Friday night the Senate gave grudging support to a provision in its health reform bill—the so-called CLASS Act, short for Community Living Assistance Services and Support. People concerned about their long-term care needs could voluntarily join a government plan which would allow them to pay premiums during their working careers. If they become disabled, they’d be entitled to a daily cash benefit, say $50, that would allow them to buy services such as a personal care attendant, home improvements that would let them stay at home, or even help pay nursing home costs. That provision, also found in the House bill, would begin to create a national long-term care insurance plan like those found in some other countries.

The vote, fifty-one to forty-seven, kept the CLASS Act in the bill—at least for now. Because they’re expensive—and because sick people, who may be candidates for a nursing home, are often turned away—long-term care policies remain a niche product. That’s why some see the CLASS Act as a baby step toward a public plan to finance long-term care, and insurers aren’t happy about the competition for the business that does exist. This is the other public plan—the one that has received almost no attention from the press or from politicians.

Which brings me to Nebraska Sen. Ben Nelson, who increasingly is becoming the man to watch as the Senate scrambles to pass something—just something—before Christmas. When Nelson appeared a few weeks ago on This Week with George Stephanopoulos, the CLASS Act made a rare appearance, so to speak.

When Stephanopoulos asked the senator about his bottom lines, he replied that he might not vote to get the bill off the floor if the Senate allowed more public funding of abortions than the House bill. He added, though, he might not vote to get it off the floor “because of other considerations as well. Even if that was perfected, where I could support that particular provision, if the public option is wrong, if the CLASS act is still in it, if — if there are a whole host of other items that are the same as they are right now, I wouldn’t vote to get it off the floor.”

In an interview with Greta Van Susteren on Fox last week, Nelson repeated his demands, saying:

The Senate will have to make a lot of changes. The public option would have to be changed dramatically or dropped from the bill. The CLASS Act, which is the community living assistance program, that the CMS actuary said will be financially upside down in a very short period of time, that needs to be out of the bill.

He also told Van Susteren that there were “a whole host of other issues, such as the tax on medical devices, the tax on insurers, that are nothing more than a sales tax on policyholders” that bothered him. That puts the CLASS Act and Nelson squarely in the middle of the abortion fight, and Nelson said the need for stronger anti-abortion language in the Senate bill is “non-negotiable,” and he would filibuster the bill without it. All of which raises the question: Which one of his demands will be part of the horse trading eventually to follow? And where will the lobbying pressure come from—single-payer advocates, who having lost on their main issue, have turned to abortion as their cause du jour? The Omaha World-Herald, which published two scathing editorials urging him to vote to stop the health reform legislation? The insurance industry?

Before he turned to politics, Nelson was an insurance lawyer, CEO of the Central National Insurance Group, executive vice president of the National Association of Insurance Commissioners, and director of the Nebraska Department of Insurance. The last two jobs put him in a perfect position to understand the concerns of the industry. The press hasn’t talked much about his insurance bona fides, and they haven’t talked much about Nelson until the last couple of weeks.

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