In a wide-ranging call with bloggers last night, senior leadership aides described some of the politics and policy behind the Senate health care bill, saying that a long debate is expected and vowing to stay in Washington as long as it takes to get the bill completed.

Jim Manley, senior communications adviser to Harry Reid, said that it was still expected that all amendments to the bill would require 60 votes, though that would have to be negotiated on a case-by-case basis. That’s good news for those who don’t want to see the Stupak amendment attached to the bill, since it would need 60 to pass (unlikely, given that it failed in two committees); it’s bad for those who want to see those harsh restrictions on legal immigrants (a five-year waiting period to access subsidies) or the undocumented (who can’t purchase insurance on the exchanges with their own money), since 60 would be such a high barrier. Aides seemed hopeful about losing the legal immigrant provision, which was in both bills so Reid “didn’t have the opportunity” to remove it in the merging stage, according to them. Failing that, the House didn’t include these provisions, so they could go in conference. (And if you don’t want Democratic support among Latinos to crater, they will.)

So far we’ve only seen Barbara Mikulski’s amendment to exempt certain women’s preventive health from cost sharing, and John McCain’s temper tantrum to recommit the bill and remove Medicare cuts (don’t mention the $1.3 trillion in cuts he offered during his Presidential campaign). Manley said that Reid would like to reach a broader agreement on structuring the debate with a set amount of amendments, but the GOP has not yet gone along with any unanimous consent requests, and “they want amendments that they can use in 30-second attack ads.” Why Democrats don’t want those kinds of amendments, and aren’t bringing them to the floor, is curious. Manley added that debates like this don’t come without risk and tough votes, but in the end they want to get this done, whether they have to work every day for the rest of the year. “We don’t have a recess…. failure is not an option.”

On the policy side, I asked leadership aides about the CBO report showing increased premium costs for the public option relative to private coverage in the exchange. While most experts attribute that to private insurers using the public option as a dumping ground for patients likely to use a lot of care through various strategies, they attributed it to the public option driving down prices in the private market. However, they agreed on the goal of preventing insurers from gaming the system, and that one way would be to tighten up the risk adjustment mechanism, so that private insurers are encouraged through payments to accept higher-risk customers. Senior leadership aides expected amendments doing just that on the Democratic side. In addition, they mentioned the minimum medical loss ratio put in before the exchanges come into being (why not after?), state-based regulation of the exchanges, and rate review authority from the federal government as ways to discourage patient dumping into the public option.

A few other bits and pieces from the call:

• While Harry Reid still has some negotiating room with remaining holdouts on the Democratic side, including continuing to float the threat of reconciliation, to this point no discussion has been given to Blanche Lincoln’s Agriculture Committee chair, though other outlets have reported that Joe Lieberman’s chair of the Homeland Security Committee may be at risk.

• On the subject of compromises of the public option, aides were tight-lipped, only saying that they’re trying to get 60 votes.

• I did get the first decent explanation about health care “cuts” from a Democrat so far. Part of these so-called cuts are improved care delivery in Medicare, part are excessive overpayments to private insurers through Medicare Advantage, and part are reductions to hospitals in payments for uncompensated care (which would be unnecessary if more people are insured). So the notion of less coverage through these cuts is little more than demagoguery. I just wish anyone on the Democratic side could explain that worth a darn.

• On opening the exchanges, leadership aides said that by 2014, states would need to include businesses up to 50 employees on their exchanges, and could allow businesses up to 100 employees. That would be mandatory by 2016, and there would be opportunities for even larger groups later.

• On repealing the insurance industry’s anti-trust exemption, thought to be a key issue for Reid but dropped amid objections from Sen. Ben Nelson, Jim Manley said, “I don’t think you’ve seen the last of that amendment.”

David Dayen

David Dayen

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