WASHINGTON — The expected approval of the Senate Finance Committee’s health care bill may have brought reform closer to the end of the beginning than the beginning of the end.

The panel’s passage of the bill, which appeared imminent at presstime, left obstacles to the enactment of legislation that ranged from small details to major hurdles. Republicans remain entrenched in opposition, and without their support Democrats will have to produce 60 Senate votes to block a possible GOP filibuster. There is also the matter of reconciling two reform bills in the Senate and three in the House.

For its part, the National Association of Chain Drug Stores is urging Congress to include medication therapy management (MTM) provisions in reform. MTM is seen as a way to improve patient care and health outcomes through medication adherence and counseling, preventing more costly forms of care over the long term.

In addition, NACDS has urged lawmakers to restructure the Medicaid pharmacy reimbursement system. Under current law and subsequent rules from the Centers for Medicare and Medicaid Services, the government estimates that pharmacies would be paid 36% below cost for many generic drugs for Medicaid patients.

Four years ago, the Deficit Reduction Act mandated the average manufacturer price as the benchmark for payment to pharmacies for generics. The law would decrease Medicaid reimbursements to pharmacies by $8.5 billion for over five years ­— a 30% cut.

A preliminary injunction from a lawsuit filed by NACDS and the National Community Pharmacists Association has temporarily blocked the cuts. Pharmacy advocates are urging lawmakers to permanently change the system to maintain health care access for millions of disadvantaged Americans.

“Pharmacies are essential to health care delivery every day, and the current H1N1 situation is yet another example of just how true that is,” says NACDS president and chief executive officer Steve Anderson. “Pharmacies are integral to the national H1N1 vaccination strategy, and this demonstrates that the accessibility of pharmacy should be tapped, and not jeopardized through damaging policies.”

Other issues that have come to the fore include the major House and Senate bills’ mandate for most Americans to have insurance. This could spark public wrath, especially if fines for violations are collected by the Internal Revenue Service.

Whether the government should force employers to provide workers’ health benefits is also still at issue. Such a requirement is favored by liberal Democrats and opposed by Republicans, with moderate Democrats undecided.

Funding for the legislation, which is projected to cost about $900 billion over a decade, is another point of contention. The House has proposed a surtax on the wealthy, while the Senate favors a levy on expensive insurance plans.

Democrats are split over the “public option” — government insurance that would compete with private plans. The more liberal House will probably include a public plan in its bill, while the Senate is likely to exclude it.

As the finance committee vote neared, Democratic members were optimistic, with Sen. Kent Conrad of North Dakota saying he had a “solid feeling” about the legislation’s direction.

Conrad also said he was still hopeful of Republican support, noting that the committee’s bill excludes a public option, an employer mandate, benefits for undocumented aliens and federal funding for abortion — which are anathema to many in the GOP.

But Republican Senate leader Mitch McConnell of Kentucky said the final bill would “raise hundreds of billions of dollars in taxes on individuals and businesses. And it’s going to expand the government’s role in the health care of every single American, whether they like it or not.”