A liberal-backed call to expand Medicare as part of the legislation drew strong opposition from Sen. Joe Lieberman, I-Conn. and quieter concerns from a dozen Democrats, raising significant doubts about its ability to survive.
Congressional officials said the administration was recommending the provision be jettisoned to clear the way for the most sweeping health care legislation in a half-century. In response, a top presidential aide, Dan Pfeiffer, said, "The White House is not pushing (Senate Majority Leader Harry) Reid in any direction, we are working hand in hand with the Senate leadership to work through the various issues and pass health reform as soon as possible."
Disputes over abortion and the importation of prescription drugs from Canada and other countries also flared.
In an attempt to generate support for the bill, Reid promised late in the day that any final compromise with the House would completely close a gap in Medicare prescription drug coverage generally known as a "doughnut hole." The Senate bill goes only part way toward that goal.
Democrats are "looking for 60 votes," said Dick Durbin of Illinois, the party's second-ranking Senate leader — a statement that has characterized their effort to overcome Republican opposition for months.
President Barack Obama, the fate of his top domestic priority in doubt, invited all Senate Democrats to a meeting at the White House complex on Tuesday — possibly the final day for an agreement if the legislation is to clear the Senate before Christmas.
In the interim, the president's Monday schedule included a meeting with Sen. Bob Casey, D-Pa., who has been trying to negotiate a compromise on the abortion issue with Sen. Ben Nelson of Nebraska. Both senators oppose abortions, but Nelson has been outspoken in demanding changes in the bill before he can vote for it.
The overall measure, costing nearly $1 trillion over a decade, is designed to expand coverage and ban the insurance industry practice of denying coverage on the basis of pre-existing medical conditions. Obama has also urged Congress to slow the rate of growth in health care spending nationally, and several days after Reid submitted a package of revisions, lawmakers awaited final word from the Congressional Budget Office on that point.
Additionally, a top administration economic adviser acknowledged Monday that the Democratic-backed health care measure would raise spending in the short run, but she said it would eventually generate more than enough savings to offset the expense of expanded coverage.
"Our bottom line is that the bills as they are coming through will genuinely slow the growth of health care spending, both public and private, by about 1 percentage point a year for an extended period," said Christina Romer, chair of the Council of Economic Advisers.
Sen. Byron Dorgan, D-N.D., led the effort to lift a long-standing ban on the importation of prescription drugs from Canada and elsewhere. Obama favored the plan as a senator, but the pharmaceutical industry is opposed, and the White House appeared anxious not to jeopardize a months-long alliance with drug makers who have been helpful in trying to pass the overhaul.
But the obstacle that loomed largest was a proposal to permit uninsured men and women to purchase Medicare coverage as early as age 55.
It emerged last week as part of a framework agreement between moderates and liberals struggling to define the role of government in the newly revised health care system. Additionally, the proposal calls for creation of nationwide plans run by private insurance companies under the supervision of the Office of Personnel Management, the agency that oversees the system through which federal employees and lawmakers obtain their own coverage.
The two provisions were seen as a replacement for Reid's initial call for a government-run insurance plan to compete with private industry.
Liberals have long wanted a government-run option, but moderates oppose it as an unwanted intrusion into the health care system. In announcing the agreement last week, Reid told reporters he could finally see the finish line for his effort to pass a health care bill.
Despite that optimism, opposition to the Medicare changes blossomed from doctors and hospitals, who are paid less to treat patients under Medicare than those covered by private insurance companies.
Lieberman announced his opposition over the weekend, but he was not the only critic.
"We appreciate the rationale underlying the proposed Medicare expansion but fear that provider shortages in states with low reimbursement rates such as ours will make such a program ineffective, or even worsen the problems states are experiencing," a dozen Democrats from across the political spectrum wrote Reid.
Democratic officials said late last week that efforts were under way to try and ease the concerns of doctors and hospitals, as well as defray the cost of buy-in coverage for consumers. Under some estimates, the price tag could reach $7,600 annually or more.
Lieberman said on Sunday he was opposed to the Medicare provision, threatening to deny Democrats his vote if it remained in the bill.
That set off an unusual round of finger-pointing, in which Senate aides anonymously accused him of having flip-flopped on the issue after privately indicating to Reid he was in favor of it.
In a pointed rebuttal, Lieberman's spokesman said, the Connecticut lawmaker had told Reid privately on Friday "that he had problems with the Medicare provision." Marshall Wittman, the spokesman, added, "This position was also told to negotiators earlier in the week. Consequently, Senator Lieberman's position came as no surprise to the Democratic leadership. Any contrary charge by aides who cowardly seek to hide under the cloak of anonymity is false and self-serving."
But Lieberman's consistency on the issue came under question within hours, when House Democrats circulated a videotape from September in which he spoke favorably of allowing men and women as young as 55 to purchase coverage under Medicare.
Wittman said those comments were made before the Senate health care bill, which includes health insurance subsidies, was finalized. He said Lieberman believes the government assistance makes a Medicare buy-in program redundant.
One other proposal to emerge from last week's negotiations appeared headed for oblivion.
The Congressional Budget Office said a requirement for insurance companies to spend 90 cents of every premium dollar on medical care would transform the industry into "an essentially governmental program" that would more properly belong in the federal budget.
Reid's bill now includes some limits on insurance company overhead, but Sen. Jay Rockefeller, D-W.Va., and other liberals advocate the 90 percent proposal.
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