Opening skirmishes in the healthcare battle that will dominate Barack Obama's domestic agenda into the new year began yesterday, after the US Senate voted to begin debating a Democrat Bill to reform the industry. The starting gun was formally fired late on Saturday, when senators narrowly voted for a motion to start discussing proposed legislation to provide guaranteed medical coverage to nearly all Americans.
Clearing that symbolic hurdle had been tricky. The Democratic leadership secured a majority of 60-39, entirely along party lines. Just one vote less would have allowed opponents of reform to mount a filibuster, wrecking the proposed Bill by talking it off the agenda.
Now the real challenge begins, preserving a fragile, filibuster-proof coalition while senators debate highly-divisive issues in the 2,000-page Bill. These include abortion rights and the so-called "public option", in which the government would run some health insurance plans. Horse-trading is already under way. Both sides are courting four "waverers", two independent members and two right-leaning Democrats who eventually backed Saturday's vote, but are known to be highly sceptical about the proposed Bill.
Republicans hit the airwaves yesterday, setting an aggressive tone for the battle to win them over to his camp. Senate leader Mitch McConnell dubbed the 2,000-page Bill a "monstrosity", andf Senator John Kyl told Fox News yesterday that it was full of "frauds and tricks" that "Bernie Madoff would really envy".
But they did not have a monopoly on outrage. Left-leaning Democrats said they were unhappy at concessions being made towards a handful of colleagues who effectively hold the balance of power.
"In the end, I don't want four Democratic senators dictating to the other 56 of us and to the country, when the public option has this much support," Ohio Senator Sherrod Brown told CNN's State of the Nation. "They don't want to be on the wrong side of history."
One of the four, Louisiana Democrat Mary Landrieu, was persuaded to support Saturday's vote only after her state was offered a sweetener of $100m [£65m] to spend on healthcare for the poor. "It is clear to me that doing nothing is not an option," she said, later. Formal debate will now begin next Monday and is likely to continue until Christmas. As it stands, the Bill will make insurance available to 31 million people who lack it at present, and allow the government, in some cases, to sell policies in competition with private companies. But it could be subject to widespread change.
Estimates put its cost at aboutd $979bn [£600bn] over the next decade. It will require most Americans to carry coverage, and prevent insurance firms from the controversial practice of refusing to cover some patients because of pre-existing medical conditions.
Democrats need only a 51-49 majority when the Bill comes down to a final show of hands, but to reach that point, they must first negotiate five or six other votes in which they must prevent the Republicans from exercising a filibuster. That could see the "public option" seriously curtailed, or even killed-off. Just starting the political process in the Senate marked an important symbolic victory for its Democratic leader, Harry Reid, proving that he boasts sufficient clout to secure 60 supporters in a vote on healthcare.
During the run-up to the vote, he accused Republicans of using wrecking tactics to stifle debate. "Imagine if, instead of debating whether to abolish slavery, instead of debating whether giving women and minorities the right to vote, those who disagreed had muted discussion and killed any vote," he said.
Whatever Bill eventually gets through the Senate will not immediately become law. Instead it will be reconciled with the Bill passed by the House of Representatives by 220 votes to 215, and then voted on again by both Houses.Reuse content