WASHINGTON -- The Senate moved closer to passing health care reform Tuesday as Democrats cleared the second of three key procedural hurdles on the sweeping $871 billion measure.
The Senate voted 60 to 39 -- along strict party lines -- to set a timetable for ending debate on the bill. It also adopted changes negotiated by Majority Leader Harry Reid.
A third procedural vote is scheduled for Wednesday afternoon, with the final vote to approve the bill set for Thursday morning, which is Christmas Eve, Reid announced Tuesday.
The final vote had been expected about 12 hours later, on the night of Christmas Eve, due to Republican delay tactics to try to hold off the measure, which Reid has insisted be passed before Christmas. An agreement Tuesday between Reid and Senate Minority Leader Mitch McConnell changed the timetable.
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President Barack Obama, who made health care reform his top domestic priority for 2009, said Tuesday he would delay leaving for his Christmas holiday in Hawaii until the Senate holds its final vote on the bill.
"I will not leave until my friends in the Senate have completed their work," Obama said. "My attitude is that if they're making these sacrifices to provide health care to all Americans, then the least I can do is be around to provide them any encouragement and last-minute help where necessary. That's the deal."
Any measure passed by the Senate would still have to be merged with the $1 trillion House version in what could be tough negotiations. But Democrats sounded increasingly confident that a bill would make it to Obama's desk.
"Health care reform is not a matter of if," White House Press Secretary Robert Gibbs said. "Health care reform now is a matter of when."
Montana Sen. Max Baucus, the powerful chairman of the Senate Finance Committee, declared that "the finish line is in sight."
"We're not the first to attempt such reforms, but we will be the first to succeed," he said.
Republicans have mounted a fierce campaign against the bill, using procedural tricks to slow debate and casting the measure as an unnecessary government intrusion in health care that will raise costs.
McConnell said Tuesday that Republican senators will raise questions Wednesday about whether the health care bill adheres to the Constitution. And he and other GOP senators continued their criticism of what they call "sweetheart deals" added to the legislation to round up support of all 60 members of the Democratic caucus to overcome a Republican filibuster.
"When you're relying on one side to get there, then 'let's make a deal' becomes the name of the game," said GOP Sen. John Thune of South Dakota. "They may have 60 votes today, but this is a long way from the finish line."
Reid, in remarks on the Senate floor Tuesday morning, acknowledged the toxic political environment now surrounding the nearly year-long debate over the measure.
Senators should set aside "personal animosity," he said. "There's a lot of tension in the Senate, but I would hope everyone would go back to their gentlemanly ways. ... Let's just all try to get along."
If a combined House-Senate health care bill eventually wins final approval from Congress and is signed by Obama, it would be the biggest expansion of federal health care guarantees since the enactment of Medicare and Medicaid over four decades ago.
Obama on Monday praised the Senate for "standing up to the special interests who prevented reform for decades and who are furiously lobbying against it now."
The influential American Medical Association, a traditional opponent of health care reform, also provided a boost to reform backers Monday by endorsing the Senate measure. The endorsement came hours after a rare 1 a.m. Senate vote to start winding down debate.
The unusual timing of this week's Senate votes is a consequence of Senate rules, the determination of Democrats to pass the bill before adjourning for the holidays, and the GOP's willingness to use every possible legislative tactic to slow the bill's progress.
All three procedural votes require Democrats to win the backing of 60 members to break a GOP filibuster. Final passage of the measure, by contrast, will require a simple majority of 51 votes.
To Democrats, Monday's vote signaled eventual victory on the Senate bill.
"The die is cast. It's done," claimed Democratic Sen. Chuck Schumer of New York.
But compromises made to win the backing of moderates such as Sen. Ben Nelson of Nebraska and Sen. Joe Lieberman of Connecticut enraged many liberal Democrats and threatened to undermine support for the bill.
Liberal Democrats are particularly upset with Reid's decision to abandon a government-run public health insurance option and an expansion of Medicare to Americans as young as age 55 -- ideas strongly opposed by Lieberman and other centrists.
Top Democrats, however, argue that the Senate bill as currently written would still constitute a positive change of historic proportions. The legislation, according to the Congressional Budget Office, would extend health insurance to more than 30 million Americans currently lacking coverage while reducing the federal deficit.
The House and Senate bills agree on a broad range of changes that could impact every American's coverage.
Among other things, they have agreed to subsidize insurance for a family of four making up to roughly $88,000 annually, or 400 percent of the federal poverty level.
They also have agreed to create health insurance exchanges designed to make it easier for small businesses, the self-employed and the unemployed to pool resources and purchase less expensive coverage. Both the House plan and the Senate bill would eventually limit total out-of-pocket expenses and prevent insurance companies from denying coverage for pre-existing conditions.
Insurers would also be barred from charging higher premiums based on a person's gender or medical history. However, both bills allow insurance companies to charge higher premiums for older customers.
Medicaid would be significantly expanded under both proposals. The House bill would extend coverage to individuals earning up to 150 percent of the poverty line, or roughly $33,000 for a family of four; the Senate plan ensures coverage to those earning up to 133 percent of the poverty level, or just over $29,000 for a family of four.
Major differences between the bills will be the focus of the conference committee that will try to merge them.
One of the biggest divides is over how to pay for the plans. The House package is financed through a combination of a tax surcharge on wealthy Americans and new Medicare spending reductions.
Specifically, individuals with annual incomes over $500,000 -- as well as families earning more than $1 million -- would face a 5.4 percent income tax surcharge.
The Senate bill also cuts Medicare by roughly $500 billion. But instead of an income tax surcharge on the wealthy, it would impose a 40 percent tax on insurance companies providing what are called "Cadillac" health plans valued at more than $8,500 for individuals and $23,000 for families.
Proponents of the tax on high-end plans argue it's one of the most effective ways to curb medical inflation. However, House Democrats oppose taxing such policies because it would hurt union members who traded higher salaries for more generous health benefits.
The Senate bill also would hike Medicare payroll taxes on families making over $250,000; the House bill does not.
Another key sticking point is the dispute over a public option. The House plan includes a public option; the more conservative Senate plan would instead create new non-profit private plans overseen by the federal government.
Individuals under both plans would be required to purchase coverage, but the House bill includes more stringent penalties for most of those who fail to comply. The House bill would impose a fine of up to 2.5 percent of an individual's income. The Senate plan would require individuals to purchase health insurance coverage or face a fine of up to $750 or 2 percent of his or her income -- whichever is greater. Both versions include a hardship exemption for poorer Americans.
Employers face a much stricter mandate under the House legislation, which would require companies with a payroll of more than $500,000 to provide insurance or pay a penalty of up to 8 percent of their payroll.
The Senate bill would require companies with more than 50 employees to pay a fee of up to $750 per worker if any of its employees rely on government subsidies to purchase coverage.
Abortion also has been a sticking point for both chambers. A late compromise with Catholic and other conservatives in the House led to the adoption of an amendment banning most abortion coverage from the public option. It would also prohibit abortion coverage in private policies available in the exchange to people receiving federal subsidies.
Senate provisions, made more conservative than initially drafted in order to satisfy Nelson, would allow states to choose whether to ban abortion coverage in plans offered in the exchanges. Individuals purchasing plans through the exchanges would have to pay for abortion coverage out of their own funds.
Nelson said on CNN's "State of the Union" on Sunday that he would withdraw his support if the final bill gets changed too much from the Senate version under consideration.
Among other things, Nelson had a provision added to the bill requiring the federal government to cover Nebraska's costs for expanded Medicaid coverage after 2016. No other state is currently slated to receive such a benefit.
