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Though comparatively less divisive than abortion debate roiling the House this weekend, the immigration issue in the health-care bill also has yet to be settled. The controversy is over whether to prohibit unauthorized immigrants from purchasing insurance that’s available through the new insurance exchanges. The Senate Finance bill includes such a prohibition, and conservatives have been pushing to include a similar one in the House bill. Members of the Congressional Hispanic Caucus oppose it, arguing that unauthorized immigrants should be able to buy coverage using their own private money, and that enacting such a prohibition could discourage legal immigrants and other groups from using the exchanges.

As The Washington Post reports, House Democratic leaders have assured members of the Hispanic Caucus that the measure won’t end up in the bill. But as the Post explains--and as various sources close to the debate confirm--Democratic leadership is anticipating Republican amendments and parliamentary measures on the floor that could force a close vote on the issue--with moderate Democrats worried about looking soft on unauthorized immigrants.

The whole episode shows just how much the Republican “government takeover” meme has warped the health-care debate. As I noted earlier this week, unauthorized immigrants are prohibited from receiving any government subsidies on the exchanges. They would simply be buying private insurance plans within the exchange infrastructure that’s set up by government. And, as I’ve argued, the logic of prohibiting unauthorized immigrants from doing so would be akin banning them from buying a tank of gas--another industry heavily subsidized and supported by government infrastructure. 

Such logic has also extended to the abortion debate. Under the original Capps amendment, the bill would have prohibited federal dollars from paying for abortion services in the insurance exchange. Anti-choicers argued such measures weren’t sufficient, as insurers offering abortion services were still participating in an exchange the government set up--which they conveniently translate into meaning “government-funded abortions.” As the Wonkroom asks, should women also be prohibited from traveling on government-funded highways to travel to abortion clinics? The fact that such extreme thinking has gathered steam is a sign of just how effective the conservative opposition has been this week in shaping the debate.

Opponents of abortion rights won a significant political victory last night, making it more likely that millions of American women will no longer be able to purchase insurance that covers abortion services.

At issue is what happens inside the new insurance exchanges, through which small businesses and people purchasing coverage on their own would shop for insurance. People purchasing coverage through the exchanges would be eligible for subsidies if their household incomes were below four times the poverty level. Abortion rights opponents don't want those subsidies going towards policies that cover abortion services, since that would mean taxpayers opposed to abortion were, in effect, paying for the procedure.

While such "mixing" of funds happens all the time, as Time's Amy Sullivan has observed, the Democratic leadership have tried to accommodate the opposition by proposing to create nominally distinct funds for abortion services or contracting out the financing to a private entity.

But the abortion rights opponents, led by Michigan Democrat Bart Stupak, wouldn't budge. They wanted the chance to introduce an amendment that would prohibit any plan that covers abortion services from accepting subsidies--a move that would effectively make policies covering abortion unavailable not only for people who need subsidies but, quite possibly, even those who don't.* After a furious day (and days) of negotiation, last night the Democratic leadership--desperate for every vote it could get--finally and very reluctantly gave in.

At around 10:40 a.m., the House erupted into applause as Representative John Dingell of Michigan took the gavel in order to preside over the House of Representatives. Dingell, the longest serving representative in Congress, has been pursuing universal health care since the day he took office in 1955.

It's a crusade that Dingell inherited from his father, John Dingell, Sr. who in 1945 co-sponsored the Wagner-Murray-Dingell bill. That bill proposed to "expand the Social Security Act to include a vast program of medical care and hospitalization insurance."

According to Dingell's office, the last time he served as Speaker Pro Tempore was April 8, 1965--the day the House passed Medicare.

Prediction: If health care reform comes up for a vote in the House of Representatives tomorrow, it will pass.

OK, that’s not much of a prediction. Speaker Nancy Pelosi won’t actually bring a bill to the floor unless she has the votes. And as of late Friday afternoon, she didn’t. On Capitol Hill, staff began talking about the possibility of a postponement until Sunday, or even early next week.

The sticking points are the ones you’ve read about elsewhere: abortion and immigration. On both issues, Pelosi and her lieutenants spent the day reaching out to both sides of each debate, trying to find mutually acceptable language. But the efforts kept failing.

Meanwhile, plenty of members are downright unhappy about the bill, because they think it’s too ambitious or, at least, more ambitious than what the Senate is likely to support. And they don’t want to take “hard votes” like raising taxes (even if it’s only on the very wealthy) if it’s not necessary. For more on the different groups--and where they stand--see Ezra Klein’s writeup here.

President Obama is still planning on paying a visit to the House on Saturday, to make a personal appeal in front of the entire Democratic caucus. He’ll remind them of the bill’s historical significance--and, you can be sure, its political significance. It’s nothing they haven’t heard before, of course. But don’t underestimate the ability of the president, in person, to change a few minds.

Update: As of Saturday morning, it's all systems go. A source reports that an abortion deal is in place, but that it's "very fragile." Pelosi either has the votes or is confident that she will have them, particularly after the presidential visit. For those who want to follow the debate today, the Washington Post has a great "viewer's guide" on everything from the debate over the Rule to the possibility that Republicans could derail things with a "motion to recommit."

A little less than a month ago, the Blue Cross Blue Shield Association--the trade group representing state-based Blue Cross and Blue Shield plans--released a misleading study suggesting that health care reform would mean higher premiums for small businesses and individuals buying coverage on their own.

The basis for the findings were calculations by the consulting firm, Oliver Wyman. But Oliver Wyman, by its own admission, had ignored or slighted elements of health care reform that promised to reduce premiums, such as the creation of insurance exchanges for people who don't get coverage from large employers and the imposition of a tax on generous plans. When MIT economist Jonathan Gruber analyzed the full Senate Finance Committee health bill, including these and other cost-cutting measures, he concluded that premiums would actually be "considerably lower":

:..for those facing purchase in the non-group market, the SFC bill will deliver savings ranging from several hundred dollars for the youngest consumers to over $8500 for families.  This is in addition to all the other benefits that this legislation will deliver to those consumers--in particular the guarantee, unavailable in most states, that prices would not be raised or the policy revoked if they became ill.

In part because the Association's paper came on the heels of another, even more egregious insurance industry study, most of the media ignored it. But it looks like at least Blue Cross affiliate has found a new way to put the material to use: By distributing the information to small businesses that buy its coverage.

TNR has obtained a pair of letters that Blue Cross Blue Shield of Illinois and its parent company have sent to those small businesses in the last two days.

For all of the crazy arguments against health care reform, a few of them are entirely sensible--and worth taking seriously. As I write in my latest Kaiser Health News column, which appeared on TNR’s home page yesterday, one of those is the worry that Congress won’t follow through with promises to raise the revenue--or find the savings--necessary to finance expansions of health insurance.

In other words, Congress may pass a law calling for reductions in Medicare expenditures or raising an assortment of new taxes. But the people affected by those changes--be they health care businesses that would lose reimbursements or everyday Americans facing the prospect of higher taxes--will complain. Once they do, Congress is likely to have second thoughts and repeal those measures.

I wrote the article thinking primarily about conservatives and libertarians who have made this case. But, to be clear, you don't have to be a conservative to have these concerns. Just a few days ago, for example, the New Yorker's John Cassidy warned about the likely high costs of health care reform:

“We are turning to socialism and away from God!” Joseph Grab said as he stood amid the thousands who gathered on Capitol Hill today to attend Michele Bachmann’s “House Call” protest against the health care reform bill. Grab, a retired engineer from Hershey, Pennsylvania, was clutching a leather-bound King James in his hand and a green sign that simply said “Pray” in the other. “This bill is going to include murdering babies, it’s going to bankrupt us, and it’s going to make totalitarianism grow,” he said gravely.

If the September 12 march on Washington--aka “the largest gathering of fiscal conservatives in history”--called for Don’t Tread on Me flags, Revolutionary War garb, and hammer-and-sickle signs outing Obama as a socialist, it still didn’t seem particularly religious. Well, this time, the Tea Partiers brought their Bibles with them. “It’s a bailout for the abortion industry!” one speaker on the steps of the Capitol cried. And before Bachmann took the stage, a preacher from Maryland led an opening prayer that praised the Almighty for “the torch of liberty lit in this land,” followed by a recitation of the Pledge of Allegiance. “One nation, UNDER GOD, indivisible…” the protesters chanted, yelling out the phrase that deserved special emphasis.

While everyone there seemed equally incensed about the “government takeover” of health care, a number of protestors I approached--particularly the middle-aged folks who brought their children with them--cited abortion as one of the most important issues that had prompted them to show up and made their religiosity clear. “Unborn babies have their rights too,” said the 12-year-old daughter of Beverly Horning, a housewife from McLean, Virginia. Horning herself said that while she was concerned about the government’s proposed intervention in the health care system, “it was the funding of abortion that brought me here.” Another man--a former Chrysler employee from Detroit who had taken a buyout when the company was imploding last year--said that he had brought his ten blond-haired children to the event after attending a National Bible Week event in town with some 17,000 other Christians.

Of course, post-health care reform, this happy union between the religious righters and the tax-haters might not be as strong, but it’s at the least a sign that different factions of the conservative base are willing to join forces under the right circumstances. When I asked Horning’s 15-year-old son this afternoon what he thought of thousands of fellow protesters around him, the bespectacled teenager sniffed and called the crowd “much smaller than the March for Life.” His mother quickly interjected, encouraging him to be more patient with the burgeoning movement. “After all,” she said. “They’ve just started.”

Jacob S. Hacker is the Stanley B. Resor Professor of Political Science at Yale University, author of The Great Risk Shift: The New Economic Insecurity and the Decline of the American Dream, and an occasional contributor to The Treatment.

Diane Archer is the director of the Health Care Project at the Institute for America's Future and the founder and past president of the Medicare Rights Center.

How short memories are in Washington. A few weeks ago, when it looked possible that Nancy Pelosi could marshal enough Democratic support to create a “robust” public insurance option with rates tied to Medicare’s, everyone was talking about the big savings and reduced premiums that a series of estimates by the CBO showed this option could create. Then, the concern was that the public insurance plan would put private insurers out of business by using the government’s bargaining power to drive too hard a bargain with providers, creating an “un-level” playing field.

Now, however, the punditocracy is abuzz about the latest CBO estimates that show that the public plan eventually embraced by Pelosi--one that would negotiate rates with providers, rather than base them on Medicare’s--might actually charge higher premiums than the average private plan. No matter that the CBO estimates clearly state that the higher projected premiums reflect its expectation that the public plan will disproportionately enroll less healthy Americans--which might be seen as a virtue, since these are folks private insurance tends to serve most poorly. And no matter that a subsequent CBO letter to the House stated that even a public plan with negotiated rates would still place “downward pressure on the premiums of private plans.” Suddenly, in the commentariat, the public plan isn’t a fearsome predator. It’s a complacent kitten. Initially not worth having because it would be too strong, it’s now, according to critics, not worth having because it would be too weak. 

In truth, both the initial fears and current dismissals are overblown. The CBO’s declining estimates of savings certainly make a strong case for having the public plan use modified Medicare rates, as we have long argued. It’s a shame the House will not be considering a bill that shows how substantially a public plan can contribute to freeing up federal dollars to help Americans afford coverage. But we should keep in mind that the prime argument for the public plan has never been about a particular payment formula. It has been that a public insurance plan is vital as an institutional check on private plans, its role evolving to reflect the emerging weaknesses (or strengths) of regulated private competition. Put simply, health reform is much more likely to succeed with a public health insurance option, even one with negotiated rates, than if private insurers are left to run the show.

Earlier today, two key groups--the American Cancer Society and the American Association of Retired Persons--endorsed the House health care reform bill. On a conference call that's just wrapping up now, the American Medical Association (AMA) pledged its support, as well. But it did so with some crucial qualifications.

The AMA made clear that it was endorsing not one but two bills: H.R. 3962, the bill that would expand insurance coverage, reorient the delivery system, etc.; and H.R. 3961, the bill that would eliminate the planned reductions in Medicare physician payments to keep them in line with the Sustainable Growth Rate (SGR).

AMA President James J. Rohack explained the group's position thusly:

From the moment the the Republican leadership released its alternative approach to health care reform, critics (including me) pointed out that it was unlikely to make a dent in the number of people without insurance. On Wednesday, the Congressional Budget Office came out with its preliminary estimates of what the bill will do. And, sure enough, the critics were right. Overall, ten years into implementation, the plan would not significantly change the number of people with health insurance. In all, 17 percent of the legal, non-elderly pouplation--or about 52 million children and working-age people--would still have no coverage.

The Republicans, to be fair, never claimed that their plan would do otherwise. Indeed, the essence of their pitch--again, as discussed previously--is that they focus on cost while Democrats focus on coverage. And the CBO certainly agrees that the Republican plan will reduce premiums. According to the projections, premiums would drop by between 7 and 10 percent for employees of small businesses, between 5 and 8 percent for people buying coverage on their own, and between 0 and 3 percent for workers who get coverage through large employers.

That finding had Republicans like Representative Tom Price crowing on Wednesday.

Giving patients greater control and making specific common sense reforms will lower the cost of health care for all Americans. The Republicans’ straightforward plan will decrease insurance premiums by up to ten percent. Meanwhile, the Democrats’ 2,000-page plan to give Washington more control via tax increases, mandates, bureaucracies, czars, and government-run insurance will not lower costs. We seek to lower costs by giving Americans more control over how they spend their health care dollars, allowing the purchase of coverage across state lines, ending costly lawsuit abuse, and providing important protections for those with pre-existing conditions. In just 200 pages, Republicans have proven that we can improve the portions of our health care system which need fixing without giving Washington control over one-fifth of our economy. Republicans have the answer to lowering health care costs – put patients in charge.

But is that really what the CBO said? Read the full write-up more closely and you’ll see the message was a bit more complicated.

Most of you know John Garamendi (if you know him at all) as the former California state official who won a special election for Ellen Tauscher's old seat in Congress. But those of us in the business of health wonkery know him as one of our own.

In the early 1990s, he developed the "Garamendi plan" for California, which later became a model for the Clinton health care plan of 1993-94. (One of Garamendi's deputies, Walter Zelman, worked closely with my old boss, Paul Starr, on the design.) As insurance commissioner, Garamendi accumulated extensive experience dealing with health insurers--and has the scars to show for it.

Hopefully, Garamendi will arrive in time to provide one more "yes" vote on health care reform, as he's promised to do. More important, he will be around afterwards, when Congress will have to watch over the implementation of whatever is passed--and, as necessary, enact changes to fix the problems. Garamendi's expertise could come in handy.