Oct. 19 (Bloomberg) -- Over the next couple of months, a sausage factory will seem tidier than the U.S. Congress. The disposition of the huge health-care overhaul will be a messy dance of legislation.

There will be more ups, downs, false starts and near deaths than a Bill Clinton or Richard Nixon political drama.

And that may make it harder to do. “The process of putting something together could make it seem more threatening to a lot of people,” says Robert Blendon, a professor of health policy and political analysis at Harvard University in Cambridge, Massachusetts. Nevertheless, he suspects this is a short-term phenomenon if any bill is finally enacted, as the focus then will be on its content.

With the caveats that the shape of the compromises is unclear and the process unwieldy, the leading indicators are:

-- Republican Senator Olympia Snowe remains the single most important member of Congress on this issue. Democrats might be able to pass a bill without her; it will be hard.

-- Rahm Emanuel will be a central figure in crafting any Senate-approved measure and the final bill. The White House chief of staff may have to delegate much of the Afghanistan account and any plans for a stealth stimulus, spending most of his time on health-care deliberations.

Public Option

-- There won’t be a full-fledged government-run program, or public option, though the measure will have a fallback safety net that will put pressure on the private health-insurance industry on premiums and coverage.

-- For all the focus on the public option, ultimately the issue of affordability and how to pay for the overhaul will be more important.

Senate Majority Leader Harry Reid of Nevada is trying to thread the needle between sharply divergent bills and views. The shape of the product he takes to the Senate floor will be crucial; it will take 60 votes, or a supermajority, to make any major changes.

It also will take 60 votes for final passage of any bill. Enter again Snowe. Her support could bring along a couple of other Republicans. More important, she provides politically necessary “bipartisan” cover for more conservative Democrats such as Ben Nelson of Nebraska and Blanche Lincoln of Arkansas.

Moreover, Snowe, whose popularity in her home state of Maine is such that she has few political constraints, genuinely wants a bill. She cares about the substance of the policy.

Just Two Numbers

By contrast, Reid isn’t deep in the specifics. Amid the dazzling array of estimates and numbers that are tossed about, only two matter to him: 60, the number of votes required for passage, and 51, the percentage he needs in a tough re-election struggle next year.

Thus, Emanuel, a master dealmaker who’s steeped in the substance of health care, from his days as an Illinois lawmaker on the House Ways and Means Committee, will have a leading role in patching together the legislation that goes to the Senate floor and any final compromise with the House. President Barack Obama, who has adopted an above-the-fray approach, will have to get down and dirty on the details now.

Emanuel has some heavyweight help from the director of the White House Office of Health Reform, Nancy-Ann DeParle, budget director Peter Orszag and chief congressional lobbyist Phil Schiliro, all versed in both the politics and policy.

Democrats’ Concessions

Their chief task may be to placate liberals -- some of whom are complaining about Snowe’s disproportionate influence -- who will have to make painful concessions to get a bill.

One such compromise will be abandoning a full public option. The backup will probably be a combination of a “trigger” that launches a government program if the private- insurance industry doesn’t meet certain criteria, along with giving states the flexibility for their own form of public plans.

The bigger issues will be affordability, making the overhaul more attractive and then deciding how to pay for it.

Reid and Emanuel will have to appease labor by softening the tax on so-called Cadillac insurance plans. A number of union leaders say too many of their contracts will be affected and plan to oppose the bill unless it’s changed. Raising the threshold, currently at about $21,000 for a family, by only several thousand dollars, would subtract as much as $50 billion in revenue over 10 years. Making that up is tough.

Cost-Cutting

There’s also pressure from Democratic lawmakers on other potentially costly measures. These range from proposals to ease the almost $40 billion in fees on medical device makers to making the government’s insurance subsidy for low-income people more generous.

In the early private talks, there are two major revenue- raisers mentioned to bring in as much as $100 billion. One is to reduce the $81 billion surplus the Congressional Budget Office projects the Senate Finance Committee bill passed last week would raise over the next decade.

The other is to adopt a long-term individual health-care plan promulgated by the late Senator Edward M. Kennedy of Massachusetts, the so-called Class, or Community Living Assistance Services and Supports, Act.

This would enable individuals to voluntarily put a small portion of their paychecks into a government fund that eventually would pick up long-term health care for them. Over the next decade it would raise money both because of the fee and because less would be spent on Medicaid and Medicare.

There may be other avenues to slap taxes or fees on the insurance industry, which is more unpopular than ever on Capitol Hill after it issued several broadsides to the Senate Democratic bills last week.

None of these considerations will be without political peril. Veteran observers have no doubt there will be several doomsday moments and dismiss the notion that everything will be approved and reconciled by Thanksgiving, the target deadline. The odds are a measure will pass -- assuming Snowe stays on board -- with Christmas lights and music in the background when Obama signs it.

To contact the writer of this column: Albert R. Hunt in Washington at ahunt1@bloomberg.net.

Last Updated: October 18, 2009 09:00 EDT