When lawmakers in the U.S. Senate and House of Representatives return to work in January, they will face the task of working out differences between major health care reform legislation. Informal talks were expected to get underway even earlier, and President Barack Obama has pledged to remain fully engaged in the process of achieving his major domestic priority.
Legislation the Senate passed and the version the House of Representatives approved earlier have both been estimated by the independent Congressional Budget Office to cost in the upper $800 billion range.
Democrats and Republicans continue to argue what the true longer-term costs will be, with 10-year costs of the House measure put at more than $1 trillion.
Lawmakers who will negotiate the differences for the Senate and House will have to ensure that a final bill is below the $900 billion the president set as a maximum figure.
Senate Democrats were forced to make concessions to some of their members and to Independents, the most significant being the elimination of a government-run insurance option to compete with private companies whose practices have been the focus of sharp criticism for decades.
Both bills seek to make health-insurance coverage accessible to between 94 and 96 percent of Americans, compared to the current 83 percent - adding about 30 million people. Most Americans would be required to obtain some form of insurance or face financial penalties.
Both would also use tax increases on higher-earning Americans, various other taxes, and reductions in payments to medical-care providers under the government Medicare and Medicaid programs to pay the costs of expanded insurance.
While the House bill would immediately bar private insurance companies from denying coverage or raising insurance premiums based on age or gender, the Senate would wait until 2014 for this to take effect, except for children who would be covered immediately. There would be no lifetime limits on coverage beginning immediately upon President Obama signing legislation.
Under the House bill, the prohibition on denying coverage would begin one year earlier in 2013, with similar prohibitions on higher premiums based on pre-existing conditions or gender.
Of course, the biggest difference between the two bills, and one likely to cause the most friction in House-Senate negotiations, involves the so-called "public option" or competing insurance the government would offer.
Using new public exchanges or marketplaces, a feature found in both bills, House lawmakers included such a government option in their bill, with rates to be negotiated by the government.
In the face of opposition from Independent Senator Joe Lieberman, and to gain his vote, Senate lawmakers first dropped the government insurance option and then an alternative plan to decrease the eligibility age for the existing government Medicare program.
The Senate measure relies on the new exchanges with emphasis on U.S. states retaining flexibility, to expand coverage to self-employed Americans, to small businesses and others currently without insurance.
In the year-long battle over reform, President Obama stressed the importance of billions of dollars in longer-term savings from reducing waste in the current health care system.
The Congressional Budget Office estimates the Senate and House bills would save $132 billion and $138 billion respectively.
Republicans who opposed both bills assert that President Obama and Democrats manipulated savings projections to conceal the true cost of reforms, while Democrats defended their figures.
"At the same time [the bill] cuts costs, the waste, the fraud, the duplication, endemic to our system and at the same time it covers 31 million people. Who would have thought we could do both in the same bill?," said New York Democrat Charles Schumer.
"The idea that the bill is going to create a situation to reduce debt is just not true," said Alabama Republican Jeff Sessions.
On new taxes, House lawmakers have proposed a 5.4 percent surtax on individuals earning more than $500,000 per year and families with incomes exceeding $1 million, along with with new fees for insurance companies, drug-makers, medical device manufacturers.
But there is pressure on the House to accept Senate provisions that would increase Medicare payroll taxes for individuals earning more than $200,000 annually, and families earning more than $250,000, with other taxes on so-called high-value insurance plans.
Both measures expand coverage under Medicaid, the existing government program servicing low income Americans, between 133 and 150 percent of the government's official poverty level, for the Senate and House plans respectively.
House-Senate negotiations will also focus on other issues, including provisions regarding abortion services, and those involving participation for illegal immigrants.
In advance of formal talks, Democratic leaders are stressing the need to come up with a consensus that can deliver health care security and quality while controlling short and longer-term costs.
Republicans have made clear they will continue to underscore what they call the long-term deficit and debt risks for the economy of the legislation President Obama hopes to be able to sign not too far into the new year.
