There’s been a lot of talk about a surprisingly high degree of bipartisan collaboration on the Senate congressional committees working on health reform, despite the lack of similar collaboration in other debates. But, now, as the HELP Committee and the Senate Finance Committee work in private to complete their reform proposals this month, there’s quite a bit of nail-biting about whether the Republican principals on the committees will defect or stay with the team. In Senate Finance, Chairman Baucus (D-Mont.) has always been very collegial with ranking member Sen. Grassley (R-Iowa), as well as with member Sen. Hatch (R-Utah). After all, they’re all from relatively similar rural state environments. Nonetheless, Hatch and Grassley have a list of complaints (the biggest one being the “public plan” concept) and we are beginning to hear rumblings of their desire to strike a different course. In the HELP Committee, ranking member Sen. Enzi (R-Wyo.) has heretofore been pretty chummy with Chairman Kennedy (D-Mass.), but he’s under pressure from his Republican colleagues to run for cover.

Meanwhile, Sen. Coburn (R-Okla.), a physician, has developed an alternative Republican bill based on tax credits and voluntary expansion of access, rather than expansion of entitlement public coverage — this is the concept Congressman Paul Ryan (R-Wis.) praised last week. To please fellow physicians, and differentiating his measure from the Dem bills this far, Coburn also has a medical malpractice section in his bill, albeit it is focused on health courts and a few other nice provisions—but far short of a cap on non-economic damages (what we really need). If a split occurs along partisan lines to support Coburn, even though it has no chance of passing, the Senate will have to resort to a max of 60 votes to get a reform bill passed, and adopt a strategy that could break into pieces if just one defector among the Dems emerges. So, there’s a lot of nervousness about what compromises will be needed to keep everybody together, aiming for the support of 70 senators on a bill that would constitute a real mandate for reform.

The House is typically much more partisan—and the Republicanss there complain that aren’t even being consulted on the Democratic plans. However, I hear from the White House that there is a surprisingly strong collaboration among the three relevant and traditionally argumentative House committees — Ways and Means (WAM), Energy and Commerce (E&C), and Education and Labor (E&L). Californians Henry Waxman (D) (E&C) and George Miller (D) (E&L) are working closely with Charlie Rangel (D-N.Y.), Chair of WAM, on a bill that might not even need to get individually marked up by the three committees. If they achieve that kind of unity, they could catch up with the momentum and lead the Senate has had thus far. Interestingly, Pete Stark (D-Calif.) has had health problems preventing him from his expected leadership role as the WAM Health Subcommittee chair for the past few months. Stark historically has favored a single-payer or “Medicare for all” plan, so a lot of observers may be somewhat relieved that he is not a strong voice in these discussions at this point. He does know a lot about health care, however, and is a valuable person on the details of many issues, including protecting the patient-physician relationship against insurance intrusion, and on his recognition that PQRI thus far has been a joke. Congress is a complex beast.

Everyone believes the process is still on track for passage of reform legislation — even if there’s a partisan split — and that two parallel bills will be on the table by July to be marked up and ready to be introduced officially on the floor of the House and Senate before the August and Labor Day recess. But if the Bipartisan vision in the Senate gets smashed, even all the king’s horses and all the king’s men will be struggling to get that back together for passage of a comprehensive bill later this year.

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