Desperately seeking a health-care cure

WASHINGTON — Congress' efforts to overhaul the nation's health-care system have been marred by confusion and a striking lack of consensus, even among the ruling Democrats, despite intense but failed efforts by President Obama and Democratic leaders to craft a plan by early August.

The House adjourned Friday for a five-week summer recess with conservative and liberal Democrats still at odds over the cost and the government's role in any overhaul, putting off a floor vote until at least September.

In the Senate, bipartisan negotiators from its Finance Committee have been unable in weeks of talks to reach agreement on several items, notably how to pay for a $900 billion plan. They anticipate no deal before the Senate adjourns Friday for a month.

Despite the Obama administration's claims that negotiators have reached agreement on 80 percent of any overhaul's terms, some of the most fundamental issues remain unresolved:

• How many of the almost 50 million uninsured Americans will gain coverage?

• How will the $900 billion estimated 10-year cost of any overhaul be paid for?

• How will escalating health-care costs be contained?

The prospects for success this fall are uncertain. Polls show public support for the changes is eroding, and members of Congress face an August back home where interest groups and political parties are mobilizing to air ads, send e-mails and call radio talk shows in bids to build grass-roots pressure behind their points of view.

"I think a lot of these issues are not well understood, and when you don't understand something, you're more susceptible to interest-group pressures," said John Holahan, the director of the Urban Institute Health Policy Research Center.

It wasn't supposed to be this way.

Obama, thinking that pressing Congress to meet a deadline would make lawmakers reach at least tentative agreements, wanted both houses to pass health-care legislation before they left on vacation.

Too many obstacles impeded quick action.

Most obvious was an increasingly wary public. A July 22-26 Pew Research Center survey found that public support for Obama's health-care initiatives is waning.

Forty-two percent approved of his handling of the issue, down 9 points since April, and 43 percent disapproved, up 17 points.

In one especially ominous sign for lawmakers heading home: Of those Americans paying close attention, 56 percent oppose the plans now before Congress.

Lawmakers, especially those from partisan-swing areas, got the message. The Blue Dog Coalition, 52 fiscally conservative House Democrats from largely rural or small-town districts, is balking at what they see as too much government intrusion and out-of-control spending.

The Blue Dogs' struggle with liberal Democrats has been a major reason House legislation stalled.

White House Chief of Staff Rahm Emanuel and other administration officials brokered an agreement last week with four of the seven Blue Dogs on the House Energy and Commerce Committee, which has been writing a piece of the bill.

Then 53 liberal members of the House Progressive Caucus sent Democratic leaders a letter calling the Blue Dog pact "fundamentally unacceptable."

In the Senate, the last hope for a significant pre-recess agreement rested with the Senate Finance Committee's six negotiators, three from each party.

Though they reached tentative agreements on a number of issues, they've had trouble finalizing a way to pay for their $900 billion plan, among other core disputes.

Even if they and the House Democrats agree on separate plans, significant hurdles will remain. House leaders must combine three committees' bills into one.

The Senate has to merge a liberal Health Committee measure with whatever compromise emerges from the Finance Committee, if one does.

If the House and Senate then both pass separate legislation, the next step will be for high-level negotiators to meet and cobble together a single measure, likely with intense White House involvement.

One major roadblock: taxes. House Democratic leaders want to impose a surcharge on families with adjusted gross incomes of more than $350,000. Senators dislike the idea. Instead, they're looking at ways to tax insurance companies that offer pricey policies.

Lawmakers may compromise on taxes but emphasize they must be able to show their constituents they'll get benefits too, that this isn't simply a liberal crusade to help the uninsured.

"More than any other issue, the devil is going to be in the details," said Sen. Olympia Snowe, R-Maine.

Any ultimate compromise would have to go back to each house for final approval.

One ray of hope for Democrats: After Oct. 15, thanks to a change in Senate procedure, a health-care bill would need only 51 votes to pass, not 60.

First, though, lawmakers must get through August's grass-roots rallies.