Eleven members of Congress begin casting the first votes on health-care reform today, transforming forever President Clinton's ivory-tower plan into a real-world mishmash of political compromises.
While Clinton's 1,342-page tome is a policy wonk's dream, the first plan to emerge from a congressional committee will be the product of deal-making and nose-counting.
"It's an attempt to see whether I can patch together enough votes to get it out of this subcommittee," says Rep. Fortney "Pete" Stark, D-Calif., chairman of the House Ways and Means Committee's health panel, whose plan to expand Medicare for the uninsured has become, for now, the only legislative game in town.
And as a result, the seven Democrats and four Republicans who will be asked to vote on it this week have come under a heavy barrage of lobbying from Washington, D.C., to Washington state.
The results already are apparent: Gone are Clinton's mandatory purchasing cooperatives, the bane of the insurance lobby - and with them much of the new bureaucracy opposed by most lawmakers.
In the next few days, efforts may be made to wipe out private price controls, ease the mandate that employers pay 80% of workers' coverage, increase subsidies for small business, add benefits for mental health and long-term care, and eliminate a 0.8% payroll tax increase that helps pay for the Stark plan.
All those efforts and others will reveal the legislative process at work - less than eight months before all House members and one-third of the Senate face the voters.
To be sure, Clinton's plan also was crafted with politics in mind. His mix of market forces and government regulation came down between conservative and liberal prescriptions already pending in Congress and was intended to please both sides.
But that was wholesale policy-making; this is retail politics. Armed with only his own vote, Stark must woo at least five other panel members to win a 6-5 tally this week.
"He's got to focus on satisfying five people - not 250 million, not 435 (House members), not 37 members of the Ways and Means Committee," says ex-representative Bill Gradison, who served on Stark's panel before leaving Congress to head the Health Insurance Association of America.
The 10 other members of Stark's panel cover the gamut from liberal to conservative, and their health-care concerns are shaped both by ideology and parochialism:
-- Liberals like Reps. Jim McDermott, D-Wash., the champion of a government-financed reform plan, and John Lewis, D-Ga., the top-ranking black lawmaker in Congress, listen to labor, academics and health-care providers.
"The overriding principle for me is universal coverage," Lewis says.
-- Mainstream Democrats like Reps. Sander Levin, D-Mich., Benjamin Cardin, D-Md., and Gerald Kleczka, D-Wis., watch out for business and the vast middle class.
Levin, whose suburban Detroit district is home to more automobile plants than any other, wants to avoid "undue cost burdens on larger industry" without increasing the burden on smaller employers.
-- Moderate Republicans like Reps. Fred Grandy, R-Iowa, and Nancy Johnson, R-Conn., as well as conservative Democratic Rep. Michael Andrews, D-Texas, want less regulation and more competition.
Grandy and Johnson come from districts where insurers, rural hospitals and small business speak loudly. Johnson also listens to providers - including her husband, a physician.
"There's a lot of concern among providers that health-care reform is going to . . . destroy them," she says.
-- More conservative Republicans like Reps. Bill Thomas, R-Calif., and Jim McCrery, R-La., must watch for parochial interests - agriculture and oil among them - while carrying the GOP banner.
Thomas disputes the effect of lobbying on the process. "This is purely the politics of what, not the politics of who," he says.
But with a roomful of lobbyists watching their every move, the 11-member health panel will be unable to ignore the "who" of health reform.
"These guys are in the crosshairs," says American Association of Retired Persons lobbyist John Rother. "They've heard from everyone."
