House Speaker Nancy Pelosi and other senior Democrats told President Barack Obama in recent meetings they want the legislation to strip the insurance industry of a long-standing exemption from federal antitrust laws, officials said. That provision is in the House-passed measure, but was omitted from the bill that the Senate passed on Christmas Eve.
They also want the final measure to include a House-passed proposal for a nationwide insurance exchange, to be regulated by the federal government, where consumers could shop for private coverage. The Senate bill calls for a state-based system of exchanges.
Additionally, House Democrats want to require insurers to spend a minimum amount of premium income on benefits, thereby limiting what is available for salaries, bonuses, advertising and other items. The House bill sets the floor at 85 percent; the Senate-passed measure lowers it to 80 percent for policies sold to small groups and individuals.
The officials spoke on condition of anonymity because the negotiations are private.
The maneuvering comes as the White House and majority Democrats intensify efforts to agree on a final measure, possibly before Obama delivers his State of the Union address late this month or early in February.
Government intervention into the insurance market is one of the most contentious Liberals long have pressed to include a government-run insurance option in the legislation, arguing it would create competition for private companies and place a brake on costs.
House Democrats included it in their legislation. In the Senate, it drew opposition from Democratic moderates whose votes are essential to the bill's fate. Even attempts to include an expansion of Medicare for uninsured individuals as young as age 55 - widely viewed as a face-saving proposal for liberals - had to be jettisoned.
Given the opposition in the Senate, Pelosi, (D-Calif.) signaled late last year she did not view a public option as a requirement for a final compromise. Asked in an interview Dec. 16 whether she could support legislation without it, she said, "It depends what else is in the bill."
More recently, she listed her goals for a House-Senate compromise without mentioning the provision she long has backed.
"We are optimistic that there is much that we have in common in both of our bills and that we will resolve or reconcile this legislation in a way that is a triple A rating: affordability for the middle class, accountability for the insurance companies and accessibility to many more people in our country to quality, affordable health care," she said.
While Obama favors a government option, he has said repeatedly it is only a small part of his overall effort to remake the health care system, and is not essential.
Pelosi and Senate Majority Leader Harry Reid (D-Nev.) have expressed optimism about chances for a swift agreement, but there appears to be relatively little maneuvering room. That is particularly true in the Senate, where 60 votes will be needed to overcome a Republican filibuster, and any change carries the risk of alienating a Democrat whose vote is crucial.
The bill's future is further complicated by a scheduled Jan. 19 election in Massachusetts. Some polls show Democrat Martha Coakley in a closer-than-expected race against Republican Scott Brown and an independent contender.
A Republican upset would deprive Democrats of their 60th vote.
Some House Democrats say the proposed government insurance option remains alive, although they speak publicly of its possible demise as long as insurance companies aren't let off the hook.
California Rep. Xavier Becerra, who's on the leadership team, said House members would only be willing to abandon the public plan if they were certain the final bill achieves the goals they want, as Pelosi described.
"We're willing to give up what's good for America as long as we get something good back," he said.
Rep. Chris Van Hollen of Maryland, also a member of the leadership, agreed.
"I think the House is very much of a view that before they'd consider dropping the public option" they have to be assured of a bill that achieves the goals they wanted the public option to meet.
But officials said little if any time has been spent in White House meetings on the issue, and there was scant discussion of it during a conference call for members of the Democratic rank and file earlier this week.