Buried in the deal-clinching health care package that Senate Democrats unveiled over the weekend is an inconspicuous proposal expanding Medicare to cover certain victims of “environmental health hazards.”
The intended beneficiaries are identified in a cryptic, mysterious way: individuals exposed to environmental health hazards recognized as a public health emergency in a declaration issued by the federal government on June 17.
And who might those individuals be? It turns out they are people exposed to asbestos from a vermiculite mine in Libby, Mont.
For a decade, Senator Max Baucus, Democrat of Montana, has been trying to get the government to help them. He is in a position to deliver now because he is chairman of the Finance Committee and a principal author of the health care bill.
Working for a 21st consecutive day, the Senate on Sunday pushed toward a final vote on Christmas Eve on the bill, which would provide health insurance for more than 30 million Americans. Democrats said on Saturday that they had secured the 60th vote needed to pass the bill, and a 60-to-40 procedural vote early Monday morning was the first in a series testing their ability to maintain party unity on the issue.
David Axelrod, a senior adviser to President Obama, appeared on television talk shows on Sunday with other White House aides in an effort to reframe the debate and to rally Democrats around the bill. Despite polls that show declining public support for the measure, Mr. Axelrod said it would prove to be popular once people learned more about it.
“People understand we’re on the doorstep of doing something really historic that will help the American people and strengthen our country for the long run,” he said.
Mr. Axelrod said the provisions benefiting specific states, like Nebraska, and favored constituencies were a natural part of the legislative process.
“Every senator uses whatever leverage they have to help their states,” Mr. Axelrod said on the CNN program “State of the Union.” “That’s the way it has been. That’s the way it will always be.”
Republicans said they would resist the legislation with every tool available, and they denounced the deal struck on Saturday. “This process is not legislation,” said Senator Tom Coburn, Republican of Oklahoma, referring to a variety of special-interest provisions. “This process is corruption. It’s a shame the only way we can come to a consensus in this country is to buy votes.”
Mr. Baucus defended the assistance for those affected by the asbestos site in his state. “The people of Libby were poisoned and have been dying for more than a decade,” he said. “New residents continue to get sick all the time. Public health tragedies like this could happen in any town in America. We need this type of mechanism to help people when they need it most.”
Items were inserted into the bill by the Senate majority leader, Harry Reid, Democrat of Nevada, to get or keep the support of various lawmakers. He needs support from all 60 members of his caucus to overcome a Republican filibuster and pass the bill by his self-imposed Christmas deadline.
Senator Ben Nelson, Democrat of Nebraska, was the critical final Democrat to endorse the bill. He obtained tighter restrictions on insurance coverage of abortion, and additional Medicaid money and other benefits for his state.
Another item in the package would increase Medicare payments to hospitals and doctors in any state where at least 50 percent of the counties are “frontier counties,” defined as those having a population density less than six people per square mile.
And which are the lucky states? The bill gives no clue. But the Congressional Budget Office has determined that Montana, North Dakota, South Dakota, Utah and Wyoming meet the criteria.
Another provision would give $100 million to an unnamed “health care facility” affiliated with an academic health center at a public research university in a state where there is only one public medical and dental school.
Senators and their aides said on Sunday that they were not sure who would qualify for this money or who had requested it.
Dr. Atul Grover, the chief lobbyist for the Association of American Medical Colleges, said he believed that Commonwealth Medical College, a new school in Scranton, Pa., was a likely candidate.
Reached at home on Sunday, Dr. Robert M. D’Alessandri, the president of the medical school, said initially, “We meet the conditions” in the Senate proposal. But then he said he was not so sure.
The Senate health bill, like one passed by the House last month, would impose tough new restrictions on referrals of Medicare patients by doctors to hospitals in which the doctors have financial interests. The package assembled by Mr. Reid would provide exemptions to a small number of such hospitals, including one in Nebraska.
Under the original Senate bill, doctor-owned hospitals could qualify for this exemption if they were certified as Medicare providers by Feb. 1, 2010. Mr. Reid’s proposal would move the deadline to Aug. 1, 2010.
Molly Sandvig, executive director of Physician Hospitals of America, which represents doctor-owned hospitals, said the change would benefit Bellevue Medical Center, scheduled to open next year in Bellevue, Neb.
Under the proposal, Ms. Sandvig said, “doctor-owners can continue to refer Medicare patients to the hospital” in eastern Nebraska.
“Senator Nelson has always been a friend to our industry,” she said. “But doctor-owned hospitals in other states were not so fortunate. They would not meet the Aug. 1 deadline.”
Another provision of the bill would increase Medicare payments to certain “low-volume hospitals” treating limited numbers of Medicare patients. Senator Tom Harkin, Democrat of Iowa and chairman of the Senate health committee, said this “important fix” would help midsize Iowa hospitals in Grinnell, Keokuk and Spirit Lake.
Another item in Mr. Reid’s package specifies the data that Medicare officials should use in adjusting payments to hospitals to reflect local wage levels. The officials can use certain new data only if it produces a higher index and therefore higher Medicare payments for these hospitals.
Senate Democrats said this provision would benefit hospitals in Connecticut and Michigan.
Mr. Reid’s proposal also provides additional money to several states to help pay for the expansion of Medicaid to cover many childless adults and parents who did not previously qualify.
Senate Democrats said Saturday that the cost would probably be less than $100 million over 10 years. But the Congressional Budget Office said Sunday that the cost of this provision, benefiting Massachusetts, Nebraska and Vermont, “is approximately $1.2 billion over the 2010-2019 period.” Massachusetts and Vermont have been leaders in providing health insurance to their residents.
Nebraska, with help from Mr. Nelson, won a particularly generous arrangement under which the federal government would indefinitely pay the full cost of covering certain low-income people added to the Medicaid rolls under the bill.
Republicans derided this provision as the “Cornhusker kickback.” And they said it was typical of the favors Democrats had given to Mr. Nelson and a handful of other senators.
“You’ve got to compliment Ben Nelson for playing ‘The Price is Right,’ ” said Senator Richard M. Burr, Republican of North Carolina. “He negotiated a Medicaid agreement for Nebraska that puts the federal government on the hook forever. Not for six years, not for 10 years. This isn’t the Louisiana Purchase; this is the Nebraska windfall.”