe (R-Maine), would increase preventative health care for women at a 10-year cost of $940 million. One aim of the measure is to blunt concerns raised last month when an independent commission recommended that women undergo mammograms less frequently.   The second amendment, authored by Sen. John McCain (R-Ariz.), would strip out the bill's primary revenue source, nearly $500 billion in Medicare cost savings. Although AARP and other seniors groups have said otherwise, Republicans are attacking the cuts as a threat that could eventually shorten lives.

The debate over the Medicare amendment was especially heated, reports the Wall Street Journal:

In a November 28 editorial, The New York Times argues that even a weak public plan would be better than no public plan because it would expand the choices available to millions of Americans.  After first discussing the limitations of the public option as it currently exists in the House and Senate health care reform bills, the NYT concludes that even a weak public option would be worthwhile:

The presence of a public plan could serve as a brake on unwarranted premium increases by the private companies. The C.B.O. [Congressional Budget Office] said a public plan with negotiated rates would place "downward pressure on the premiums of private plans." A public plan would also provide a safe harbor for people who do not trust the insurance industry and would prefer a government plan even if its premiums were higher. And it would be a place to test innovative ideas for controlling costs and improving quality.

The C.B.O., a notably cautious evaluator, could be wrong in its assessments. The plan might turn out to be better at negotiating lower rates. And with no need to turn a profit, it might be able to charge less than private plans and attract millions more people than expected. That could force private plans to lower their own rates.

We are not holding our breath. The public plan could face enormous practical problems entering markets where private insurers already have well-established networks of providers or where hospital groups already have the upper hand in negotiating with insurers.

Even a weak public plan would be better than no public plan. It would expand the choices available to millions of Americans and could help slow the relentless increases in the cost of health insurance. Congress certainly owes Americans a more rational and informed debate.

Read the full editorial here. 

The Senate's health care overhaul bill would substantially reduce premium costs for 57 percent of people who buy subsidized coverage through new exchanges, while rates would hold steady or decline slightly for large and small employers, a long awaited analysis from the Congressional Budget Office showed today.

People who buy their own coverage but don't qualify for government subsidies, however, could see increases of 10 percent to 13 percent, mainly because the coverage offered in the exchanges would cover more benefits compared with what is currently purchased, and thus would be more expensive.

Read the full CBO report here. 

Debate begins today on the Senate's health care reform bill, with both Democrats and Republicans planning to offer amendments on divisive subjects such as abortion and taxes.    The one thing that all observers agree on is that the debate will be contentious.  As reported in Politico,

the reasons are clear: deep divides among Democrats on a public insurance plan, abortion, tax hikes and cost-cutting. Liberals want the plan to be generous enough. Moderates fear a budget-buster. And everyone is trying to avoid angering seniors...  [Senate Majority Leader Harry] Reid (D-Nev.) is far from having the votes to move his $848 billion package to final passage. At least four centrists have pledged to oppose it in its current form, largely over the public option. Reid is in a bind. Stay to the left, and moderates vote no. Move a tad to the right, and Reid faces insurrection from the left, as liberals in his own caucus and in the House vow not to compromise any further on their signature issue.

The Washington Post's coverage focuses on the overall cost of the proposed bill and the evidence surrounding costs and projected long term savings:

Kaiser Health News and NPR reported last week that the focus on the cost of health reform has focused almost entirely on the overall costs of the various proposals, while very little attention has been paid to how much an individual or family will have to pay. 

That could be a costly miscalculation, says health economist Jonathan Gruber of the Massachusetts Institute of Technology. "Let's put it this way: It is 10 times as important as the public option and has received one one-hundredth of the coverage," he says. That's because, in the end, whether or not people can afford health insurance may have a bigger impact on the bill's political popularity than whether the final price tag exceeds a trillion dollars.

The bills now before Congress do address affordability by providing government subsidies for insurance premiums for people who earn less than four times the poverty level.   But insurance premiums are just part of what people pay for their health care.  Deductibles and co-pays can be substantial additional costs.  Gruber notes that the House provides substantially more help with these additional costs than does the Senate bill:

For the full story, click here, 

The Hill posted an article on Sunday summarizing what it sees as the seven pivotal issues that stand  will be subject of debate and possible amendment as the Senate takes up its health care reform bill next week:

Public option: An issue that unites Republicans and divides Democrats on ideological grounds inevitably was bound to haunt the Senate Democratic leadership. The notion of creating a government-run health insurance plan to compete with private companies is seen as vital by liberal Democrats but centrists range from skeptical to deeply antagonistic, even though states could opt out. 
The best hope for a positive outcome for the Democrats could rest on the chances that liberal Sen. Chuck Schumer (D-N.Y.) along with centrist public option supporter Sen. Tom Carper (D-Del.) can forge yet another compromise version of the program to satisfy centrists such as Sens. Ben Nelson (D-Neb.) and Joe Lieberman (I-Conn.), who have threatened to filibuster the bill over the public option. Sen. Olympia Snowe (R-Maine) is waiting in the wings with her "trigger" compromise.

Abortion: It wouldn't be American politics if the forces on both sides of the abortion issue weren't at loggerheads. The healthcare bill already includes language that is supposed to keep federal dollars away from abortion funding but the Catholic bishops, and Nelson, don't think it goes far enough. Democratic Sens. Bob Casey Jr. (Pa.) and Kent Conrad (N.D.) each voted in committee to beef up the abortion restrictions so their actions on the floor will be key. Sen. Orrin Hatch (R-Utah) authored the failed committee amendments and is sure to raise objections to the bill on abortion.

A press release from the Government Printing Office announced that the Senate health care reform bill is available on their Federal Digital System. 

The U.S. Government Printing Office (GPO) has made available the U.S. Senate's health care reform bill in electronic and printed form.  The authentic, electronic version is available on GPO's Federal Digital System (FDsys), named by Government Computer News as one of the Government's best Web sites.  GPO authenticated the document by digital signature. This signature assures the public that the document has not been changed or altered. A digital signature, viewed through the GPO Seal of Authenticity, verifies the document's integrity and authenticity.

Link to FDsys:  www.fdsys.gov

Direct link to the Senate bill: 
http://www.gpo.gov/fdsys/pkg/BILLS-111hr3590AS/pdf/BILLS-111hr3590AS.pdf

Direct link to the House bill:  
http://www.gpo.gov/fdsys/pkg/BILLS-111hr3962IH/pdf/BILLS-111hr3962IH.pdf

In a 60-39 vote, the Senate voted tonight to proceed with the debate on the Senate Finance Committee's health reform bill.  After days of indecision, the two final Democratic holdouts -- Sens. Blanche Lincoln (Ark.) and Mary Landrieu (La.) -- joined the rest of their caucus in supporting a procedural motion to begin debate.   No Republican voted for the measure.   

While Saturday's vote was a key victory for Senate Democrats and a necessary step in moving the health reform bill to a vote, it is just the beginning of what will likely be a struggle to get the bill passed.  As reported in The Washington Post,

[E]ven as Democrats heralded their victory, they conceded that it represents the end of the beginning -- and not the other way around.   Like Sen. Ben Nelson (D-Neb.), a holdout until Friday, Lincoln and Landrieu said they will press Reid for further changes to the bill before committing to its final passage. Above all, the Democratic caucus remains bitterly divided over a government insurance option.   Reid quelled an uprising by liberal senators weeks ago by adding a public option to the legislation. But although he included an opt-out clause for states, some moderates -- including Landrieu and Lincoln -- have told Reid they will oppose the Senate bill on final passage unless the provision is dropped.  For Democratic leaders, the weeks ahead are likely to bring costly concessions. Lawmakers are already requesting changes to the legislation, raising concerns related to Medicare, abortion and employer requirements.

For the complete story in the Washington Post, click here.  For coverage from The Wall Street Journal, The New York Times, and the Los Angeles Times click here, here, and here. 

For the text of the bill, click here.