Who should be in the business of health care?
On a most fundamental level, that’s the debate that is nearing a deafening roar on the Senate floor.
And it is a question at the core of the high-stakes meetings underway today at the Capitol between the majority leader, Harry Reid of Nevada, Senator Ben Nelson, Democrat of Nebraska, and top White House officials, aimed at locking down 60 votes for the Democrats’ big health care bill.
President Obama and Congressional Democratic leaders decided long ago that private employers should continue to play the predominant role in providing benefits to most Americans.
The federal government and state governments already have a big hand in insuring the poor, children and Americans over age 65 — not to mention the disabled and federal employees, including the military and veterans.
In the end, the fight centers on who should be responsible for the 46 million people, and counting, who do not fall into any of the categories above.
Even if the Senate passes its bill by Christmas, that fight will not be resolved.
The health care bill passed by the House last month favors a heavier role for the federal government, by creating a single national marketplace for new government-approved health plans. The Senate bill would leave far more authority in the hands of the states, which would oversee their own “exchanges” where plans could be compared and purchased.
The House bill includes a broader expansion of Medicaid, the federal-state insurance program for low-income Americans, and it raises Medicaid payment rates for primary care doctors.
But because states will ultimately have to pay some of the costs of the proposed Medicaid expansion, it is one of the major concerns about the Senate bill that Mr. Nelson has been raising with Senate leaders and the White House. Mr. Nelson has suggested that states should be allowed to choose some other way to provide insurance coverage to people who might gain it through an expansion of Medicaid, but he has not explained how that might work.
Republicans, who oppose both versions, say government should mostly keep its big nose out and that more incremental steps should be taken to control health care costs.
Mr. Nelson’s top concern, of course, is how the legislation deals with the issue of insurance coverage for abortions. But as a former governor and state insurance commissioner, he is also extremely mindful of the impact that the federal government’s decisions have on local officials.
In an appearance on Fox Television on Friday, Gov. Dave Heineman, Republican of Nebraska, urged Mr. Nelson to vote against the Democrats’ bill. “This bill is not in Nebraska’s best interests,” he said.
He added, “This has an unfunded Medicaid expansion, an unfunded mandate that would cost my state, a small state, hundreds of millions of dollars.”
The Senate health care bill actually provides for the federal government to pick up the full cost of the Medicaid expansion for three years. After that, the federal government would continue to contribute more than it has previously to Medicaid coverage for the new enrollees. But states would share some of the cost.
Both the House and Senate versions of the legislation envision that smaller employers would take on some new responsibilities for helping their workers to obtain health insurance.
But there is no question that for low-income and moderate-income Americans, government — at the federal or state level — would have a major role under the Democrats’ proposals.
At the moment, both bills seek to expand the government’s role by creating a new long-term care insurance program, known as the Class Act. But critics, including some Democrats, believe the proposal is financially untenable.
It raises money by collecting premiums at the outset, but in future years could subject the government to a huge financial liability. Removing the Class Act from the bill is one of Mr. Nelson’s demands.
Doing so, however, would blow a $72.5 billion hole in Mr. Reid’s bill, erasing more than half of the $130 billion in future deficit reduction that Democrats have boasted that the legislation would provide.
Mr. Nelson also had a hand in forcing Mr. Reid to drop the proposal for a government-run insurance plan, or public option.
As part of the deal to drop the public option, Mr. Reid’s final bill is expected to include a proposal to create at least two national insurance plans modeled after those offered to federal workers, including members of Congress. The new plans would be overseen by the Office of Personnel Management, the same federal agency that now oversees the Federal Employee Health Benefits Program.
While the personnel office is a government agency, the insurance plans it oversees are private. Even when the F.E.H.B.P. was created in 1959, a debate was raging over the who should be in the business of providing health benefits. Some officials had proposed a single government employee plan, according to Walton Francis, an insurance expert who has studied the history of the program. But various private insurance plans, sponsored by labor unions that up until that point had covered groups of federal workers, demanded that they be allowed to stay in business.
Another proposal included in Mr. Reid’s bill, which was first put forward by Senator Maria Cantwell, Democrat of Washington, seeks to strike a similar balance by allowing states to create basic health plans, administered by private insurers, to cover moderate-income people who do not qualify for Medicaid.
Those provisions would essentially allow states to take money from the federal government that otherwise would go toward subsidizing private insurance plans and allow the states to negotiate with private insurers to create their own offerings.
It is unclear which of these provisions would survive in the final legislation, or even if Congress will ultimately approve a bill. But the debate over who should be in the business of health care will continue.