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The 60th vote?

The health-care bill, according to Senate sources, is at 59 votes. Joe Lieberman, for better or worse, seems placated. The question is who will be number 60.

No one thinks Susan Collins will even entertain the notion. Olympia Snowe also seems unlikely. Both might sign onto a bill that will pass without them -- "if you can get 60, you can get 62," as some in the Senate say -- but neither is expected to provide the crucial vote to break a filibuster.

Enter Ben Nelson. Nelson, recently, has been persistently constructive. His Stupak-like abortion language was defeated, and though that didn't end his efforts on the issue, it didn't unleash a torrent of filibuster threats. He was a member of the Team of Ten that concocted the Medicare buy-in compromise. He's been waiting for CBO scores and offering amendments and attending meetings with leadership.

But his proposals are getting, well, weirder. His latest idea is to let states opt out of the plan altogether. The reason? The Medicaid expansion, he says, is an "underfunded mandate."

As my colleague Alec MacGillis explains, this doesn't make much sense. The federal government picks up 93 percent of the new Medicaid costs in the bill. The losers here are states that have generous Medicaid programs, like Maine or Massachusetts. They'll still be paying up to 50 percent of those costs, because they're paying them now, and the bill doesn't alter those current arrangements. Nebraska, by contrast, is getting a sweet deal.

Meanwhile, if states can, as Nelson suggests, find cheaper ways to cover low-income residents than Medicaid, they can already opt out using the innovation waivers built into the bill. But they can't. It costs about 30 percent more to cover someone through private insurance rather than on Medicaid. One of the ways the House bill saved money was by moving more people onto Medicaid, as it was less costly than giving them subsidies for private insurance.

And while a case could be made that removing Medicare buy-in, and even the public option, wasn't harming the basic structure of the bill, it's hard to say the same for a process in which states would simply opt out of the whole thing, with no need to achieve the objectives in other ways. On the other hand, maybe Nelson is just negotiating. "There's always a lot of room which you have to have between the bid and the ask," he told reporters today, "and we're seeing if we can close the gap."

As Steve Pizer and Austin Frakt note, this is part of what made Lieberman's maneuvering so frustrating. Unlike Nelson, Lieberman is from a fairly liberal state. Keeping Nelson's vote, just as a matter of political theory, is going to be harder than keeping Lieberman's. But since Lieberman insisted on killing the public option himself, now Nelson has to take his own stand. It almost makes one yearn for the days of stimulus, when the conservative Democrats and moderate Republican cohered into a single voting bloc, and so got the compromising done all at once.

Photo credit: By Karen Cooper/Face the Nation via Associated Press

By Ezra Klein  |  December 18, 2009; 3:28 PM ET
Categories:  Health Reform  
Save & Share:  Send E-mail   Facebook   Twitter   Digg   Yahoo Buzz   StumbleUpon   Technorati   Google Buzz   Previous: The purpose of health-care reform is to cover more people, not figure out how to cover fewer people
Next: The Senate doesn't work


This is getting comical. I hope Ben N uses his power here to get money for Nebraska and not make a big moral stand.

Posted by: ideallydc | December 18, 2009 3:46 PM | Report abuse

Why do we believe Senate sources re Lieberman this time around?

Posted by: Art27 | December 18, 2009 3:46 PM | Report abuse

Nelson all by his lonesome. That's good news! The loss of power in the Senate would be stunning and swift if he killed the bill as the lone vote. He's making his list of demands, but he'll cut a deal, and they will make it a good one for him.

Posted by: cmpnwtr | December 18, 2009 3:47 PM | Report abuse

Connecticut's population - 3.5 million.

Nebraska's population - 1.8 million.

So two senators, representing states with a combined 5.3 million Americans, are holding hostage a health care bill that would benefit the entire country.

Posted by: simpleton1 | December 18, 2009 3:48 PM | Report abuse

The state of NE already prepared an analysis indicating this bill would cost them quite a bit of money. Why is that not even mentioned here. Furthermore, I object to those who claim this bill is going to help anyone. Forcing people to buy insurance via a mandate is not the same as covering them. I hate to repeat a Dean talking point, because I despise him, but it is the truth. There are no cost containment measures in this bill, nothing to keep premiums down and the fact that the US government is on the brink of forcing private individuals into buying insurance from private companies is quite simply mindboggling. This makes the overreach of Prohibition same mild by comparison.

Posted by: Bob65 | December 18, 2009 4:02 PM | Report abuse

We had Nelson, until Lieberman blew stuff up.

Posted by: adamiani | December 18, 2009 4:35 PM | Report abuse

Ezra - a question for you - while Reid is chasing Nelson to be the 60th vote, what has happened to Olympia Snowe? It seems her big problem was the public option, but that has since been taken out. What is her major objection now, as this bill closely resembles the finance committee bill that she did in fact support.

Posted by: kmani1 | December 18, 2009 5:11 PM | Report abuse

I thought I heard Snowe's demand now is the timing of the process. She insists - who knows why - that the bill be held over until next year.

Posted by: Art27 | December 18, 2009 5:22 PM | Report abuse

This seems like a good moment for some liberal Senators to work together with Nelson to push for full federalization of Medicaid spending. If he's really concerned about this "underfunded mandate," one good solution would be to treat it like it covered people we actually care about (compare Medicare...)

Posted by: NS12345 | December 19, 2009 1:20 AM | Report abuse

just like in California, the Republicans as a united minority with the help of similar pimping Democrats can and do control the government. they decide who is getting "our" money.

watch the game, the players. all for show. to distract us all from the looting done by businesses now embeded with their "agents" in Congress.

hook line and sinker

Posted by: BernardEckholdt | December 19, 2009 3:04 AM | Report abuse

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