Sen. Ben Nelson (D-Neb.) dealt a blow to health care reform last week when he said that any overhaul that involved the creation of a public plan that patients could buy into would be a "deal breaker" for him.
Because Democrats in the Senate can pass an overhaul with only 50 votes, Nelson's lone vote isn't crucial in itself, but conservative Democratic senators have a tendency to travel together. Once one leaves the Democratic herd, others quickly follow, not wanting to be the last one to bolt and sink the bill but not wanting to go along with it, either.
Take the Employee Free Choice Act. When votes starting breaking against EFCA, labor's top priority, there was a "centrist" stampede for the safety of the boss's office.
Sen. Charles Schumer (D-N.Y.) is moving quickly to herd those cats back before they all scatter. Nelson and his allies object to a public health care option because they say it will have unfair advantages over private plans and drive them out of business.
"My belief is if you put a private plan in competition with a public plan, the public plan will win out, either in the short term, intermediate term or long term, because it's not a level playing field any way you look at it," Nelson tells the Huffington Post.
Schumer wants to hit that argument head on. "We think the public plan has major advantages to the consumer without having extra advantages built in. So we're willing to say: level playing field. Let's compete. We'll do a better job," he says.
That leaves the Nelsons of the Senate, along with the insurance industry lobby, in the difficult political position of opposing competition.
Schumer's plan would give no subsidy to a public plan and require that it abide by the same rules as private plans. It would outperform the private plans, he says, because it would focus on long-term health rather than quarterly profits.
"A public plan will much more take into account public goods, insuring those no one else will insure and putting a greater emphasis on primary care. It's basically patients over profits. The public plan is consumer-oriented first. The private plans are profit-oriented first. That's the fundamental difference," he says in an interview with the Huffington Post. "They don't have to make a profit. They don't have to advertise."
The public plan would be fully funded by premiums from patients and fees from doctors and hospitals. Without details yet of the costs of the public plan from the Congressional Budget Office, it's hard to know what the premiums or payments will be, but Schumer wants it to pay more than Medicare to encourage doctor participation. (Here's background on the fight over the public plan.)
"I'm saying, overall, Medicare pays less than the private plans. And to have [the public plan] pay a little more, that's okay," he says.
Schumer has taken some heat from the left for his compromise, with advocates pushing for a more generously funded public plan. Schumer says he agrees with them and "personally would go further, but the key was to get a broad enough consensus that people say, 'Hey, the public option is very real.' And I think we've accomplished that."
The compromise proposal puts the onus on Nelson to answer: Why shouldn't people have the option to buy into a public plan if it doesn't cost the government anything?
"The great worry that we have is there will be no public option in the Senate bill and I think the proposal that we've made really has helped put it back on the map. We can debate whether it goes far enough," says Schumer.
"A public plan keeps the private insurers honest. Having it on the table is a huge benefit even if you don't agree with each specific detail, or even if you don't think it goes far enough, which would be basically where I'm at. But my job is to make sure a public plan is in the bill."
Nelson's proposal for reform sounds familiar to participants in the debate. He wants to gradually cover the uninsured, bring down costs and increase quality.
"There are two aspects of it and some aspects of the first can be going on during the second as well. First of all you have to have a reform of the health delivery system," he says, "aimed at reducing the cost, increasing the quality, reducing the quantity and improving the health care. The second piece of it is to find a way to insure the 45 to 50 million Americans who aren't insured...You find a way to have them insured without destabilizing the 150 million Americans who have a private plan."
The details of his plan are familiar, too. Compare Nelson's plan here to the insurance industry's proposal here.
Democrats have public opinion on their side. A recent poll showed overwhelming support for a public option. GOP pollster Frank Luntz, in a memo to Republicans leaked to Politico Wednesday, tried to get through to the GOP that obstruction alone is no answer.
"You simply MUST be vocally and passionately on the side of REFORM," Luntz writes in a confidential 26-page report. "The status quo is no longer acceptable. If the dynamic becomes 'President Obama is on the side of reform and Republicans are against it,' then the battle is lost and every word in this document is useless. Republicans must be for the right kind of reform that protects the quality of healthcare for all Americans. And you must establish your support of reform early in your presentation."
Schumer says that, so far, his plan has been well received, with members in his party at both ends recognizing the political necessity of compromise and consensus.
"The reaction overall is good," he says. "Neither the most conservative nor the most liberal would write the plan this way in the Democratic caucus, but both would say it's a reasonable place to be right now."