One of the peculiarities of reconciliation is that it is a creation of the 1974 Budget Act and is linked to the annual budget cycle in Congress. It has been used to pass more than 22 tax cuts and deficit reductions over the years.
But the Budget Act specifies that Congress must complete action on its budget resolution by April 15 of each year. Once the budget resolution conference report is adopted by both the House of Representatives and the Senate, its terms govern the remainder of the budget process for that year - meaning no further spending measures can be introduced, including healthcare reform.
Cooperation in Congress ElusiveThe President tried to set the framework for last Thursday's healthcare summit by stressing the common ground legislators and the White House share on the issue, leading with, "The thing is, we basically agree."
Yet somehow the conclave didn't spark a bipartisan breakthrough that would alter the political landscape and allow meaningful health reform to move forward with support from both parties.
Almost every Republican told Obama that lawmakers should start over and draft a new bill - something White House officials have ruled out.
"A step-by-step approach sounds good in theory, but the problem is, we can't solve pre-existing conditions if we don't do something about coverage," Obama said.
The reality is that there is a vast philosophical and policy gulf on health care in Washington. Even though the summit was billed as a fresh start, the stage was already set for a political standoff when Obama last Monday released a new plan based on weeks of negotiation between House and Senate Democrats.
The meeting may have simply put a moderate political polish on what will end up with Democrats force-feeding a bill through Congress that is unlikely to win even one Republican vote.
After asking the Republicans in the room to do some "soul searching" to find a way to work with Democrats on health care, Obama made it very clear that if they do not find a way, Democrats will move forward without them.
That leaves reconciliation as the most likely path to implementing Democrats' version of health care reform.
For a reconciliation bill, no filibusters are allowed. Also, while it usually requires a supermajority of 60 Senators to silence a Senator who's using unlimited debate to hold up a measure, in reconciliation it only takes 51 votes to shut down the process and pass a bill.
But even reconciliation is strewn with obstacles that could cause the effort to collapse.
"This path is fraught with potholes and pitfalls, and we're just going to keep hammering away at it," U.S. Rep. Diana DeGette, D-CO, a key
Hot Button Issues Still ThereObama's plan effectively resolved about 95% of the differences between the House and Senate versions of the legislation passed last year.
The president improved the Senate bill by eliminating controversial kickbacks to a handful of Senators including $300 million in Medicaid relief promised to the state of Louisiana, and more than $22 million to Nebraska. He also delayed the enactment of a tax on high-end "Cadillac" insurance plans offered by some employers.
Still, the plan left disagreements over hot-button issues such as abortion and immigration unsolved.
The less restrictive version of the two bills allows companies operating in the proposed insurance exchange to cover at least some of the costs of abortion. Some conservative members of the House flatly oppose that provision, while members of the pro-choice caucus view it as too weak.
At the same time, some House democrats oppose a provision in the Senate plan that prohibits illegal immigrants from buying insurance in the exchanges, despite the fact they would have to do so with their own money.
The stalemate leaves Democrats with a narrow window of opportunity to move the legislation forward. But even with the aid of reconciliation, it is unclear to many lawmakers exactly what topics can be covered.
Differences between the House and Senate versions of the legislation would be subject to review by Alan Frumin, the Senate Parliamentarian, who will determine what issues can be addressed.
"The first thing that has to happen is we have to clarify what issues can be fixed in reconciliation and what issues can't," said DeGette, laying out what negotiators will likely take up in the coming weeks. "Then we have to see if we have consensus around that plan. Then we have to figure out what other agreements we need to make to fix these other issues, like the abortion issue."
Mid-Term Elections LoomIt remains unclear if the unresolved issues would cause enough Democrats to vote to sink the bill, sending health reform to the legislative graveyard for the foreseeable future.
Without any Republicans on board, Democrat party leaders must persuade their most vulnerable colleagues to vote for a bill that could be used against them in the November elections.
However, White House Office of Health Reform Director Nancy-Ann DeParle said Sunday on NBC's "Meet the Press" that Democrats "will have the votes to pass this in Congress." She added that Obama is ready to use reconciliation and repeated the president's call for "an up or down vote" on reform legislation.
But some observers have their doubts.
House Democrats last year just barely passed their bill. Now, after several retirements and deaths, Democrats have fewer votes they can count in favor of the bill.
U.S. Rep. Jason Altmire, D-PA, voted against the health care bill in the House the first time around and said last week's summit did not make him much more optimistic about the bill's success.
"I don't see very many at all who voted no who are going to switch their votes unless there are substantial changes in the bill," he told the New York Times.
Frumin most likely will interpret the rules to allow easier passage. Yet no matter how much legislative sleight-of-hand the Democrats employ, it will be difficult to pass everything Obama wants in the reconciliation process.
But whatever the legislators decide, the clock is now ticking.
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