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Tenuous support may unravel as compromise is negotiated

By Michael Kranish
Globe Staff / December 25, 2009

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WASHINGTON - The American Medical Association’s announcement this week that its member doctors supported the Senate health insurance legislation was widely seen as a key endorsement that helped sew up passage of the historic bill yesterday.

But the announcement was not as unequivocal as it appeared. The AMA president-elect, Dr. Cecil B. Wilson, told the Globe that “support’’ was not the same as an “endorsement’’ and that the group will withhold final judgment as it lobbies for further changes in a House and Senate compromise.

The AMA’s nuanced stance underscores a political problem facing President Obama and Democratic leaders in Congress: even where they have cut deals with lobbying groups and advocates, support for the health care overhaul remains fragile.

Tentative agreements could unravel early next year as House and Senate members try to bridge differences in their bills on issues ranging from taxes to abortion to physician payment scales, with every move endangering the coalition needed to pass the legislation.

The dynamic goes beyond the negotiations looming in the conference committee, which will begin hashing out a compromise next month.

Many Americans will learn in the upcoming months and even years that while painful elements of the bill such as Medicare cuts and perhaps higher taxes on wealthy Americans would take effect quickly, the subsidies to help lower-income people buy insurance would not be introduced for three years under the House bill and four years under the Senate version.

That could prove to be a liability for Democrats, an opening that Republicans, who have been in lockstep opposition to the bills, are sure to exploit.

“They face a significant ‘expectations gap’ because people’s health care costs are going to continue to go up, but it will be some time, 2014 probably, before the key benefits of the legislation kick in,’’ said Drew Altman, president of the Kaiser Family Foundation, a nonpartisan groups that tracks health care issues. “The public could become quite frustrated.’’

The House and Senate put off some of the biggest benefits of the bill because they needed a way to shrink the immediate cost of the legislation to keep the president’s pledge that it will not increase the deficit.

As for the AMA, it wants to persuade the conference committee to address its concerns about a commission that would set certain reimbursement rates for physicians before deciding whether to endorse a final version of the bill.

“The decision about support for the final bill will be based on looking at what’s there in the totality,’’ the AMA’s Wilson said in a telephone interview.

A delicate deal on abortion in the Senate, designed to appease Democrat Ben Nelson of Nebraska, could unravel because of objections from House members. Hospitals, meanwhile, want to revisit a deal they struck to accept $155 billion in lower Medicare payments, saying the cut should be smaller because the legislation envisions fewer people getting insurance than was originally envisioned.

In the long term, Democrats believe a health care expansion covering nearly all Americans may become as popular as Medicare and Social Security. But in the shorter term, some Republicans are already viewing the delayed enactment of major benefits as an ideal window in which to fight for repeal of the bill, or at least the elimination of some of its key measures.

And Senate and House negotiators will have part of their attention focused on the political impact on the 2010 midterm elections as they make their decisions. Two crucial Senate leaders on the health care effort are up for reelection and already trailing in some polls: Senate majority leader Harry Reid of Nevada and Senator Christopher Dodd of Connecticut.

Reid, who was lauded effusively yesterday by fellow Democratic senators for his leadership, isn’t getting the same reception at home, where a Mason-Dixon poll showed that only 38 percent of Nevadans approve of his performance.

The poll showed that he trailed two main Republican challengers, a former local basketball star and a former television reporter.

The idea of repeal could become a real concern for Democrats. In 1988, with much fanfare, Congress approved a measure designed to provide Medicare insurance to senior citizens for catastrophic health care events, which at the time was seen as a key step toward implementing wider health care legislation. But the measure was pilloried by seniors who objected to paying a surtax to fund the measure, and it was repealed on a bipartisan vote a year later.

That is one reason why the Democratic euphoria yesterday over Senate passage may prove premature, according to Stuart Rothenberg of the nonpartisan Rothenberg Political Report.

“It reminds me of ‘Mission Accomplished,’ ’’ Rothenberg said, referring to the infamous banner that was hung on an aircraft carrier when former President George W. Bush in 2003 announced major combat operations were over in Iraq.

Not only do Democrats have to reconcile a bill and get it signed by the president, Rothenberg said, but they have to do so without splitting apart the party as House liberals attack the Senate version, which does not contain a government insurance plan that was favored by the party’s progressives.

He predicted a painful period of bargaining to get the bill into law, followed by an equally painful span in which Democrats try to convince the public that the legislation is worth its cost. Even in victory, he said, Democrats are going to be under extraordinary political pressure that could result in midterm election losses.

“The worst-case scenario would have been no bill at all,’’ Rothenberg said. “A close second is getting a bill. This is the kind of thing that people are going to complain about. Health care is always going to be expensive and cumbersome and it is going to be a pain, a problem. There are always going to be people who are dissatisfied, saying, ‘We changed the system, how come I still have to do this, how come it is still so expensive?’ ’’

While Rothenberg doubts that a repeal will be successful, he and many other analysts said the aura of victory may be short-lived if Republicans are successful in using passage of the bill as a means to bring down their top target of Reid.

“To supporters of the bill, his defeat probably [would] make him a martyr,’’ Rothenberg said. “To Republicans, it makes him an example.’’

Michael Kranish can be reached at kranish@globe.com.

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