WASHINGTON — Despite the strains of sky-high costs and public skepticism, the government is moving steadily toward a vast health care overhaul that would at least partly fulfill a six-decade quest for universal coverage and could rein in soaring costs for everyone else.
The White House is ramping up its behind-the-scenes lobbying of Congress. President Barack Obama is signaling that he could drop some key principles of his campaign if necessary to jump-start negotiations, opening the door to broad tax increases and a plan that could, he now concedes, push people into a government-run insurance program against their will. Senate Democrats also said this week that they were heading toward agreement again after a momentary stall.
"We have a lot of hard slogging to go, but . . . I think that we are in good shape," White House Chief of Staff Rahm Emanuel said Thursday.
Republicans, too, concede that the Democrats who control Congress and the White House are back on track to push an overhaul into law.
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"They're going to be pushing their version of reform through. And they probably will get it done by the end of the year," said Rep. Paul Ryan, R-Wis. "Unfortunately, it doesn't look like it's going to be a bipartisan health care reform, or the kind that we've been proposing, because Democrats, quite literally, they have the votes."
The votes? Probably. The details? Not quite yet.
Two big questions still loom: How will the government pay for insurance for the 50 million people now uninsured, and will the government offer its own insurance to compete with 1,300 private insurance companies in hopes of driving down costs?
Obama thinks he's found a way to pay for almost all of a price tag estimated at $1 trillion over 10 years: by cutting Medicare and Medicaid and by raising taxes on those making more than $250,000 a year through limits on their itemized tax deductions.
Many congressional Democrats prefer to raise taxes on health insurance itself, however, which is now deducted from taxable income.
Some propose capping the deduction at $13,000 to $17,000 a year, so that the most expensive plans would be taxed and even discouraged.
Obama, who opposed taxing health coverage when Republican John McCain proposed it during their campaign, now says he's open to some version of it.
"I continue to believe that's not the best way to do it," Obama said at a White House town hall meeting this week. "But I think there are people in good faith who are saying a cap would at least prevent these 'Cadillac' plans that end up having people over-utilizing the system. . . . I'm pushing my idea. Other folks are pushing their ideas. There's going to have to be some compromise at the end of the day."
Some of his allies don't like that.
"Six months after he's sworn in to office, to say, 'I changed my mind on this,' is wrong," independent Vermont Sen. Bernard Sanders said. "It's a regressive way to raise revenues."
Congressional Democrats also are debating whether to include a so-called "public option," which would be a government program akin to Medicare available to everyone.
Supporters say it would create competition and drive down costs; critics say the government plan, with no profit margin and perhaps taxpayer subsidies, would drive private insurers out of business.
For the first time, Obama conceded this week that the availability of lower-cost government insurance could violate one of his keystone promises: not to force people to give up doctors or insurance plans they like. He acknowledged that companies providing health insurance might choose the less expensive government insurance over their private insurers, thus forcing employees into the government fold.
"When I say . . . you have a doctor and you like your doctor, that you don't have to change plans, what I'm saying is the government is not going to make you change plans," Obama said at a White House news conference.
Obama clearly wants the government insurance option.
"The president has made it pretty clear he . . . feels very strongly that having a public option to compete with private insurers is the best way to cost containment," Health and Human Services Secretary Kathleen Sebelius said Friday.
That feeds complaints from opponents that the Democratic plan would lead eventually to most Americans getting insurance from the government.
'We don't need a board in Washington deciding what treatments are appropriate for patients," said House Minority Leader John Boehner, R-Ohio. "We don't need government bureaucrats to get in between the relationships between doctors and their patients, and we certainly don't need to raise trillions of dollars of new taxes to pay for this government-run option."
The government insurance option isn't yet final, however. Several Senate Democrats propose instead that nonprofit cooperatives also could provide competition and drive down costs.
As Obama works to build public support for an overhaul, he's leaving it to Congress to work out details, albeit with aides such as Emanuel and chief congressional lobbyist Phil Schiliro in contact with Congress to make sure things stay on track. White House lobbyists sit in on hearings and congressional negotiations. Emanuel, Sebelius and White House health care adviser Nancy-Ann DeParle met at the Capitol this week with Senate Democrats from key committees.
DeParle also has been meeting with others, notably Sen. Olympia Snowe, R-Maine, one of the three Republicans on the Senate Finance Committee who've been trying to craft a compromise on funding.
"We've let the legislators play their role of being legislators and drafting the bill, working through some of the issues, weighing in, putting our thumb down on the scale where they've hit some of the difficulties and the rough patches," Emanuel said.
The White House doesn't want to tell Congress what to do, he stressed, a lesson from the failed health care effort in 1993-94 when Bill Clinton was president and Emanuel was a top aide.
This time, he said, "we didn't kind of come with a prescriptive: 'Here is our tune, here it is, here's health care reform. Now could you mark it up and go pass it?' That's just not the way the process works, nor is it productive to letting the process work."
That's fine with Sen. Christopher Dodd, D-Conn., who's chairing the health committee in the absence of Edward Kennedy, D-Mass., who's battling cancer.
"I don't want a repeat of 1993," Dodd said. "At various points he will need to get involved. And at various points he will need to get uninvolved."
(David Goldstein and Margaret Talev contributed to this article.)
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