Democrats Clinch a Deal on Health Bill

WASHINGTON — Senate Democrats said on Saturday that they had clinched an agreement on a far-reaching overhaul of the nation’s health care system, and that they were on track to approve the legislation by Christmas over fierce Republican opposition.

As the Senate convened in a driving snowstorm, Democratic leaders said a breakthrough came when Senator Ben Nelson, Democrat of Nebraska, agreed after 13 hours of negotiations on Friday to back the bill, making him the pivotal 60th vote.

“Change is never easy, but change is what’s necessary in America,” Mr. Nelson said during a morning news conference. “And that’s why I intend to vote,” he said, “for health care reform.”

If Senate Democrats could win passage of their bill, it will need to be reconciled with a version adopted last month by the House, and Mr. Nelson issued a pointed warning that he would vote against the measure if any changes were not to his liking.

Because the Democrats nominally control 60 seats in the Senate — the precise number needed to overcome Republican filibusters — every senator in the Democratic caucus effectively has veto power over the bill. No Republican is willing to support it.

The legislation, the most sweeping overhaul of the nation’s health care system in more than a generation, seeks to extend health benefits to more than 30 million uninsured Americans by expanding Medicaid and providing subsidies to help moderate-income people purchase private insurance.

The bill also imposes tight new regulations of the health insurance industry, barring insurers from denying coverage based on pre-existing medical conditions and limiting how much extra they can charge for people based on their age.

The majority leader, Harry Reid of Nevada, racing against the clock to complete the bill by his self-imposed holiday deadline, introduced a 338-page package of last-minute amendments, including the key provisions needed to win Mr. Nelson’s support.

Republicans, who vowed to use every procedural weapon to stop the bill, immediately forced a reading of the Mr. Reid’s, which was expected to take 10 hours and had to be done by midnight to keep Democrats on track for a final vote on Christmas Eve.

Mr. Reid’s amendment includes tighter restrictions on insurance coverage for abortions sought by Mr. Nelson. Health insurance plans would not be required or forbidden to cover abortions, but states could prohibit the coverage of abortions by plans that are offered for sale through new government-regulated marketplaces.

The amendment also includes a special extension solely for Nebraska: increased federal contributions to the cost of an expansion of Medicaid, the state-federal insurance program for the poor.

Mr. Reid introduced his amendment after the Senate easily approved and sent to President Obama a $626 billion defense spending bill in an extraordinary session that began before sunrise, and reflected the increasingly toxic atmosphere in a chamber that normally prides itself on decorum.

Despite the 88-to-10 vote, the Pentagon bill was the focus of some angry partisanship.

Republicans, who typically vote in unison for defense spending measures especially at a time when the country is fighting two wars, tried to derail the bill this week in an effort to throw yet another roadblock in the path of Democrats on health care.

The year-end spending measure also included a two-month extension of jobless pay and health coverage for the unemployed.

The snow flying outside the Capitol added to what has already been a chaotic few weeks for the Senate, which has met every day since Nov. 30 and was convened for the third consecutive weekend.

The sergeant-at-arms had four-wheel drive vehicles at the ready to bring senators in for votes. And while senators wore the jackets and ties required on the Senate floor, dress shoes gave way to snow boots. Senator Robert C. Byrd, Democrat of West Virginia, who is 92 years old and uses a wheelchair, received an ovation from colleagues when he arrived in the chamber.

Republicans remained deeply opposed to the health care legislation. Senator Olympia J. Snowe, a Maine Republican who had been considered a possible Democratic ally, said she would oppose the measure, saying it was being rushed through.

“It is a take-it-or leave it package,” she said.

Senator Richard Burr, Republican of North Carolina, said that Democrats would pay a political price.

“The lines are drawn,” Senator Burr added. “He has to get 60 votes. If he doesn’t get 60 votes, the American people win. If he does get them, America’s payback will come in the form of the 2010 elections.”

At the core of the deal to win Mr. Nelson’s was an agreement on the emotionally charged issue of insurance coverage for abortions. Mr. Nelson wanted tight restrictions, but an amendment that he proposed to add them to the bill was defeated by his Democratic colleagues who support abortion rights.

Under Mr. Reid’s amendment, states would have the authority to bar coverage for abortions by new government-approved health insurance plans.

A section of the bill titled “state opt-out of abortion coverage” explains how this would work: “A state may elect to prohibit abortion coverage in qualified health plans offered through an exchange in such state if such state enacts a law to provide for such prohibition.”

Some health plans receiving federal subsidies could offer coverage for abortion, but they could not use federal money to pay for the procedure. They would have to use money taken from premiums paid by subscribers and would have to keep it separate from federal money.

The government would subsidize premiums for many low- and moderate-income people. Under Mr. Reid’s amendment, some health plans receiving federal subsidies could offer coverage for abortion, but they could not use federal money to pay for the procedure. They would have to use money taken from premiums paid by subscribers and would have to keep it separate from federal money.

State insurance commissioners would police the “segregation of funds.”

Two of the senate’s champions of abortion rights, Senators Barbara Boxer, Democrat of California and Patty Murray, Democrat of Washington, issued a joint statement, saying they were satisfied with the agreement.

“We said all along that we wanted to ensure there was a firewall between private and public funds — this compromise achieves that,” they said. “We said we would not accept language that prohibited a woman from using her own private funds for her legal reproductive health care – this compromise meets that test.”