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The hurdles to expanded healthcare (MS)

THE GREAT healthcare debate is now officially on, and though the goal of dramatically expanded coverage is in distant view, perils and pitfalls abound along the path forward. One came Monday in the form of a Congressional Budget Office analysis saying Senator Kennedy’s legislation would insure only an additional 16 million people, and at a cost of $1 trillion over 10 years. Although Kennedy’s staff stresses that the bill CBO evaluated was merely a work in progress, CBO’s estimate clearly raises concerns.

A bigger issue, however, is whether liberal overreach will get in the way of possible bipartisan accomplishment. The critical issue there centers on proposals for some kind of public plan for health coverage.

Liberals want a robust public plan. In its purest form, that would mean a Medicare-like option for those under 65, plus the requirement that healthcare providers take part in such a plan as a condition of participating in Medicare.

Conservatives view that kind of government-run option as the nose of the single-payer camel poking its way into the private-sector tent.

Here’s the political problem for Democrats: They don’t have the 60 Senate votes needed to end a filibuster. And even if they did have 60 Democratic members or Democratic-leaning votes, they probably wouldn’t have that margin for that type of a public plan, since a number of moderate Democrats have expressed opposition or skepticism.

“There is a strong sense that there is not sufficient support in the Senate for a robust public plan,’’ reports one Democratic Senate aide close to the process.

That reality leaves Democrats with this choice: Try to push healthcare reform through under reconciliation rules that would allow the sidestepping of a filibuster and passage with 51 votes or search for a palatable compromise.

The first course complicates the policy as well as the politics. For example, by dramatically shortening the required break-even time frame, it would make the already tricky financing for healthcare expansion more difficult.

“It requires squeezing an elephant through a keyhole,’’ says the Senate aide.

Nor are conservative worries about such a public plan necessarily ill-founded. A large government-run Medicare-style plan would squeeze healthcare providers, who might then compensate by demanding higher payments from plans without similar market leverage. That already happens with Medicare, so it’s not merely a theoretical fear. (Full disclosure: My wife works for a not-for-profit health-insurance organization.)

Different proposals float around for restricting public plans in ways designed to ensure fair competition. But though the design is tricky, the political test is simple: a bill that can clear the Senate without resorting to reconciliation rules.

Why? Because something as complex as healthcare reform needs the broadest support realistically possible. Democrats shouldn’t attempt to push it through with the slenderest of majorities, under a process Republicans will portray as an abuse of the rules.

Yes, there’d be hypocrisy there, given the GOP’s past use of reconciliation. Still, if Democrats yield to political temptation and try to pass an ambitious public plan with a bare majority, it will almost certainly become a major partisan flashpoint, making any healthcare legislation that results a political football for the next few election cycles.

“To make a robust public plan the litmus test could doom healthcare reform,’’ says Phil Johnston, former New England regional director for the US Department of Health and Human Services. Mind you, Johnston is a longtime liberal. He chairs the Blue Cross Blue Shield of Massachusetts Foundation, which played an important role in expanding healthcare coverage here. But he’s also politically realistic.

“Personally, I am a single-payer guy, so I would obviously prefer a strong public option, but the politics are such that it is not going to happen,’’ he says. “So let’s keep our eyes on the prize, which is to deliver affordable health insurance to 47 million people who don’t have it.’’

Obama himself has reportedly said that he would rather win 70 Senate votes for a healthcare bill that gives him 85 percent of his goals than have a bill that grants him everything he desires pass 52 to 48. The president will be wise to let that instinct guide Democratic efforts in the debate ahead.

Scot Lehigh can be reached at