Early Christmas Eve morning, the Senate passed its health reform bill – the Patient Protection and Affordable Care Act (H.R. 3590) – by a vote of 60 to 39, with only Sen. Jim Bunning (R-Ky.) absent from the historic vote. The final Senate vote came after 25 consecutive days in session, which was necessary to accommodate often repetitive debate and numerous votes on procedural matters and proposed amendments to the bill. With Christmas and winter storms growing ever closer, Senate Republicans agreed to yield enough debate time to allow the final vote on the health reform bill to occur at 7:00 a.m. the day before Christmas instead of 7:00 p.m., as originally scheduled by Senate Majority Leader Harry Reid (D-Nev.) When it was time for Senators to cast their votes, ailing 92-year-old Sen. Robert Byrd (D-W.Va.), who once again had been wheeled onto the Senate floor to ensure that Reid had a 60-vote majority, triumphantly raised his hand when his turn came and declared: “This is for my friend Ted Kennedy. Aye.” When Majority Leader Reid was called to vote, he apparently was so exhausted that he initially voted “no” before changing his vote on the bill to “yes.” This slip-up evoked laughter from the Senate floor, including chuckles and teasing from Reid, to add a little levity to a vote which Democrats heralded as historic and unprecedented.

As 2010 begins, the House of Representatives and the Senate have each passed a health reform bill, with many of the same constructs and yet, with several key differences. So, what might we expect next?

To address the differences, both large and small, in the House and Senate reform bills, Congressional leaders will need to arrive at a consensus bill which can, again, attract enough votes to pass both chambers of Congress. Yesterday morning, January 4, 2010, it was reported that the House and Senate likely will achieve their compromise bill entirely through informal negotiations between House and Senate representatives, without convening a formal conference committee, which would permit Republicans to use further procedural steps to stall the reform process. Whether or not a formal conference committee is convened, conventional wisdom says that the House will yield to the substance of the Senate bill since Harry Reid does not have the luxury of losing a single vote in the Senate and has slim prospects for picking up Republican support for a compromise bill. However, from a political perspective, House Speaker Nancy Pelosi (D-Calif.) cannot be viewed as having been steamrolled by the Senate because she has her own fractious caucus to hold together who passed the House’s health reform bill by only a three-vote margin.

Finding a compromise bill may be challenging because Democratic Congressional leaders will need to do more than split the difference between a more moderate Senate bill and a more liberal House bill. The most controversial and emotional issues to be resolved between the competing House and Senate health reform bills are abortion coverage and the public option, as well as how to pay for the expansion of health care coverage under each of the two bills. Some pro-life House members have expressed opposition to the less restrictive abortion coverage language in the Senate bill while some House progressives are angry that the Senate dropped the government-run public option and oppose the restrictions on abortion coverage found in both the Senate and House bills.

In examining how each bill pays for expanded health care coverage, the Senate bill imposes fees on health industry businesses, makes cuts to Medicare and Medicaid, increases the Medicare payroll tax on high wage earners, taxes health insurers on the value of high-cost “Cadillac” health plans which they offer and impose certain penalties on individuals who do not maintain health insurance and certain employers which fail to offer health insurance. The most significant difference in the House bill is that, thus far, the House has refused to tax Cadillac plans and instead raises income taxes on individuals who earn more than $500,000 per year and families whose yearly earnings exceed $1 million, a measure which is not expected to find sufficient support in the Senate.

In the effort to merge the two Congressional health reform bills, it is anticipated that progressives in the House will fight to impose health insurance reforms (e.g., eliminating pre-existing condition exclusions and lifetime maximums) and to begin the expansion of health care coverage (through Medicaid expansion, the payment of government subsidies and operation of the health insurance exchanges) in 2013 as opposed to delaying such measures until 2014, as proposed by the Senate. House progressives also may insist on retaining new Medicaid eligibility for individuals with incomes up to 150 percent of the federal poverty limit instead of the 133 percent cap proposed in the Senate reform bill. Congressional negotiators also may have to grapple with the extension of health care coverage to undocumented immigrants – an issue which has the potential to become politically volatile. Under the House bill, undocumented immigrants would be permitted to purchase health care coverage offered through the national exchange with their own funds, although they would not be entitled to federal subsidies to assist with the purchase. In contrast, the Senate bill bars access to any health insurance policies sold through the state exchanges to undocumented immigrants, whether such immigrants are using their own funds or government subsidies. It is anticipated that the House negotiators will push for these more progressive measures included in the House reform bill in exchange for relinquishing their demands for inclusion of a public option in the final legislation.

With the many substantive issues that require resolution in the House and Senate reform bills, and the deeply-held interests and convictions of the various lawmakers who have to be assuaged to achieve a successful resolution, the President is no longer pressuring Congress for a speedy conclusion to the legislative process. The White House and Congressional leaders have publicly conceded that it is unlikely that the President will have signed health care reform legislation prior to his State of the Union address later this month. Given the demanding Congressional schedule leading up to the Christmas break, the House will not convene until January 12, and the Senate will not convene until January 18. Even though the Congress will not resume for some days, it is believed that Congressional leaders and the Administration already have begun behind-the-scenes negotiations and that Congressional staffers have begun much of the work necessary to reconcile the two bills. Forgoing a formal conference committee undoubtedly will speed up results. However, Democrats seem to be reconciled to the fact that their efforts to overhaul the nation’s health care system may not be completed until some time in February.