President Barack Obama has laid out the path for Democrats' last-ditch effort to save health care reform, and despite some relief among lawmakers that a final strategy is set, it's almost certainly headed for a white-knuckle finish.
The sticky choices faced by Democratic Reps. Betsy Markey of Fort Collins and Diana DeGette of Denver show the hurdles confronting House leaders as they try to wrangle the votes to approve the Senate version of the bill, then fix key elements through a maneuver known as reconciliation.
By some measures, the path should be clear: Health care reform is Democrats' biggest domestic priority, and many experts say failure to pass it could be a disaster for the party going into the 2010 elections.
"At stake right now is not just our ability to solve this problem, but our ability to solve any problem," Obama said.
But after nearly a year of acrimonious debate, health care reform is not going to live or die by the big picture, but by the fine-grain calculations of individual lawmakers in what may be one of the most difficult votes of their careers.
As co-chair of the Pro Choice Caucus and a fierce abortion-rights advocate, DeGette is facing strong pressure from national groups not to approve a health care bill with the current language restricting insurance coverage of abortion contained in the Senate bill -- but the reconciliation process allows no clear way to change it.
"Our bottom line is fix it," said Nancy Keenan, president of NARAL Pro-Choice America. "We have tremendous champions in the House, Diana DeGette being one of them. And we expect, whether at this stage or another stage, that they get the job done."
A vulnerable Democrat
Markey, who declined requests to be interviewed for this story, is a vulnerable Democrat who last year voted against a reform bill viewed skeptically by moderates and conservatives in her Republican-leaning district.
But that vote has cost her dearly with party loyalists back home, and she's now squeezed between the unpleasant prospect of alienating either her base Democratic voters or the independents she'll need in a tough 2010 fight.
"She is in a challenging district, I understand that," said Alan Phipps, a Fort Collins Democrat who volunteered for Markey's 2008 campaign. "But if I was her, I would rather be a one-term congressman and do the right thing than do the wrong thing and get elected."
The fate of health care now largely hangs on the calculations of conservative Blue Dogs such as Markey and lawmakers, like DeGette, who have drawn a line in the sand around the bill's treatment of abortion.
While the political drama around health reform focused for much of the last year on passing the bill through the Senate, the tables have turned.
House Speaker Nancy Pelosi has for weeks struggled to overcome the deep unease many in her caucus have toward the Senate version of the bill, which under the reconciliation process now becomes the template.
Under the current strategy, the House must first pass the Senate bill, then both chambers will approve a small number of jointly agreed fixes. Reconciliation allows the changes to be made with a simple majority of 51 votes in the Senate but restricts changes to budget-related provisions.
The distrust between Democrats in the House and Senate has become so intense that some House members want at least 51 senators to sign a letter agreeing to the fixes ahead of time. Those include delaying implementation of a tax on high-cost, "Cadillac" health plans and removing some of the controversial side deals that benefited the states of swing-vote senators such as Sen. Ben Nelson of Nebraska.
"Maybe an oath in blood"
"Maybe pinkie swearing by the senators. Maybe an oath in blood," DeGette said. "But I don't think a verbal commitment by (Senate Majority Leader) Harry Reid is enough to get the votes in the House for a process like that."
But even then, the plan could easily go wrong, starting with a tangle over abortion.
The House passed health care reform in November by a five-vote margin, with at least 12 of the "yes" votes coming from lawmakers who now say their assent was contingent upon restrictions on the way policies in the exchange covered abortion -- restrictions dropped in the Senate version.
DeGette, on the other hand, has said that at least 40 lawmakers who voted "yes" not only see the tougher restrictions as unacceptable, many may not even accept the compromise language now in the Senate bill.
Since the abortion provisions aren't budget-related, any fix would require an agreement by the White House to push entirely separate legislation, complicating things further.
"I want to vote for the bill," DeGette said. "I helped write the bill. But the one thing we have learned is that we can fix a lot of things later, but if you really give up a woman's right to choose, you can't fix that later. That's gone."
Convincing some to switch
Pelosi will have to make up votes lost on the abortion issue by persuading lawmakers who voted against the bill the first time to switch, Markey possibly among them.
Markey, who this week gave no indication of where she was leaning, released only a brief written statement Thursday.
"We don't yet know what the House may be asked to vote on in the coming weeks, but when we do I'll look at that bill like I look at every bill that comes up in the House -- through the eyes of a Colorado small businesswoman," she said.
That belies the difficulty of a vote that analysts say is likely to cost her significantly either way.
"I can tell you that I've heard from a lot of people who volunteered for her and contributed to her who said at the time of her first vote on health care, 'That's it. What did I work so hard for if she is just going to vote like a Republican?' " said Robert Duffy, a political scientist at Colorado State University in Fort Collins.
"But who knows," he added, "maybe they've concluded that the Democratic base is going to be depressed anyway and that historically the in party always loses seats in a midterm. So the way to go is to appeal to as many moderate voters as possible and fiscal conservatism is the way to do it.
"Either way, it's a gamble."