Yesterday, Congress released a summary of the American Jobs and Closing Tax Loopholes Act (HR 4213), which contains a number of provisions related to health programs, to be considered by both houses next week. Here are the major health-related aspects:

-Extends eligibility for the 65% COBRA premium subsidy for individuals terminated from employment until December 31, 2010

-Creates a 3-year 'patch' for the scheduled Medicare physician payment rate (SGR) reductions

-Extends the enhanced Medicaid FMAP through June 30, 2011

-Expands the 340B discount drug program for low-income and uninsured individuals to include inpatient drugs

-Extends hospital geographic 508 reclassifications through FY2011

-Authorizes CMS to collaborate with the IRS to establish a data match to identify fraudulent providers

-Updates the method used to determine the localities used for Medicare’s physician geographic adjustment factor in California, utilizing an approach that is based on metropolitan statistical areas

Yesterday, the House passed the Patient Protection and Affordable Care Act by a 219-212 vote, to be signed into law tomorrow. The landmark legislation establishes a fundamental social precedent, putting our country on the path toward a healthier future for all Americans. After nearly 100 years of debate, we finally decided as a society that health care is not merely a privilege of the few, but a right for all.

In the coming days, we have many to thank personally and just cause to celebrate. This moment could not have been achieved without the steadfast leadership of our elected officials and the tireless efforts of countless health advocates. We sincerely thank all of our colleagues, supporters and readers for making coverage of the uninsured a priority in their lives. The law's passage is truly only the beginning and we are even more motivated to begin the critical process of implementation, looking forward to the day when America's universal health care system will be the world's finest.

"Americans can always be counted on to do the right thing...after they have exhausted all other possibilities." -Winston Churchill

Reconciliation Bill (Legislative Text)

Reconciliation Bill (Section-by-Section Summary)

CBO Score (pdf)

CBO Score (blog)

You can now start the 72 hour clock for public viewing before the likely vote in the House on Sunday. Reports indicate that leadership is within 5 votes of passage. Also, head here to see a useful side-by-side comparison to the original House and Senate bills.

Today: The House Budget Committee 'marks up' the reconciliation bill, effectively moving it to the Rules Committee after a 48 hour waiting period

Tonight/Tomorrow: The legislative language and CBO score of the reconciliation bill are made public

Wednesday, March 17 - Thursday, March 18: The House Rules Committee takes up the actual reconciliation bill, where the rule will be made on how the bill will specifically be voted on. The options include:

1) Voting TWICE, where the House votes once on the Senate bill and once on the reconciliation bill

2) Voting ONCE, where the House votes simultaneously on the Senate and reconciliation bill

3) Voting ONCE, where the House votes only on the reconciliation bill and deems the Senate bill passed (the preferred version by Speaker Pelosi and others, as there is technically not a recorded vote on the Senate bill's 'special deals')

Early reports indicate the reconciliation bill removes the special deals for Nebraska and Florida, though preserves the appropriations for Louisiana Medicaid and a Connecticut hospital. It also modifies the Cadillac tax to only those making more than $250,000 and increases the medical device industry tax from 2.5% to 2.9%. The bill will also likely include a student loan overhaul ($62B in savings), which will result in additional offsets toward health reform spending.

Friday, March 19 - Sunday, March 21: The reconciliation bill goes to the House floor for limited debate, with passage at any time (using one of the above options) before Sunday to send to the Senate

Despite last week's reports, it is still not entirely clear whether the President must sign the Senate bill into law before a reconciliation bill can be voted on in the Senate.

Two powerful associations indicated their strong support of passage today, including the American Geriatrics Society (representing over 16,000 geriatric health care professionals) and the AAMC (representing every American medical school, 128,000 faculty members, 75,000 medical students, and 110,000 resident physicians).

We are in the defining final weeks for federal health reform, and the path before us is clear; first pass the Senate bill as-is in the House and then create a package of budgetary fixes requiring only majority support in the Senate. House members are reluctant to pass the Senate bill before action is taken on the smaller bill, but this is the sole option as a reconciliation bill can only amend existing law. As such, House Representatives are asking for assurance from a majority of Senators that the reconciliation process will be aggressively pursued.

That goal was apparently reached today as the 50th Senator to indicate support for the reconciliation process was achieved. A CBO score of the smaller bill’s legislative language is expected this week, which should allow Representatives to indicate their final stance.

President Obama issued a letter to Congressional leadership today, outlining the Republican priorities that he agrees with and wishes to pursue in his Compromise 2.0 to be released tomorrow. These include 1) undercover health professionals to deter fraud and waste in Medicare and Medicaid, 2) additional appropriations for state malpractice reform, 3) increasing reimbursements under Medicaid, and 4) inclusion of high-deductible plans into the Exchange, in conjunction with Health Savings Accounts (HSAs).

The final provision is the most noticeable, and has it pros and cons. High-deductible plans are often not adequate in providing sufficient comprehensive coverage, though the inclusion of 'young invincible' policies in the federal reform bills do mandate preventive services. If ultimately included, the combination with HSAs could make individuals more cost conscious of their health care, but it is necessary that individuals do not become underinsured and are protected with cost-sharing maximums. The letter ends with strong language recognizing the major rifts between the Democrats and Republicans, but rejects the case for piecemeal reform. Read the full letter here.

A 3-step timeline has also been proposed in a memo obtained by Inside Health Policy:

According to the Democratic memo, the timeline may be:

Step one: The House passes the Senate's health reform bill by March 19. The bill then goes to the president for signature without going through conference.

As part of this step, there are reports that House leaders want to see a letter signed by at least 50 Senate Democrats committing to passing tweaks to the Senate bill worked out between the two chambers, but a Democratic policy consultant says such a letter is unlikely to transpire. More likely, the source said, Senate Majority Leader Harry Reid (D-NV) would privately vow to House Speaker Nancy Pelosi (D-CA) that he has the votes.

Step two: After the Senate bill becomes law, the House then amends the Senate bill through a reconciliation bill, to be passed by March 21.That bill would be the only opportunity to amend, add or strike provisions in the Senate bill.

Step three: The Senate begins debate on the reconciliation bill by March 23. Debate is limited to 30 hours. Votes begin March 26, the first day of Easter recess, at which point Reid announces that the Senate will stay in session through recess to consider all amendments. Vote on final passage follows consideration of the last amendment.

The goal is to pass health reform before the Spring recess (March 29-April 9), so as to avoid a repeat of last year's brutal August break, sources said.

Senate whip count update: 43 Senators are now on record in support of reconciliation and 35 support inclusion of a public option.

"We're going to get it done this year. It would have been much easier to pass it in July. It would have been easier to pass it in November. But again, as the president said, it’s hard. We don’t give up just because things are hard in this country. And we shouldn’t give up – elected officials and leaders in the Congress should not give up just because it’s hard...There’s just a lot of technical questions, given the [reconciliation] process, that have to be answered. To get the little pieces to work you’ve got to have the main pieces of legislation that holds those together...We’ll go when we believe we have a bill that holds together and achieves the goals of reform and has the votes.”

Also watch this fascinating back-and-forth between the President and House Republicans (especially the Q&A) at the GOP Conference in Baltimore today, much of which harps on the health reform struggles (at 45:, 49:, and 80: ).

Early reports indicate that the President's State of the Union address will provide some needed clarity amidst the plethora of speculation surrounding the fate of health reform. Though unlikely to prescribe a timed path, Obama should (hopefully) be able to negate the 'alternative' paths like a pared-down bill, or multiple 'popular' bills. Here is an early excerpt of the speech:

By the time I’m finished speaking tonight, more Americans will have lost their health insurance. Millions will lose it this year. Our deficit will grow. Premiums will go up. Co-pays will go up. Patients will be denied the care they need. Small business owners will continue to drop coverage altogether. I will not walk away from these Americans. And neither should the people in this chamber.

In Congress, Speak Pelosi floated a two-track strategy that is showing major support in the House. She verified that she would indeed have enough votes in the House through amendments in the reconciliation process, but also intends to fashion additional non-budgetary bills to ease her Caucus' concerns. For example, the repeal of the anti-trust exemption (a wildly popular provision in the House, but absent from the Senate bill) would not qualify as a budgetary issue under reconciliation but could be fast tracked as a separate bill to be voted on while the Reconciliation Bill develops and the Senate bill waits.

This would make House members uneasy with the Senate bill happier in the short run, provides tangible results for a disgruntled public, gives reconciliation a little breathing room to come to fruition, and most importantly keeps positive momentum towards comprehensive health reform. Like legislative appetizers before the main course.

All signs point to the reconciliation process in order to pass a companion bill that allows for House majority support of the Senate version. Here are the major changes that are expected to be in the companion (which look quite similar to those compromises reached during the conference committee process):

- Raising the Medicare payroll and unearned income tax on families making more than $250,000 to 2.35 percent, which could raise up to $125 billion.

- $50 billion more in subsidies to help lower and middle-income people afford insurance. Democrats had said earlier this month they hoped to increase the number by $100 billion.

- About $150 billion in cuts to privately administered Medicare Advantage programs. The Senate bill proposes $120 billion in cuts while the House comes in with a $170 billion reduction.

- A deal with labor unions to delay a tax on expensive insurance plans until 2018 for state and local government workers and those with collective bargaining agreements The threshold at which the 40 percent tax would kick into effect was raised from $23,000 for a family to $24,000.

- Removing the so-called “Cornhusker Kickback” that ensured Nebraska would never have to pay for reform’s Medicaid expansion with state money.

- Closing the gap in seniors’ prescription drug coverage.

- A package to extend a number of non-controversial tax credits for things like research and development. Most of the credits expired at the end of the last year and one source saw their inclusion more as legislative housekeeping than a move to sweeten the bill to win moderate votes.

The bill will most likely be created in the House (with significant Senate and White House input) before it is voted on and goes to the Senate. Democratic Senators Evan Bayh, Blanche Lincoln, and Ben Nelson have already proclaimed they will vote 'No' on any health bill that goes through reconciliation, but thats a-ok since it would only need 51 'Yes' votes.

The reconciliation bill can only contain provisions that effect the federal budget and not increase the deficit, and the one person who decides what qualifies as a 'budgetary issue' is the Senate Parliamentarian, the soon-to-be power-monger celebrity named Alan Frumin. The former Parliamentarian Robert Dove recently commented on the process, and added an interesting tidbit on this authority:

"Vice President Biden is the ultimate decider. But no vice president has tried to play that role in reconciliation. We haven’t had vice presidents that have tried to play important procedural roles for a very long time. The last one was Nelson Rockefeller, in 1975, and before him Hubert Humphrey, in the 1960’s. But no vice president has ever tried to play a role in reconciliation....If he were to show up, and he wants to make these decisions, yes. He has the authority to do that. He is the president of the Senate."

Also head to a recent CBPP article for an overview of the history and use of reconciliation, where 19 bills have utilized the process since 1980 including:

1985 Continuation of Employer-Sponsored Coverage (COBRA)
1996 Welfare Reform
1997 Children's Health Insurance Program (CHIP)
1997 Medicare Advantage Program
2001 Tax Cuts
2003 Tax Cuts

CBPP Conclusion: Since rising health costs are the single largest reason for projected long-run deficits, it is appropriate that health reform be considered through the reconciliation process.

The absence of exit polling in the Massachusetts special election has allowed for rampant speculation of voter intentions, but a recent post-election poll indicates that health reform is still widely supported by constituents in the Bay State (where the effects of health reform can already be seen). The poll was conducted by the Kaiser Family Foundation, the Harvard School of Public Health, and The Washington Post and finds that:

- Only 11% of voters, including 19% of Brown voters, want Brown to “stop the Democratic agenda“:

- 52% of voters were enthusiastic/satisfied with Obama administration policies.

- 44% of voters believe “the country as a whole” would be better off with health care reform, but 23% believe Massachusetts would be better off.

- 68% of voters, including 51% of Brown voters, approve of Massachusetts’ health care reform.

As Speaker Pelosi has indicated she does not currently have the votes to pass the Senate bill, it is again time to call your local California Representative. Below are the critical Congresspeople, first being those Progressives who have vowed to oppose any bill that doesn't contain a public option, followed by the centrist Blue Dog Democrats who have issues with the Senate abortion language.

Public Option Coalition
Bob Filner (CA-51)
Michael Honda (CA-15)
Barbara Lee (CA-09)
Grace Napolitano (CA-38)
Laura Richardson (CA-37)
Lucille Roybal-Alard (CA-34)
Linda Sanchez (CA-39)
Jackie Speier (CA-12)
Pete Stark (CA-13)
Maxine Waters (CA-35)
Diane Watson (CA-33)
Lynn Woolsey (CA-06)

Blue Dogs
Loretta Sanchez (CA-47)
Adam Schiff (CA-29)
Jane Harman (CA-36)
Jim Costa (CA-20)
Dennis Cardoza (CA-18)
Joe Baca (CA-43)

You can find their contact info and your Rep's phone number here.

Broad consensus surrounds the viable path that should now be taken in Congress: Pass the Senate Bill and Fix it Through Reconciliation. Paul Krugman lays it out quite bluntly , and 47 of the nation's leading health policy experts have signed on, as well. Below are our thoughts for your reference, and a reminder of what will occur if Congress falters:

Weighing the Options in Federal Reform
Op-Ed on How to Restore California to Greatness

The Consequences of Reform Failure

From the White House Council of Economic Advisers:

-Health care expenditures would likely rise from their current level of 18 percent of GDP to 28 percent in 2030 and 34 percent in 2040
-The number of uninsured people in the United States would rise from 46 million in 2007 to 72 million in 2040
-Essentially all of the rise in average employee compensation due to increasing productivity over time would go to health insurance, and essentially none would go to take-home wages
-Steeply rising Medicare and Medicaid spending will be amplified by a 65% increase (25 million people) in the 65+ population resulting in unsustainable increases in the budget deficit

From the Urban Institute Health Insurance Policy Simulation Model:

-The amount of uncompensated care would more than double in 45 states
-Every state would see Medicaid/CHIP spending rise by 75%
-Every state would see the employer-sponsored insurance (ESI) population degrade
-27 states would see ESI premiums double, and 46 states would see employer costs increase by 60%
-The number of uninsured would increase by more than 30% in at least 27 states

Waking up today, federal health reform became a completely different beast. Seemingly inevitable legislation that would fundamentally transform the American health care system for the better is now showing signs of mortality. It would be too easy to lament on the "if only"s, and even easier to kick the can down the road. The fact is, though, both houses of Congress have already passed health reform legislation. Forever forward, regardless of the outcome, there is no escaping 'Yes' votes from those Congressmen that are fearful for his or her reelection as opposing candidates are going to use it against them in either case. That being said, the political risks of abandoning the plan are far greater than reaching compromise and sending a bill to the President. Substantive disagreements are debatable, but futility guarantees defeat.

So the question is, then, what are the next steps? To reduce the shock value and bring this situation back down to earth, read the latest from David Leonhardt. He posits that "the bills before Congress are politically partisan and substantively bipartisan" and explains the need to unify around an already centrist bill. How will this be done?

It's hard to say. The day has been filled with speculation, suggestion, and prognostication. Rumors of the bill being chopped up into pieces or vastly scaled down were rampant, though a White House memo indicates this is not likely. Persuading moderate Republicans in either the Senate or House is equally unlikely.

The greatest consensus, even backed by labor in SEIU's Andy Stern, would be to have the House pass the Senate version and attach a provision guaranteeing improvement (like the excise tax modifications and increased subsidies) through budget reconciliation from the Senate side. Kent Conrad expressed support for this as well, and Pelosi vowed the House would move forward with reform. Looking at this option, it appears that a group of House liberals (led by Raul Grijalva) are unwilling to accept the Senate bill as-is. It is quite possible that Pelosi would be willing to lose some liberals in favor of a more centrist bill if she can pick up enough moderate Dems along the way (remember that 39 Ds voted 'No' on the more robust House version).

We should be clearer on the chosen path in the next few days, as Congressional leadership and the White House appear committed to the cause they already own.

As I have mentioned in the past, health reform requires 60 votes in the Senate, and the progressiveness of the bill is based on that fact. Here are the alternatives, some realistic and some not:

1) Ron Pollack's idea. Have the House pass the Senate bill as is, but only after the crafting of a separate budget reconciliation bill that deals with the financing and subsidies. The House would then vote on both measures before sending the budget bill to the Senate where it would only requires 51 votes. Both bills could then be signed by the President simultaneously. This could conceivably create a more generous bill in terms of financing and affordability (as the reconciliation bill could disregard centrist Senate Democrats like Lincoln, Landrieu, and Nelson), but would also preserve troublesome Senate provisions like state-based Exchanges, the abortion language, and other non-budgetary aspects that were better on the House side. Here is how reconciliation would work according to Jeff Davis.

2) Push the conference package through Congress before Brown is sworn in, probably on January 29th. This is somewhat unrealistic given the potential backlash, though today's official scheduling of the State of the Union Address for January 27th gives it some merit.

3) Get back Olympia Snowe. This will push the bill back towards the Finance Committee's version, though it is doubtful she will come on board.

4) Pass the Senate bill. The House can pass the Senate version verbatim and send it straight to the President, though numerous House members have reservations about this. Encouragingly, Speaker Pelosi and House Majority Leader Hoyer have indicated this would be a viable last resort as something is better than nothing.

Meetings in the White House continued this afternoon after the conclusion of yesterday's 1 a.m marathon. Discussion centered around the types and extent of subsidies and benefits, though the President and Congressional leaders were unable to finalize a bill before the end of today's session. Talks are expected to continue tomorrow, though tangible progress was made today:

Biologics
Some more Presidential arm-twisting today, where it appears that Obama was able to reduce the exclusivity period of expensive biologic drugs (a $300B industry over the next 20 years) from 12 years to 10 years before introduction of generic versions.

Health Insurance Exchange
Though not finalized it appears the Exchange will be a hybrid of the two bills' versions, meaning a state-based structure with significant federal regulation and oversight (details to come).

Medicaid Financing
In the wake of the Nebraska debacle, Ben Nelson has called for the removal of his state's special treatment and it appears that Obama and lawmakers intend to increase the amount of federal aid to all 50 states for the Medicaid program (revenue for full financing is still being explored).

Insurance Subsidies
Aiming to improve affordability, it appears that an additional $10B in fees will be imposed on medical device manufacturers to provide additional subsidies for low-income individuals and families in the Exchange.

Insurer Antitrust Exemption
Here is a letter from a large group of Senators (including CA's Dianne Feinstein) calling for repeal of the exemption (in the House bill, not in the Senate bill):

Dear President Obama, Majority Leader Reid, and Speaker Pelosi:

The White House reached an agreement with Labor leaders today over the controversial excise tax. Unions had major concerns with the tax on high-cost plans, as collective bargaining agreements have historically resulted in more generous benefits as opposed to an increase in wages. In addition, these agreements are often multi-year deals (as opposed to year-to-year agreements in non-union firms) and as a result labor advocates felt that the tax would unfairly hit many middle-class families for years to come. Below are the changes, and now that the revenue provision is supported by groups like the SEIU and AFL-CIO the House should similarly follow suit:

-Excise tax threshold INCREASED from $8,500/$23,000 for individuals/families to $8,9000/$24,000, begins in 2013.
-Indexing of threshold UNCHANGED at CPI (inflation)+1% (important cost-containment mechanism as health inflation is comparatively greater)
-After 2015, tax threshold EXCLUDES dental and vision plans for ALL Americans (around a $2,000 value)
-INCREASED threshold adjustments for plans with high number of older workers, women, high risk individuals and qualified retirees.
-Delay of tax until 2018 for unions and state/local employee plans to be able to re-negotiate their collective bargaining agreements
-Open the Exchange to ALL employer plans by 2017

The final clause is extremely significant, as it establishes validity that the future Exchange will not just be another high-risk pool subject to adverse selection for those outside the group market. When large companies enter the Exchange, new-found bargaining power can better hold insurers to adequate consumer protections and high-value care. Insurers will want to go after the increased market share, and more customers in a regulated market means more effective innovation and competition. When companies that have been successful at holding down health care costs (like Safeway) are able to quickly enter the Exchange, transparency mechanisms within can translate these effective practices across organizations and industries.

The compromise sacrifices $60B of revenue over 10 years, so lawmakers will have to include another source (most likely the increased Medicare payroll/investment tax). This was the snowball-at-the peak though, as the rest of the spending differences couldn't be addressed until the financing was there. As such, a bill may be score-able enough to be sent to CBO by tomorrow while Congress works out non-budgetary differences (that Obama will be sure to address in today's Issues Conference {Obama's remarks at 7:30 in the video} with the House Democratic Caucus). The CBO may need as many as 10 days to score the bill, though, and some reports indicate that the President's Signature/State of the Union Address combo may even get pushed back to February 9th.

Top Congressional leaders have just ended eight hours of negotiations in the White House Cabinet Room with President Obama and members of his Administration in order to reach agreement on a final health care bill. The attendees included Representatives Pelosi, Rangel, Steny Hoyer (Md.), James Clyburn (S.C.), George Miller (Calif.), and Henry Waxman (Calif.) in addition to Senators Chris Dodd, Harry Reid (Nev.), Dick Durbin (Ill.), Max Baucus (Mont.) and Tom Harkin (Iowa). Union leaders were also in attendance.

The President continued his newfound 'executive influence' today by calling for a National Health Insurance Exchange, and this is now the central fighting point for the House. In addition to the compromises reached earlier this week with a combination scaled-back Excise tax (also supported by Obama)/Medicare payroll tax expansion, it appears that the House is now willing to remove their employer 'pay-or-play' requirement in favor of the less-robust Senate version. The Senate employer shared responsibility provision protects many employees from unaffordable insurance, but there may be some market distortion issues that you can read about here and here.

Provisions still on the table:

-133% FPL Medicaid expansion (more likely) vs. 150% Medicaid expansion
-Degree of income-related insurance subsidies (which may now be lowered to the Senate's level as revenue will be lost as a result of the employer requirement agreement unless new revenue sources are created)
-Fate of insurer anti-trust exemption
-Fate of Medicare Independent Payment Advisory Board
-Extent of Medicare Advantage payment reductions

Congress continues to reconcile differences between the House and Senate bills this week, and it seems as if they are definitely making progress towards a compromise. Yesterday President Obama indicated his preference for the high-end insurance tax as opposed to the high income tax in order to raise revenue for reform, though a combination of scaled down versions of the two is a more realistic scenario. There are also talks of basing the Cadillac plan excise tax on generous benefits as opposed to cost which could be a more accurate assessment on excessive benefits in order to raise revenue and help contain costs in the long term.

Senator Ben Nelson's deal to fully fund Medicaid expansion in Nebraska continues to receive criticism from Nebraskans and non-Nebraskans alike, now including public disapproval from Senators Sherrod Brown, Blanche Lincoln and 13 attorney generals. As a result, Nelson is now calling for full federal financing of Medicaid for every state, though it is unclear if the idea can hold water given the potential price tag.

As I have noticed in past votes: What if elected Congressmen actually represented their local constituents' best interests as opposed to their own political ideology? Head here to read about a very interesting stratification of how reform will effect individual states, and which political party represents them.

The chart below from the study shows states that are the biggest 'winners' in the bottom left ranging to the biggest 'losers' in the top right (progressing up the left column, then up the right column)

Authors' Conclusion: Most legislators have decided their position on reform without any consideration of the relative costs and benefits.

As we usher in the new year, it now seems certain that Congress will bypass a traditional Conference Committee and utilize 'ping pong' in order to merge the House and Senate health reform bills. This decision became clear after Senate Republicans vowed to fight the bill every inch of the way, for numerous procedural hurdles would have significantly delayed Conference proceedings on the Senate side. The Senate version has limited wiggle room, so Speaker Pelosi and top House Democrats will most likely use Reid's Senate bill as a template and incorporate various House provisions (see the post below for the major differences) before subsequent House and Senate votes. The State of the Union Address is still the tentative deadline, though now it looks like the speech will be delivered the first Tuesday in February.

The following weeks will be paramount for finding ways to maximize health reform, as the current 'phase' allows Democratic leadership to easily include amendments in order to bolster coverage expansion, consumer protections, cost-containment mechanisms, infrastructure funding, and insurance regulation. This process may just be simply choosing the better language between the existing House and Senate bills, but there is also opportunity to include novel provisions. Ben Nelson's compromise for full federal funding of Medicaid expansion in Nebraska, and Medicare coverage for residents of Libby, Montana sickened by a mineral mine are two examples of good policy injected late in the game on the Senate side.

Another provision receiving ample attention is a clause regarding the construction industry, which will now be subject to an employer pay-or-play mandate for firms with more than five employees (compared to 50 employees for firms in other industries). In the previous language, firms with less than 50 employees would be exempt from the mandate, effectively excluding the entire construction industry as 90% of these companies employ less than 20 workers. The new provision places a modest employer mandate on the traditionally 'lowest bidder' industry, which will protect many non-union workers who would have faced higher costs otherwise. Read further about the clause effects here, which should improve coverage and affordability for the nearly 786,000 construction workers in California. Moving forward, it is imperative to clarify, articulate, and ultimately include language in order to improve other 'niche' circumstances like these.

The perspective this week has already shifted toward how best to effectively and efficiently merge the House and Senate bills. There is still not a preferred strategy between the conference committee or ping pong, but either way it is clear that Congressional leaders will cut their vacations short and return next week to consider the bill. With such a slim margin of compromise on the Senate side, it will be very difficult for the upper house to give too much ground and risk losing votes. The goal for a final bill is still by the State of the Union, though the process would have to go quite smoothly to make this January 19th deadline.

Here are a few of the major discrepancies that need to be ironed out between the House and Senate versions, respectively:

Exchange: National v. State
Medicaid expansion: 150% FPL vs. 133% FPL
Financing: High-income tax vs. Excise tax/Payroll tax
Consumer Choice: Public Option vs. National non-profit plans
Abortion language: Stupak amendment vs. State coverage opt-out
Employer Responsibility: Pay-or-play vs. Limited mandate to very large employers

The Senate has moved up their vote to 7 a.m. ET tomorrow, giving advocates a well-deserved Christmas present and finally passing health reform out of both houses of Congress! The Spotlight will return next week with limited activity until January 4th.

Happy Holidays!

Here is an updated version of the ITUP Health Reform Comparison Matrix, which includes the new CBO scores for both the House and Senate bills as well as the Senate Manager's Amendment.

There are also reports that the Senator Menendez (D-NJ) amendment (which never made it to the floor) has the assurance of Senator Reid that it will be included in the bill during Conference Committee. The amendment would allow states to waive the five-year waiting period and extend Medicaid coverage immediately to legal immigrants, opening Medicaid to an additional 600,000 residents. It appears, though, that the final bill will not allow unauthorized immigrants to purchase insurance through the Exchange (a provision that is present in the House but generally opposed in the Senate and White House).

Tempers are definitely flaring on the Senate floor now that the passage of a bill is inevitable, but freshman Senator Roland Burris injected some impressive holiday cheer today during the debate.

The final vote for passage out of the Senate has been moved forward, and is officially set for Christmas Eve, Thursday at 8 a.m. ET.