Barack Obama, Health Care Reform

OBAMA FOR USA. Mr. Obama's 2009 budget shows the scope of his ambitions on health care reform, a campaign pledge. It asks Congress to set aside more than $600 billion as a down payment on efforts to remake the health care system over the next decade. But Mr. Obama has left the overhaul -- and its hard details -- to the Democrats who control both houses of Congress.

The leaders of the major Congressional committees dealing with health have agreed on a broad outline and have won some concessions from the insurance industry. The resulting health-care bill would almost surely create a new public health insurance program, to compete with private insurers. It would require employers to provide insurance to employees or contribute to its cost. Employers who already offer insurance could be required to provide more or different benefits.

Some powerful Democrats, including Senator Max Baucus, the chairman of the Finance Committee, and Rep. Charles B. Rangel, head of the Ways and Means Committee, balked at Mr. Obama's proposal to pay for the expansion of health care by imposing limits on tax deductions taken by some high-income households. The White House has indicated willingness to consider alternatives, including taxing employee health benefits, even though that position was espoused by Mr. McCain during the presidential campaign, and sharply criticized then by Mr. Obama.

To fulfill Mr. Obama's promise of reform, though, Democrats may have to resort to reconciliation, an obscure procedure that allows budget bills -- in this case, including provisions concerning the financing of health care -- to pass by majority vote, without the threat of a filibuster. Mr. Emanuel said the possibility of going that route might be an important cudgel to persuade more Republicans to enter into serious negotiations over the bill.

Doctors, hospitals, drug makers and insurance companies joined Mr. Obama on May 11 to announce their commitment to a sharp reduction in the growth of national health spending. The plan could save $2,500 a year for a family of four in the fifth year and a total of $2 trillion for the nation over 10 years. That could make it less expensive for Congress to enact comprehensive health insurance coverage.

The president is preparing a push for health care legislation that will include speeches, town-hall-style meetings and much deeper engagement with lawmakers.

He also staked out more specific positions on key issues than he had before, saying in a letter to legislators that he favored the creation of a government-run insurance plan and that all individuals should be required to buy insurance unless they can't afford it. He also supported a requirement that businesses offer insurance or contribute to a fund to make it available, with exemptions for small businesses facing "special challenges.'' The proposals for a public plan and the so-called "pay or play'' requirement for businesses have been vehemently opposed by Republicans.

As the health care debate heated up, the American Medical Association let Congress know that it will oppose creation of the government-sponsored insurance plan, which Mr. Obama and many other Democrats see as essential. The opposition, which came as Mr. Obama prepared to address the powerful doctors' group on June 15 in Chicago, could be a major hurdle for advocates the plan. The A.M.A., with about 250,000 members, is America's largest physician organization.

The White House said on June 14 that President Obama intends to pay for his health care overhaul partly by cutting more than $200 billion in expected reimbursements to hospitals over the next decade - a proposal that is likely to provoke a backlash from cash-strapped medical institutions around the country.

Mr. Obama, in closed-door talks, has been making the case that reducing malpractice lawsuits - a goal of many doctors and Republicans - can help drive down health care costs, and should be considered as part of any health care overhaul, according to lawmakers of both parties, as well as A.M.A. officials. It is a position that could hurt Mr. Obama with the left wing of his party and with trial lawyers who are major donors to Democratic campaigns. But one Democrat close to the president said Mr. Obama, who wants health legislation to have broad support, views addressing medical liability issues as a "credibility builder" - in effect, a bargaining chip that might keep doctors and, more important, Republicans, at the negotiating table.

Republicans continued to express strong concerns over the Obama administration's plan for a public insurance option. "I think that, for virtually every Republican, a government plan is a non-starter," Senate Minority Leader Mitch McConnell said on CBS's "Face the Nation" on June 14. "We know that, if the government gets in this business, pretty soon nobody else will be in the business."

On July 14, Mr. Obama told critics who think he has lost momentum in his bid to overhaul health care: "Don't bet against us." He moved aggressively to reclaim control of the health care debate, summoning top Democrats to the White House to urge them to stick to his legislative timetable - he wants the House and the Senate to pass bills before the August recess. The next day, voting on strict party lines, the Senate Health, Education, Labor and Pensions Committee approved a bill to revamp the system, as Democrats said that the legislation held the promise of more universal health coverage and more effective and affordable medical care while Republicans argued that the measure was unaffordable and would lead not to better care but to the denial of it.

That same day, after a meeting of Finance Committee Democrats, the senators emerged to say that, despite pressure from the White House, they would not be bound by deadlines, including the president's insistence that bills be completed before the summer break. Senator Charles E. Schumer of New York, the No. 3 Democrat in the majority leadership, said that efforts to broker a bipartisan deal with Republicans remained on track and that Democrats had no intention at this point of pushing health care legislation on their own.