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President Obama was in Ohio on Monday to give his third campaign-style, outside-the-Beltway health care overhaul sales pitch in the past half-dozen days.

But back in Washington, the furious action was behind the scenes, as Democratic leaders continued their desperate arm-twisting for health care’s too-close-to-call end game. And interest groups shoveled millions of dollars into last-ditch efforts to influence the outcome of the historic bill.

That outcome, which hinges on a key House vote expected later this week, remained wildly uncertain.

“Everyone knew it was going to be a nail-biter going into this,” says health analyst Alec Vachon. “It’s now all about vote wrangling.”

By The Numbers

To pass the health care overhaul, Democratic House Speaker Nancy Pelosi has to persuade at least 216 of her 253-member caucus to support the version of health care legislation that the Senate approved last December.

Among her formidable challenges: convincing recalcitrant House Democrats who find aspects of the Senate bill unpalatable that a subsequent smaller, so-called fix-it bill – known as reconciliation – will ultimately pass both chambers with at least some of their desired changes.

Health care overhaul advocates are banking on Pelosi’s powers of persuasion, as well as those of the president, to move enough Democratic fence-sitters to get to the magic 216 majority number.

Most vote counters say that as of Monday, Pelosi is still around a dozen votes short.

“There’s a path to victory for the Democrats, but a lot of things will have to go right,” says David Dayen, a blogger with the progressive Web site Firedoglake.

Dayen, who has been closely tracking the votes, says that Obama, Pelosi and Democratic leaders will have to persuade at least a half-dozen Democrats who voted “no” on the House version of health care legislation last fall to support the Senate version.

“That’s a tall order,” Dayen says.

One of those original “no” votes belonged to Ohio Rep. Dennis Kucinich, a hero to progressives who favors universal health care. He voted against the House bill last November because he said he viewed it as a sellout to Wall Street and the insurance companies.

Kucinich has said he’ll vote no again this week. And it just so happens that on Monday, Obama not only delivered his speech in the heart of Kucinich’s district but also met privately aboard Air Force One with the congressman and Ohio Rep. Marcia Fudge, who has not committed her vote.

Oddsmakers, no doubt, will be watching the two closely in coming days.

Also watching the horse trading for votes are investors who participate in the prediction market Intrade, which on Monday listed Obama’s health care legislation with a 70 percent chance of passing by June. That represents a significant increase from early this month, when it was listed with around a 30 percent chance.

High-Stakes Wooing

Private Air Force One meetings, behind-the-scenes deals, promises of something back home – the art of individual vote corralling takes many forms.

“It’s like romance – you say different things to different people,” says Vachon, the president of Hamilton PPB, which provides health policy advice to corporations and investors.

Vachon recalls that during the heated 2008 debate over the Bush administration’s Medicare prescription drug plan, he asked a member being courted by the White House whether he had asked for money for a bridge to be built back in the member’s district.

“He told me, ‘We don’t have a river,’ ” Vachon said. “I told him, ‘Hey, you could get that, too – go large!’ ” 

He was only half-joking.

There are at least a dozen House members who don’t like language in the Senate health care bill that limits federal spending on abortions because they believe it is weaker than House-approved language included in the so-called Stupak amendment.

But though Michigan Rep. Bart Stupak, who fashioned the amendment, has said that he’ll be a “no” vote this week, it appears that there are a handful of other Stupak amendment supporters who are moving to the “yes” category.

“It looks like Rep. Stupak is losing members. He said he had 12, but I only count six now as a firm ‘no,’ ” Dayen says. “And four or five are on the fence.”

Under the rules of reconciliation, Democratic leaders aren’t allowed to change the Senate’s abortion language because it doesn’t involve the budget. Instead, party leaders have been working to convince Stupak coalition members that the upper chamber’s abortion coverage provisions aren’t appreciably different than the House language.

But it leaves open the question of what promises Democratic leaders are making to sway members of Stupak’s coalition.

Vachon is among those who have long said that they believe Pelosi will find the votes – though he’s not sure how.

“This could be an epic fail – where she gets just 202 votes,” he says. “Or there could be the crowd effect” that will bring her a winning majority.

The Politics Of ‘No’

Still, the bottom line for many nervous House Democrats is how their health care vote will play back home in advance of the November elections.

And, of course, it depends on their district.

For some, voting against the health bill after they voted for it won’t win them any credit from opposition Republicans or the Tea Party movement. For others, pressure is being brought to bear by progressives and unions talking about backing potential primary challengers to Democrats who oppose the health care measure.

“There is a lot of pressure from all sides,” Dayen says.

Just ask Kucinich.

When Obama introduced Kucinich at Monday’s event, an audience member called out: “Vote yes!”

To which Obama replied: “Hear that, Dennis?”

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Rep. Nancy Pelosi, D-Calif., walks out of January’s Democratic Caucus meeting on health reform. Democrats are showing increasing resolve to pass legislation using a maneuver known as reconciliation. But first, Democrats need to settle disputes within their own party over a handful of reform issues. (Mark Wilson/Getty Images)

Congressional Republicans are scheduled to join President Obama and Democratic leaders Thursday for a six-hour televised summit on the White House’s stalled drive for a national health care overhaul.

But it’s increasingly clear that the only bipartisan compromise expected to emerge at Blair House is over who gets to sit where at the big table.

Indeed, the compromise that most of Washington is focused on now will be post-summit – and within the ranks of a fractious Democratic caucus that’s trying to navigate a route to health care legislation.

After all, Republicans have doubled down on their criticism of the Democrats’ initiatives and continued calls for a complete legislative do-over. Meanwhile, Democrats are showing increasing resolve to push their legislation through with a maneuver known as reconciliation that would require no GOP votes, just simple majorities in the Senate and House.

But before that can happen, Democrats need to resolve bitter disputes within their own party over a handful of overhaul issues. The major areas of intracaucus contention include not only abortion and benefit plan taxes, but the process of reconciliation itself. Here’s a breakdown of some of the key sticking points:

Abortion: What would a health care debate be if it didn’t include a battle over abortion? The House bill carries a provision pushed by about a dozen anti-abortion Democrats – and excoriated by pro-choice members – that would prevent individuals from using federal subsidies to buy insurance plans that offer abortion coverage.

The Senate bill would allow subsidies to be spent on insurance plans that include abortion coverage. But women would be required to personally pay the company for the specific cost of abortion coverage. (Federal law restricts public funding for abortion.)

Though the differences appear negligible, and Obama’s plan didn’t wade into the issue, anti-abortion House Democrats say they can’t support the Senate version. House Speaker Nancy Pelosi’s people insist that they’ll muster a majority nonetheless.

Budget Reconciliation: Reconciliation is a parliamentary procedure that allows legislation written as a budget bill to pass through the Senate with a simple majority, preventing minority party filibuster. Once seen as a distant and not-very-palatable option to use to pass comprehensive health care, Democrats – including Majority Whip Dick Durbin of Illinois – have said that Senate leaders are preparing to use the maneuver. A number of Democrats facing re-election in the fall have resisted the path, fearing a backlash at the polls.

But many Democratic skeptics began warming to the notion after Democrats lost their 60-vote Senate supermajority when Republican Scott Brown was elected in Massachusetts. However, the use of reconciliation still needs to be sold – particularly to moderate House members – and it must be done at a time when Republicans have ratcheted up rhetoric surrounding the procedure, used by both parties in the past.

Public Option: A public insurance option is one created by the government and offered to the uninsured as an alternative to private coverage. Though declared dead by the White House, the public option contained in the House bill still has its dogged advocates in the Democratic caucus.

To wit: Twenty-three senators signed a letter urging party leaders to include the option in a reconciliation bill. But when Pelosi, a longtime supporter, acknowledges there aren’t enough Democratic votes in the Senate to pass a public option, the give-and-take may simply give succor to the party’s liberals, but it won’t end in compromise.

Says West Virginia Sen. Jay Rockefeller, a strong proponent of a public option: A diminished public option just isn’t worth the political fight.

Cadillac Tax: Labor unions were furious when the Senate approved a version of the health overhaul bill that included a tax on high-cost insurance plans – including those often awarded in collective bargaining. House leaders were none too pleased, either.

So when Obama unveiled his plan this week, presto! Under his proposal, the tax would be delayed until 2018, and he also bumped up the value of plans that would be taxed – benefiting both union and nonunion holders of benefits-rich plans.

But House Democrats want the tax provision excised from the Senate bill, which forms the basis of the reconciliation legislation, before it comes to the House for a vote – and that could complicate its path. Republican Sen. Judd Gregg has asserted that if the Senate legislation is altered, it would have to be put to a new vote in the chamber.

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Democrats have been showing a fresh determination to make Republicans’ near-unanimous opposition to a national health care overhaul – and its implications for women – the GOP’s Achilles heel during next year’s midterm elections.

Democrats have produced a hit list of 32 House Republicans from districts that voted for President Obama last year. And they’re touting a video of Republican men repeatedly interrupting Democratic women during Saturday’s House floor debate on health care.

But that tactic just got a lot more complicated.

There is growing outrage among the Democrats’ own activist base over new and far-reaching abortion restrictions contained in the historic health care bill approved Saturday by the Democratic-controlled House.

And some of the party’s staunchest supporters are suggesting that Democrats will have their own problems with health care – and women voters – come 2010 because of the proposed abortion limits and the Catholic Church’s pivotal role in ensuring that restrictions would make it into the bill.

“This has already hurt the Democrats,” says Terry O’Neill, president of the National Organization for Women, which has now turned its attention to the Senate, where members are considering their own health care legislation.

When and if the Senate passes a health care bill, it will be melded with the House version and sent back to both chambers for a vote. Few are predicting that the abortion limits will survive.

But the party still has to engage in some immediate damage control.

“It really breaks my heart when your supposed friends pass a health care bill for 49 percent of the population, and a partial health bill for the other 51 percent of the population,” said O’Neill. “We’re furious at the Democrats, and dismayed about what’s going on.”

In an interview Monday with ABC, President Obama acknowledged the growing backlash among the Democrats’ liberal base, saying “there are strong feelings on both sides” of the abortion amendment issue. “And what that tells me,” the president said, “is that there needs to be some more work before we get to the point where we’re not changing the status quo.”

“I laid out a very simple principle, which is this is a health care bill, not an abortion bill,” he said.

“And we’re not looking to change what is the principle that has been in place for a very long time, which is federal dollars are not used to subsidize abortions.”

Will Language Survive?

The so-called Stupak amendment included in the House bill would prevent women eligible for government tax credits for health insurance from using that money to enroll in any plan that covers abortion. Of 258 House Democrats, 64 voted for the amendment, along with 176 Republicans, guaranteeing its passage.

The U.S. Conference of Catholic Bishops actively lobbied for the amendment, offered by Democrat Bart Stupak of Michigan and Republican Joe Pitts of Pennsylvania. The Catholic Church, though opposed to abortion funding, has long advocated for universal health care as a fundamental human right and essential to the common good. Stupak was among 19 Democrats who in midsummer vowed to oppose any health overhaul plan that didn’t specifically prevent taxpayer money from being used for abortions.

The Senate is far less likely to impose such restrictions. And though both pro-choice and anti-abortion activists say they don’t expect the abortion language to be in a final bill hammered out between House and Senate leaders, the Catholic Church isn’t going away. Its leaders have pronounced unacceptable two bills now under consideration in the Senate.

Barry Lynn, who heads Americans United for Separation of Church and State, said he’s been “horrified” by the church’s influence on the sweeping health care bill.

“What we saw over the weekend was an act of unparalleled arrogance on the part of church officials,” he said. “Basically, they were claiming they would kill health care for the sick and the poor if the Democrats didn’t give them the votes to impose religious doctrine into law.”

“It’s scandalous that this religious group has such extraordinary control over the fate of women’s lives in this country,” Lynn said.

Backlash Among Liberal Lawmakers

By late Monday, Democratic Rep. Diana DeGette of Colorado had collected more than 40 signatures from fellow members who vowed they would not vote for a combined House-Senate health care bill if it contains language “that restricts women’s right to choose any further than current law.”

And Florida Rep. Debbie Wasserman-Schultz, in a Monday interview with MSNBC, said that she is confident the abortion language will be stripped.

“We’re all going to be working very hard – particularly the pro-choice members – to make sure that’s the case,” she said.

And there’s no question that they’ll have some vigorous prodding from their base.

“We were outraged that these people – all these people who voted for the Stupak amendment – were willing to just ignore the needs of women,” said Judy Waxman of the National Women’s Law Center.

Ted Miller, communications director for NARAL Pro-Choice America, echoed the sentiment. “We will hold those lawmakers who voted for this measure accountable for abandoning women and capitulating to extreme factions of the anti-choice movement,” he said.

“Our focus now is defeating any attempt to add the Stupak abortion ban to the Senate bill,” he said.

Waxman characterized the health care debate as a “perfect storm” for the Catholic Church because of the narrow margin of passage for the overall bill.

“We are hopeful we will not have this amendment,” Waxman said. “In fact, we will make sure this amendment is not in the Senate version.”

The Democratic strategists who are cooking up ways to get out the vote next year may be trying to make sure of the same – so that health care ends up being a negative next year not for them, but for their erstwhile opponents.

Related stories:

KHN: How The House Abortion Restrictions Would Work

NPR:

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Democrats have little time to savor the narrow passage of their historic heath care overhaul in the House of Representatives as attention turns to the deeply divided U.S. Senate. Majority Leader Harry Reid’s challenge is to corral enough votes to bring a companion bill to the floor of his chamber before a White House-imposed Christmas deadline.

The Nevada Democrat, facing a tough re-election back home, threw Senate negotiations into turmoil recently when he embraced a public insurance option.

The option is a key component of the newly minted House bill, but is opposed by a handful of moderate Senate Democrats, as well as Sen. Joseph Lieberman, an independent.

And Reid needs the support of all 58 Senate Democrats, as well as Lieberman and fellow independent Sen. Bernie Sanders of Vermont, to secure the 60 votes necessary to block a Republican filibuster.

Reid has said that the public insurance option he supports would allow states to opt out of the program. An analysis of the cost of the proposed Senate plans by the nonpartisan Congressional Budget Office is expected later this week.

The House has proposed paying for its plan by increasing taxes on wealthy Americans. The Senate versions have favored taxing generous insurance benefit plans – anathema to union members, and opposed by House leaders.

Reid must first reconcile two competing Senate health care bills in the weeks ahead before moving to a vote. Then the House bill and any health care legislation from the Senate would have to be merged by a joint congressional committee before being sent to President Obama for his signature.

Reid avoided any promises about Senate action. In a statement released after the House vote, he said, “We realize the strong will for reform that exists, and we are energized that we stand closer than ever to reforming our broken health insurance system.”

Democrats Celebrate

On the House floor, announcement of the 220-215 vote was greeted by wild applause from the Democratic side of the aisle. Afterward, Rep. Patrick Kennedy, a Democrat from Rhode Island, invoked his recently deceased father. During his four decades in the Senate, Massachusetts Sen. Edward Kennedy made health care reform his life’s work.

“My dad was a senator,” Kennedy said, “but tonight his spirit was in the House.”

House Speaker Nancy Pelosi, the first woman to preside over the House, managed to overcome the defection of 39 Democrats to the “no” column and attract a lone Republican to give her just two more votes than the 218 she needed to get the overhaul legislation passed – and to hand the president a big win for his top domestic priority.

“I thank the president for his tremendous leadership, because without President Obama in the White House, this victory would not have been possible,” Pelosi said at a press conference immediately after the vote.

“He provided the vision and the momentum for us to get the job done for the American people,” she said.

In a brief appearance Sunday afternoon at the White House, Obama said he was grateful for “courageous” legislators who voted for the House overhaul given “the heated and often misleading rhetoric around this legislation.”

“Now it falls on the United States Senate,” he said, to deliver the “change we promised to the American people.”

“I am absolutely confident it will,” he said in an earlier statement, “and I look forward to signing comprehensive health insurance reform into law by the end of the year.”

Victory Came With A Cost

But the struggle for passage in the House, after a full day of rhetorical scuffles and contentious debate, came at some cost to Democrats who support a woman’s right to have access to legal abortion – presaging what will likely be a topic of considerable debate in the Senate.

To win the votes of conservative party members who oppose abortion, House Democratic leaders endorsed an amendment to their legislation that bars the use of government subsidies to buy any insurance plan that covers the procedure. The move angered many in the party’s 190-member House pro-choice caucus, who said they viewed it as an invasion of women’s medical privacy. The amendment, however, ensured the politically necessary support of some Roman Catholic lawmakers and the U.S. Conference of Catholic Bishops.

Conservative Democrats won the hard-fought chance to offer the abortion restriction amendment during debate, and with the support of all but one House Republican, it passed by a vote of 240 to 194. Arizona Republican John Shadegg voted “present” to the amendment.

With such close margins and the struggle over the abortion issue, it had been uncertain if Pelosi could gather the votes needed to pass the bill – even though Democrats enjoy an 81-vote edge in the House. But with passage secured, Majority Leader Steny Hoyer joked, “For all of my friends in the press who’ve been assaulting me in the hallways, asking if we have the votes, the answer is yes.”

Earlier Saturday, President Obama, in an unusual weekend visit to the Capitol, personally urged lawmakers to “rise to the moment” and “finish the job.”

The House Democrats’ plan would cost close to a trillion dollars over the next decade, and would mandate that most employers cover their workers. It also requires people who are not insured through their employers to buy coverage, and it expands government programs to help them pay for that. The bill bars insurance companies from denying coverage to people based on pre-existing conditions, and includes other insurance industry reforms.

Freshman Rep. Joseph Cao of Louisiana was the lone Republican to vote for the bill. He represents a heavily Democratic district, and faces an uphill re-election battle next year. His fellow Republicans were united in the reasons for their opposition. “The American people need to understand this is about a government takeover of the whole health care system,” said Georgia Rep. Paul Broun.

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Senate Majority Leader Harry Reid began private meetings Wednesday with fellow Democrats and the White House to merge his chamber’s two health care overhaul bills into a single plan that could win a filibuster-proof majority in the Senate.

Work on combining the Senate’s Finance and health committees’ bills was supposed to be, in theory at least, the less contentious part of this new phase of overhaul negotiations. But the question of what will hit the Senate floor for debate in less than two weeks remains large and open.

Reid’s task is complicated by the fact that although Senate Democrats enjoy a 60-vote, filibuster-proof majority, it is a fragile caucus that includes a handful of moderates whose votes on President Obama’s signature domestic initiative are not a given.

And already at least one of Reid’s fellow Senate Democrats, New York’s Charles Schumer, is agitating for a final bill that includes a public insurance option – something missing from the measure passed this week by the more conservative Senate Finance Committee.

“In one sense, the debate begins all over again,” says Bob Moffit, director of health policy studies at the conservative Heritage Foundation.

The long-awaited $829 billion proposal approved Tuesday by the Senate Finance Committee with a single Republican vote “concludes one big chapter of the health care debate,” Moffit says. “But you’re not going to see that bill again.”

Opposition Pumps Up The Volume

Schumer wasn’t the only one stirring the pot in the wake of Tuesday’s vote.

Interest groups have ratcheted up their message machines this week – from insurers denouncing the Finance Committee proposal for failing to require that all Americans obtain coverage to unions balking at proposed taxes on generous benefit packages.

So Reid, with a tough re-election battle back home in Nevada and a looming showdown with House Speaker Nancy Pelosi over her chamber’s competing legislation, has to devise a strategy that not only melds the Finance Committee’s bill with the more liberal offering from the health committee but still gives the president a win.

There are a few certainties: There is little doubt that the ultimate Senate bill will include changes that prohibit insurers from denying coverage to Americans with pre-existing health conditions or canceling coverage when a policyholder gets sick.

And both Senate bills contain similar provisions for creating state-based insurance exchanges – or pools – that can be used by poor and low-income individuals and families, and small businesses, to purchase more affordable coverage.

The Finance Committee’s plan to expand Medicaid coverage to more poor Americans is also expected to make the final bill, though details on how to pay for it – and for many other bill provisions – have yet to be worked out.

But the Finance Committee bill is the only proposal that does not include a government-run plan, and it does not require employers of a certain size to offer coverage to its employees.

“Do you impose an employer mandate that unions want, but employers will fight to the death?” Moffit asks. “Do you include a public plan that moderate Democrats don’t want? Do you impose an individual mandate?”

Those big, fundamental questions are unanswered, says Michael Tanner, a senior fellow at Cato Institute. “There are real problems yet to be resolved,” he says. “This is not even halfway there.”

Different Mandates, Different Parameters

The Senate Finance Committee bill would require that most individuals obtain insurance, but its proposed phased-in penalties for failure to comply are nominal and would do little, critics argue, to encourage insurance purchase.

It proposes that penalties of $200 per adult begin in 2014 and reach $750 by 2017. The Senate health committee has proposed a penalty of up to $750 a person, with no phase-in period.

The insurance industry had banked on a vastly increased pool of potential clients under a mandated-coverage plan. Now the industry is attacking the Finance Committee’s proposal as guaranteeing an increase in the cost of premiums.

Also at odds are the competing Senate committee proposals for employer mandates, which have emerged as one of the stickiest issues Reid faces.

The Finance Committee would require that businesses with more than 50 employees foot the bill for government insurance subsidies for which their workers may qualify. The health committee bill demands that employers pay for part of the cost of worker coverage or face a penalty. Both bills include exemptions for small employers.

A merged Senate bill will very likely include both an individual and employer mandate, but just who will be exempted is expected to be one of the issues dominating closed-door sessions over the coming days.

Meeting Obama’s Objectives Without A Public Option

Schumer may be pushing hard again for a public option to be included in the final Senate bill, but Obama suggested Tuesday that the Finance Committee bill – sans public option – brought Congress closer to achieving the president’s core objectives: dramatically expanding the number of Americans covered by insurance, and bending the cost curve.

Len Nichols, director of the health policy program at the nonpartisan New America Foundation, said there has been “fertile thought” around an alternative to a full-blown public option.

That alternative, he says, could be some kind of a melding of so-called trigger proposals advocated by both Democratic Sen. Tom Carper of Delaware and Sen. Olympia Snowe of Maine, the only Republican on the Finance Committee to vote for the proposed overhaul plan.

Under a trigger plan, a public insurance option would kick in if a state fails to meet federal insurance coverage goals.

“I would not be surprised at all to see that emerge” from the Senate’s bill-merging discussions, Nichols says.

“Some kind of trigger is the best way to square the circle,” he says. “It shows the right that there’s no government takeover going on here, and moderate Democrats can get onboard.”

But on Capitol Hill Wednesday, Reid said he wanted to note where he stands at the start of bill negotiations.

“I believe in a public option,” he said, adding, pointedly: “Remember: I said I do.”

A Win For Obama?

And that may be the path to what Obama could define as success on his signature domestic issue.

Even with a plan emerging that would contain an alternative to a full-blown public insurance option, and with considerably watered-down mandates for individuals to buy insurance and employers to pay for at least some coverage costs, the White House would most likely declare victory.

“The reason this is historic has almost nothing to do with the specifics,” Nichols says, “but [with] the commitment now on the part of five congressional committees to make health insurance and health care affordable for all Americans – and to simultaneously bend the cost curve.”

“We’ve never gotten this far before,” he said.

But, for overhaul opponents, the game has only begun – and it will play out in the home districts of members of Congress facing re-election in 2010.

“If this is defeated, it will be defeated at the grass-roots level,” says John Goodman, president and CEO of the National Center for Policy Analysis, which has gathered the signatures of more than 1.3 million who oppose the “nationalization” of health care.

“There is,” Goodman says, “a real intense battle going on out there.”

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A few months ago, Republican Sen. Chuck Grassley of Iowa positioned himself to be the key GOP player in negotiations to advance President Obama’s top domestic priority – overhauling the nation’s health care system.

As ranking minority member on the Senate Finance Committee, Grassley has been a leading voice in the committee’s bipartisan “Gang of Six” that had been struggling to hammer out a bill before Congress recessed for August.

But Grassley’s evolution – from legislator once complimented by Obama for his willingness to work across the aisle to one of the president’s chief critics on health care – is a sign that the chances for passing a bipartisan health care bill have all but disintegrated. And as Grassley has pivoted from defending bipartisan work on a Senate bill to criticizing a competing House bill, he has increasingly sown confusion over just where he stands in negotiations to overhaul health care.

In the process, the five-term senator criticized the president as “intellectually dishonest” and prompted some Democratic leaders to say efforts at a bipartisan deal are dead. He has also drawn sharp criticism himself for echoing in recent days the questionable argument that a Democratic plan would ration health care for seniors.

In an interview on Wednesday, Grassley insisted he is still interested in working toward a bill with broad-based appeal, though his assertion this week that he would vote against any bill – even one he supports – if it fails to attract wide GOP support has raised questions about his commitment to bipartisan negotiations.

What happened to Grassley the compromiser, who less than four months ago hailed the momentum Obama created for a health care overhaul and touted the promise of “bipartisan health reform proposal”?

Those questions make Grassley bristle.

“I’m sitting down talking with the idea that we come out with a product,” he told NPR Wednesday. “I’ve said that we’ve got to have a bipartisan bill, and bipartisanship is not three Republicans and 58 Democrats.”

“You asked me why I said lately that I would not be going with a bill that got a few votes,” Grassley said. “I’ve been saying that all year. You’re asking me a question like I just said it…”

“I’m not going to walk away from the table,” he said. “If I get away from the table, it’s because I’m pushed away from the table.”

But in recent days, Grassley’s comments suggest that he’s doing some of the pushing. During town hall meetings in Iowa, he alluded to government programs that would “pull the plug on Grandma.” He recently engaged in a tit-for-tat Twitter argument over health care “death boards” with Sen. Arlen Specter, a Pennsylvania Democrat. And he invoked gravely ill Sen. Edward Kennedy when inaccurately suggesting that under a British-style, state-run health plan, the Massachusetts Democrat would have been denied treatment for cancer because of his advanced age.

“I regret using Sen. Kennedy’s name,” Grassley told NPR. But he said he has no regrets about comments he made about British-style health systems, or addressing concerns – real or imagined – about end-of-life issues under a government plan.

Pressure And Pushback

Partisan and ideological pressure pushed Grassley back from working too closely with Democrats on a health care bill, says political analyst Charlie Cook, along with an altered political world where the public’s appetite for systemic change has receded dramatically over the past year.

“The pressure has been really intense to hold ranks and not give Obama a victory,” says Cook, the publisher of The Cook Political Report. “And, ideologically, this health care overhaul has been tough for conservatives to swallow.”

When Grassley said that he would not back a bill that didn’t attract wide GOP support, he was simply engaging in an unusual moment of political candor, Cook says.

“If he can’t bring along the Dick Lugars, the George Voinoviches and other Senate Republicans who might be open to something,” Cook says, “he’s wasting his time.”

Says Grassley: “We’re restructuring 16 percent of the gross national product. Health care is a life-or-death issue for every person in America, and my principle has been the same as [Montana Democratic] Sen. [Max] Baucus’s during this whole year of discussion of health care – that it ought to be done on a broad, consensus basis, which we’ve always signaled is 70 to 80 votes.”

A Target For Upset Conservatives

Back home in Iowa, long before the boisterous town hall meetings of summer, Grassley was kicked around by conservatives after he attended the president’s spring health care forum at the White House. Though he argued that it was better for his party to have a seat at the table than not, critical letters to the editor began appearing in local newspapers, and conservative pundits on cable television made Grassley, up for re-election next year, a favorite target.

“He’s an example of a leader who is genuinely trying to make something happen and winds up getting hit from both sides,” says David Yepsen, the former Des Moines Register political reporter who followed Grassley for decades.

“But he understands his state and has a very tough chasm to bridge back there,” says Yepsen, now director of the Paul Simon Public Policy Institute at Southern Illinois University, Carbondale.

Though Iowa went for Obama over GOP nominee John McCain in the presidential election last fall, the state’s Republicans earlier made former Arkansas Gov. Mike Huckabee – who stressed his Christian conservative credentials – their top choice in the statewide caucuses. And last year, they ousted their longtime national party committee members and replaced them with more conservative picks.

Iowa remains a largely conservative place, says Diane Bystrom, director of the Catt Center for Women and Politics at Iowa State University. Grassley increasingly felt the heat, she says, as opposition to health care became entrenched on the right, and more false rumors and innuendo spread about plans being considered in the House and Senate.

“Sen. Grassley’s conservative credentials were being questioned at town meetings, and his pushback was to make sure his meetings were crowd pleasers,” Bystrom said.

No Peril At Home

Though part of Grassley’s strategy may be electoral self-preservation, there are no indications that he’ll face any serious challenge next year if he runs for a sixth term, as he has said he will.

“Charles Grassley isn’t in danger in this state,” says Bystrom, noting that the senator has been elected with more than 65 percent of the vote since his second term and pulled in 70 percent in 2004.

So, just what will Grassley do when Congress reconvenes in September and will again take up health care negotiations?

“The short answer is, we just don’t know,” Cook says.

With the president’s proposal for a public insurance option withering on the vine, Grassley says he is among Republican senators more amenable to the alternative of yet-to-be-defined health care co-ops, owned and managed by members. The concept is familiar in rural states, where agriculture and utility co-ops have been around for decades.

“I can support co-ops if they want to do it as we’ve known co-ops in America for 150 years – where they serve the purposes of the consuming public, whether it’s health care or whether it’s co-ops as we know them in the Midwest, providing electricity or to sell supplies to farmers,” Grassley said.

He opposes suggestions by Democrats like New York Sen. Chuck Schumer to create a national co-op, characterizing it as moving “right back to a public option.”

The Future Of Bipartisan Progress

Grassley’s commitment to bipartisan negotiations may become clearer Thursday evening when Baucus, chairman of the Senate Finance Committee, has scheduled a teleconference with his fellow Gang of Six members. Baucus said the group will meet again before Congress reconvenes.

Grassley says any deal will have to reflect the position of the GOP caucus: “No public option, no pay-or-play, no things that are going to lead to any rationing of health care, no interference with doctor-patient relationships, and tort reform.” A pay-or-play mandate would require employers to either provide employee health coverage or pay a tax to a national fund that would provide coverage.

The ball, as Grassley sees it, is in the Democrats’ court.

“Have you ever stopped to think that maybe 40-45 percent of the Democrats are so liberal they think that Baucus shouldn’t be talking to any Republican?” Grassley said. “So it seems to that [Baucus] has some problems. It seems to me that [House Speaker Nancy] Pelosi has signaled problems.”

“And I see a lot of stuff coming out of the White House this week that is very defensive,” Grassley said.

In a statement released Wednesday, Baucus asserted that “bipartisan progress continues.”

“The Finance Committee,” he said, “is on track to reach a bipartisan agreement on comprehensive health care reform that can pass the Senate.”

Whether Grassley will be part of that deal is anybody’s guess, but the odds, this week any way, appear long.

From The Senator

NPR caught up by phone with Grassley on Wednesday, while the senator was on a bus tour of his home state. Here are some excerpts from that interview, about the ongoing health care overhaul negotiations:

On the circumstances in which he would stop negotiating with the other members of the Senate Finance Committee’s bipartisan “Gang of Six”:

“I’m at the table to represent the interests of my party in overall reform. … I’m also at the table because Iowa … has high quality and low reimbursement under Medicare. I’ve got to be at the table to represent Iowa’s interests to see that we don’t continue to get screwed by Medicare. And so I’m at the table for those reasons. And I’ve always said I’m not going to walk away from the table. If I get away from the table, it’s because I’m pushed away from the table.”

On whether the public insurance option is dead, given Health and Human Services Secretary Kathleen Sebelius’ suggestion Sunday that the public option is “not the essential element” of a health care overhaul:

“I believe it is. There again, you send up a trial balloon like [Sebelius] did last Sunday on talk shows and you think, yeah, well, maybe the president is taking my advice when I gave it to him a week ago. … I said something like, ‘Can you make a public statement that you would sign a bill without a public option?’ He didn’t answer me, but I saw [Sebelius’ comments] as a trial balloon. And then the next day I saw him backpedaling.”

On whether, absent a public option, he could bring any more Republicans onboard:

“I can’t really answer that question until you have a product to show them. Don’t forget, there’s no point in my talking to Democrats if I can’t get Republican support – because that’s my goal.”

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No matter which side of the issue members come down on, they will find that the people who put them in office remain deeply confused about what the still-being-written overhaul might bring.

And most Americans are equally suspicious of – and confused by – claims being made by both supporters and opponents of President Obama’s most ambitious domestic initiative.

With Congress still struggling to fashion legislation and Obama letting the details take shape on Capitol Hill while he sells its broader parameters during appearances that include town hall meetings, most outside Washington have no idea what the overhaul will look like, what it will cost and how it could affect them personally, says Mark Blumenthal of Pollster.com.

“Much of this story has been a big, inside-Washington debate about cost and bending the cost curve,” he says. “It’s a remote, technical discussion.”

Polls show that the delays in reaching agreement on a bill – coupled with growing concern about the billions already spent on bailouts and the stimulus package – have spurred skepticism about whether Obama’s biggest domestic initiative will help the country, and who it will benefit.

‘Babble’ From D.C.

Iowa’s senior Sen. Chuck Grassley, a Republican, has been one of a half-dozen Senate Finance Committee members who have been struggling to piece together a bipartisan bill.

But that proposal, senators have said, won’t be ready until after the August recess. That means voters back home, desperate for concrete information about the overhaul, will have to wait longer for clarity.

And after the Senate leaves for recess this week, Grassley is guaranteed to face the same questions back in Iowa that Congress members will face across the country. That group includes Grassley’s fellow Iowan Rep. Bruce Braley, who is part of a group of House Democrats fighting for a fix in disparities in how Medicare reimburses rural and urban health care providers.

“There is intellectual acceptance that health care is a problem and that it costs too much,” says Graham Gillette, who runs his own public relations strategy company in Des Moines, Iowa. “But for most Americans, the confusing babble that’s coming out of Washington sounds worse.”

“And after the fear-mongering and mud-throwing of the last few weeks,” he says, “that’s not hard to understand.”

In Iowa, a national labor union has aired television advertisements that targeted Grassley’s support for a proposal that would tax health care benefits. The state’s Democratic and Republican parties have stepped up their rhetoric in anticipation of the August recess. Volunteers who helped Obama win the Iowa caucuses last year are being recruited to make phone calls to remind supporters that a national health care overhaul was one of the reasons they voted for him.

The Need Is Clear

For the past decade, David Lind’s company, based in Clive, Iowa, has conducted an annual survey assessing the state of health insurance in the Hawkeye State. It’s meant for his clients in the employee benefits sector.

What his surveys have found, he says, reflect not only conditions in Iowa but around the country. The numbers are sobering.

“We have found in the past 10 years, health insurance premiums have basically doubled,” he said. “That mimics what we’ve seen on a national basis.”

Employers facing these dramatic increases in premiums have increasingly had to pass costs to their employees, Lind says, by increasing deductibles that employees pay and hiking co-pays for office visits and prescription drugs.

The average deductible for a single person in Iowa has increased 200 percent over the past decade; family deductibles have gone up 180 percent over the same period, his data show. And the smaller the employer, Lind says, the higher the employee deductibles and copay requirements.

“Rather than drop health insurance, employers are reconfiguring plan design and ratcheting the [employees’] cost share upward,” he said. “But employers are still taking the brunt of the increases in premiums.”

Frog In A Pot

Des Moines-based pollster J. Ann Selzer likens the situation to the old frog-in-the-kettle analogy: “People are like frogs in a pot of warm water, with the temperature slowly rising,” she says. “It feels warm now – but they don’t realize how hot it’s getting.”

For many, she says, the status quo holds appeal – particularly in the face of heavy push-back from Republicans opposed to the tenets of Obama’s overhaul goals.

Lind says his clients are particularly concerned about the status of a proposed public insurance plan that would compete with private insurers.

“There needs to be a meaningful discussion about what it means to actually have a public plan next to a private plan, so there isn’t a hidden tax,” he says.

“The dialogue seems to be more about politics than what’s really happening,” Lind says. “Let’s get all the facts out there, have complete transparency of what it looks like, and then we can apply the facts to it.”

A Message Problem

When pollsters ask straight-up questions about whether people favor or oppose revamping health care, there is a little more opposition than support, Blumenthal says.

But when the surveyors ask more specific questions about what the plan might include, there is “remarkably consistent support in the 50-55 percent range,” he said.

What hasn’t been communicated well enough to the folks back home is what an overhaul could do – including guaranteeing that you won’t lose your insurance if you change jobs, for example, or if you have a pre-existing medical condition, Blumenthal says.

“I don’t get a sense that Americans have a very good idea of what the ‘it’ is,” he says. “In the absence of a real strong case being made for this [what’s happening] is that people are hearing and processing messages from the other side.”

The Politics Of Confusion

People are confused, and there’s the fear of the unknown, says Gillette, who volunteered for Obama in Iowa during his presidential run. And that uncertainly is compounded by the complexities involved in the administration’s push for sweeping changes in one big overhaul bill.

“If Washington could have broken the problem into pieces – cost containment, for example, and insurance portability – they could have hammered out some agreements and given people some confidence that progress was being made,” he said.

“The approach they took was almost all-or-nothing,” he says. “That is confusing, and, to many, scary.”

And that’s what Grassley and his congressional colleagues will face in coming weeks: confusion, skepticism and the still-lingering question of what the overhaul will look like and what will it mean for households in Iowa and beyond.

“The play’s not over yet,” Blumenthal says. “But proponents will be in a much better position to sell it when they have something concrete.”

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President Obama was in Ohio on Monday to give his third campaign-style, outside-the-Beltway health care overhaul sales pitch in the past half-dozen days.

But back in Washington, the furious action was behind the scenes, as Democratic leaders continued their desperate arm-twisting for health care’s too-close-to-call end game. And interest groups shoveled millions of dollars into last-ditch efforts to influence the outcome of the historic bill.

That outcome, which hinges on a key House vote expected later this week, remained wildly uncertain.

“Everyone knew it was going to be a nail-biter going into this,” says health analyst Alec Vachon. “It’s now all about vote wrangling.”

By The Numbers

To pass the health care overhaul, Democratic House Speaker Nancy Pelosi has to persuade at least 216 of her 253-member caucus to support the version of health care legislation that the Senate approved last December.

Among her formidable challenges: convincing recalcitrant House Democrats who find aspects of the Senate bill unpalatable that a subsequent smaller, so-called fix-it bill – known as reconciliation – will ultimately pass both chambers with at least some of their desired changes.

Health care overhaul advocates are banking on Pelosi’s powers of persuasion, as well as those of the president, to move enough Democratic fence-sitters to get to the magic 216 majority number.

Most vote counters say that as of Monday, Pelosi is still around a dozen votes short.

“There’s a path to victory for the Democrats, but a lot of things will have to go right,” says David Dayen, a blogger with the progressive Web site Firedoglake.

Dayen, who has been closely tracking the votes, says that Obama, Pelosi and Democratic leaders will have to persuade at least a half-dozen Democrats who voted “no” on the House version of health care legislation last fall to support the Senate version.

“That’s a tall order,” Dayen says.

One of those original “no” votes belonged to Ohio Rep. Dennis Kucinich, a hero to progressives who favors universal health care. He voted against the House bill last November because he said he viewed it as a sellout to Wall Street and the insurance companies.

Kucinich has said he’ll vote no again this week. And it just so happens that on Monday, Obama not only delivered his speech in the heart of Kucinich’s district but also met privately aboard Air Force One with the congressman and Ohio Rep. Marcia Fudge, who has not committed her vote.

Oddsmakers, no doubt, will be watching the two closely in coming days.

Also watching the horse trading for votes are investors who participate in the prediction market Intrade, which on Monday listed Obama’s health care legislation with a 70 percent chance of passing by June. That represents a significant increase from early this month, when it was listed with around a 30 percent chance.

High-Stakes Wooing

Private Air Force One meetings, behind-the-scenes deals, promises of something back home – the art of individual vote corralling takes many forms.

“It’s like romance – you say different things to different people,” says Vachon, the president of Hamilton PPB, which provides health policy advice to corporations and investors.

Vachon recalls that during the heated 2008 debate over the Bush administration’s Medicare prescription drug plan, he asked a member being courted by the White House whether he had asked for money for a bridge to be built back in the member’s district.

“He told me, ‘We don’t have a river,’ ” Vachon said. “I told him, ‘Hey, you could get that, too – go large!’ ” 

He was only half-joking.

There are at least a dozen House members who don’t like language in the Senate health care bill that limits federal spending on abortions because they believe it is weaker than House-approved language included in the so-called Stupak amendment.

But though Michigan Rep. Bart Stupak, who fashioned the amendment, has said that he’ll be a “no” vote this week, it appears that there are a handful of other Stupak amendment supporters who are moving to the “yes” category.

“It looks like Rep. Stupak is losing members. He said he had 12, but I only count six now as a firm ‘no,’ ” Dayen says. “And four or five are on the fence.”

Under the rules of reconciliation, Democratic leaders aren’t allowed to change the Senate’s abortion language because it doesn’t involve the budget. Instead, party leaders have been working to convince Stupak coalition members that the upper chamber’s abortion coverage provisions aren’t appreciably different than the House language.

But it leaves open the question of what promises Democratic leaders are making to sway members of Stupak’s coalition.

Vachon is among those who have long said that they believe Pelosi will find the votes – though he’s not sure how.

“This could be an epic fail – where she gets just 202 votes,” he says. “Or there could be the crowd effect” that will bring her a winning majority.

The Politics Of ‘No’

Still, the bottom line for many nervous House Democrats is how their health care vote will play back home in advance of the November elections.

And, of course, it depends on their district.

For some, voting against the health bill after they voted for it won’t win them any credit from opposition Republicans or the Tea Party movement. For others, pressure is being brought to bear by progressives and unions talking about backing potential primary challengers to Democrats who oppose the health care measure.

“There is a lot of pressure from all sides,” Dayen says.

Just ask Kucinich.

When Obama introduced Kucinich at Monday’s event, an audience member called out: “Vote yes!”

To which Obama replied: “Hear that, Dennis?”

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Rep. Nancy Pelosi, D-Calif., walks out of January’s Democratic Caucus meeting on health reform. Democrats are showing increasing resolve to pass legislation using a maneuver known as reconciliation. But first, Democrats need to settle disputes within their own party over a handful of reform issues. (Mark Wilson/Getty Images)

Congressional Republicans are scheduled to join President Obama and Democratic leaders Thursday for a six-hour televised summit on the White House’s stalled drive for a national health care overhaul.

But it’s increasingly clear that the only bipartisan compromise expected to emerge at Blair House is over who gets to sit where at the big table.

Indeed, the compromise that most of Washington is focused on now will be post-summit – and within the ranks of a fractious Democratic caucus that’s trying to navigate a route to health care legislation.

After all, Republicans have doubled down on their criticism of the Democrats’ initiatives and continued calls for a complete legislative do-over. Meanwhile, Democrats are showing increasing resolve to push their legislation through with a maneuver known as reconciliation that would require no GOP votes, just simple majorities in the Senate and House.

But before that can happen, Democrats need to resolve bitter disputes within their own party over a handful of overhaul issues. The major areas of intracaucus contention include not only abortion and benefit plan taxes, but the process of reconciliation itself. Here’s a breakdown of some of the key sticking points:

Abortion: What would a health care debate be if it didn’t include a battle over abortion? The House bill carries a provision pushed by about a dozen anti-abortion Democrats – and excoriated by pro-choice members – that would prevent individuals from using federal subsidies to buy insurance plans that offer abortion coverage.

The Senate bill would allow subsidies to be spent on insurance plans that include abortion coverage. But women would be required to personally pay the company for the specific cost of abortion coverage. (Federal law restricts public funding for abortion.)

Though the differences appear negligible, and Obama’s plan didn’t wade into the issue, anti-abortion House Democrats say they can’t support the Senate version. House Speaker Nancy Pelosi’s people insist that they’ll muster a majority nonetheless.

Budget Reconciliation: Reconciliation is a parliamentary procedure that allows legislation written as a budget bill to pass through the Senate with a simple majority, preventing minority party filibuster. Once seen as a distant and not-very-palatable option to use to pass comprehensive health care, Democrats – including Majority Whip Dick Durbin of Illinois – have said that Senate leaders are preparing to use the maneuver. A number of Democrats facing re-election in the fall have resisted the path, fearing a backlash at the polls.

But many Democratic skeptics began warming to the notion after Democrats lost their 60-vote Senate supermajority when Republican Scott Brown was elected in Massachusetts. However, the use of reconciliation still needs to be sold – particularly to moderate House members – and it must be done at a time when Republicans have ratcheted up rhetoric surrounding the procedure, used by both parties in the past.

Public Option: A public insurance option is one created by the government and offered to the uninsured as an alternative to private coverage. Though declared dead by the White House, the public option contained in the House bill still has its dogged advocates in the Democratic caucus.

To wit: Twenty-three senators signed a letter urging party leaders to include the option in a reconciliation bill. But when Pelosi, a longtime supporter, acknowledges there aren’t enough Democratic votes in the Senate to pass a public option, the give-and-take may simply give succor to the party’s liberals, but it won’t end in compromise.

Says West Virginia Sen. Jay Rockefeller, a strong proponent of a public option: A diminished public option just isn’t worth the political fight.

Cadillac Tax: Labor unions were furious when the Senate approved a version of the health overhaul bill that included a tax on high-cost insurance plans – including those often awarded in collective bargaining. House leaders were none too pleased, either.

So when Obama unveiled his plan this week, presto! Under his proposal, the tax would be delayed until 2018, and he also bumped up the value of plans that would be taxed – benefiting both union and nonunion holders of benefits-rich plans.

But House Democrats want the tax provision excised from the Senate bill, which forms the basis of the reconciliation legislation, before it comes to the House for a vote – and that could complicate its path. Republican Sen. Judd Gregg has asserted that if the Senate legislation is altered, it would have to be put to a new vote in the chamber.

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Democrats have been showing a fresh determination to make Republicans’ near-unanimous opposition to a national health care overhaul – and its implications for women – the GOP’s Achilles heel during next year’s midterm elections.

Democrats have produced a hit list of 32 House Republicans from districts that voted for President Obama last year. And they’re touting a video of Republican men repeatedly interrupting Democratic women during Saturday’s House floor debate on health care.

But that tactic just got a lot more complicated.

There is growing outrage among the Democrats’ own activist base over new and far-reaching abortion restrictions contained in the historic health care bill approved Saturday by the Democratic-controlled House.

And some of the party’s staunchest supporters are suggesting that Democrats will have their own problems with health care – and women voters – come 2010 because of the proposed abortion limits and the Catholic Church’s pivotal role in ensuring that restrictions would make it into the bill.

“This has already hurt the Democrats,” says Terry O’Neill, president of the National Organization for Women, which has now turned its attention to the Senate, where members are considering their own health care legislation.

When and if the Senate passes a health care bill, it will be melded with the House version and sent back to both chambers for a vote. Few are predicting that the abortion limits will survive.

But the party still has to engage in some immediate damage control.

“It really breaks my heart when your supposed friends pass a health care bill for 49 percent of the population, and a partial health bill for the other 51 percent of the population,” said O’Neill. “We’re furious at the Democrats, and dismayed about what’s going on.”

In an interview Monday with ABC, President Obama acknowledged the growing backlash among the Democrats’ liberal base, saying “there are strong feelings on both sides” of the abortion amendment issue. “And what that tells me,” the president said, “is that there needs to be some more work before we get to the point where we’re not changing the status quo.”

“I laid out a very simple principle, which is this is a health care bill, not an abortion bill,” he said.

“And we’re not looking to change what is the principle that has been in place for a very long time, which is federal dollars are not used to subsidize abortions.”

Will Language Survive?

The so-called Stupak amendment included in the House bill would prevent women eligible for government tax credits for health insurance from using that money to enroll in any plan that covers abortion. Of 258 House Democrats, 64 voted for the amendment, along with 176 Republicans, guaranteeing its passage.

The U.S. Conference of Catholic Bishops actively lobbied for the amendment, offered by Democrat Bart Stupak of Michigan and Republican Joe Pitts of Pennsylvania. The Catholic Church, though opposed to abortion funding, has long advocated for universal health care as a fundamental human right and essential to the common good. Stupak was among 19 Democrats who in midsummer vowed to oppose any health overhaul plan that didn’t specifically prevent taxpayer money from being used for abortions.

The Senate is far less likely to impose such restrictions. And though both pro-choice and anti-abortion activists say they don’t expect the abortion language to be in a final bill hammered out between House and Senate leaders, the Catholic Church isn’t going away. Its leaders have pronounced unacceptable two bills now under consideration in the Senate.

Barry Lynn, who heads Americans United for Separation of Church and State, said he’s been “horrified” by the church’s influence on the sweeping health care bill.

“What we saw over the weekend was an act of unparalleled arrogance on the part of church officials,” he said. “Basically, they were claiming they would kill health care for the sick and the poor if the Democrats didn’t give them the votes to impose religious doctrine into law.”

“It’s scandalous that this religious group has such extraordinary control over the fate of women’s lives in this country,” Lynn said.

Backlash Among Liberal Lawmakers

By late Monday, Democratic Rep. Diana DeGette of Colorado had collected more than 40 signatures from fellow members who vowed they would not vote for a combined House-Senate health care bill if it contains language “that restricts women’s right to choose any further than current law.”

And Florida Rep. Debbie Wasserman-Schultz, in a Monday interview with MSNBC, said that she is confident the abortion language will be stripped.

“We’re all going to be working very hard – particularly the pro-choice members – to make sure that’s the case,” she said.

And there’s no question that they’ll have some vigorous prodding from their base.

“We were outraged that these people – all these people who voted for the Stupak amendment – were willing to just ignore the needs of women,” said Judy Waxman of the National Women’s Law Center.

Ted Miller, communications director for NARAL Pro-Choice America, echoed the sentiment. “We will hold those lawmakers who voted for this measure accountable for abandoning women and capitulating to extreme factions of the anti-choice movement,” he said.

“Our focus now is defeating any attempt to add the Stupak abortion ban to the Senate bill,” he said.

Waxman characterized the health care debate as a “perfect storm” for the Catholic Church because of the narrow margin of passage for the overall bill.

“We are hopeful we will not have this amendment,” Waxman said. “In fact, we will make sure this amendment is not in the Senate version.”

The Democratic strategists who are cooking up ways to get out the vote next year may be trying to make sure of the same – so that health care ends up being a negative next year not for them, but for their erstwhile opponents.

Related stories:

KHN: How The House Abortion Restrictions Would Work

NPR:

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Democrats have little time to savor the narrow passage of their historic heath care overhaul in the House of Representatives as attention turns to the deeply divided U.S. Senate. Majority Leader Harry Reid’s challenge is to corral enough votes to bring a companion bill to the floor of his chamber before a White House-imposed Christmas deadline.

The Nevada Democrat, facing a tough re-election back home, threw Senate negotiations into turmoil recently when he embraced a public insurance option.

The option is a key component of the newly minted House bill, but is opposed by a handful of moderate Senate Democrats, as well as Sen. Joseph Lieberman, an independent.

And Reid needs the support of all 58 Senate Democrats, as well as Lieberman and fellow independent Sen. Bernie Sanders of Vermont, to secure the 60 votes necessary to block a Republican filibuster.

Reid has said that the public insurance option he supports would allow states to opt out of the program. An analysis of the cost of the proposed Senate plans by the nonpartisan Congressional Budget Office is expected later this week.

The House has proposed paying for its plan by increasing taxes on wealthy Americans. The Senate versions have favored taxing generous insurance benefit plans – anathema to union members, and opposed by House leaders.

Reid must first reconcile two competing Senate health care bills in the weeks ahead before moving to a vote. Then the House bill and any health care legislation from the Senate would have to be merged by a joint congressional committee before being sent to President Obama for his signature.

Reid avoided any promises about Senate action. In a statement released after the House vote, he said, “We realize the strong will for reform that exists, and we are energized that we stand closer than ever to reforming our broken health insurance system.”

Democrats Celebrate

On the House floor, announcement of the 220-215 vote was greeted by wild applause from the Democratic side of the aisle. Afterward, Rep. Patrick Kennedy, a Democrat from Rhode Island, invoked his recently deceased father. During his four decades in the Senate, Massachusetts Sen. Edward Kennedy made health care reform his life’s work.

“My dad was a senator,” Kennedy said, “but tonight his spirit was in the House.”

House Speaker Nancy Pelosi, the first woman to preside over the House, managed to overcome the defection of 39 Democrats to the “no” column and attract a lone Republican to give her just two more votes than the 218 she needed to get the overhaul legislation passed – and to hand the president a big win for his top domestic priority.

“I thank the president for his tremendous leadership, because without President Obama in the White House, this victory would not have been possible,” Pelosi said at a press conference immediately after the vote.

“He provided the vision and the momentum for us to get the job done for the American people,” she said.

In a brief appearance Sunday afternoon at the White House, Obama said he was grateful for “courageous” legislators who voted for the House overhaul given “the heated and often misleading rhetoric around this legislation.”

“Now it falls on the United States Senate,” he said, to deliver the “change we promised to the American people.”

“I am absolutely confident it will,” he said in an earlier statement, “and I look forward to signing comprehensive health insurance reform into law by the end of the year.”

Victory Came With A Cost

But the struggle for passage in the House, after a full day of rhetorical scuffles and contentious debate, came at some cost to Democrats who support a woman’s right to have access to legal abortion – presaging what will likely be a topic of considerable debate in the Senate.

To win the votes of conservative party members who oppose abortion, House Democratic leaders endorsed an amendment to their legislation that bars the use of government subsidies to buy any insurance plan that covers the procedure. The move angered many in the party’s 190-member House pro-choice caucus, who said they viewed it as an invasion of women’s medical privacy. The amendment, however, ensured the politically necessary support of some Roman Catholic lawmakers and the U.S. Conference of Catholic Bishops.

Conservative Democrats won the hard-fought chance to offer the abortion restriction amendment during debate, and with the support of all but one House Republican, it passed by a vote of 240 to 194. Arizona Republican John Shadegg voted “present” to the amendment.

With such close margins and the struggle over the abortion issue, it had been uncertain if Pelosi could gather the votes needed to pass the bill – even though Democrats enjoy an 81-vote edge in the House. But with passage secured, Majority Leader Steny Hoyer joked, “For all of my friends in the press who’ve been assaulting me in the hallways, asking if we have the votes, the answer is yes.”

Earlier Saturday, President Obama, in an unusual weekend visit to the Capitol, personally urged lawmakers to “rise to the moment” and “finish the job.”

The House Democrats’ plan would cost close to a trillion dollars over the next decade, and would mandate that most employers cover their workers. It also requires people who are not insured through their employers to buy coverage, and it expands government programs to help them pay for that. The bill bars insurance companies from denying coverage to people based on pre-existing conditions, and includes other insurance industry reforms.

Freshman Rep. Joseph Cao of Louisiana was the lone Republican to vote for the bill. He represents a heavily Democratic district, and faces an uphill re-election battle next year. His fellow Republicans were united in the reasons for their opposition. “The American people need to understand this is about a government takeover of the whole health care system,” said Georgia Rep. Paul Broun.

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Senate Majority Leader Harry Reid began private meetings Wednesday with fellow Democrats and the White House to merge his chamber’s two health care overhaul bills into a single plan that could win a filibuster-proof majority in the Senate.

Work on combining the Senate’s Finance and health committees’ bills was supposed to be, in theory at least, the less contentious part of this new phase of overhaul negotiations. But the question of what will hit the Senate floor for debate in less than two weeks remains large and open.

Reid’s task is complicated by the fact that although Senate Democrats enjoy a 60-vote, filibuster-proof majority, it is a fragile caucus that includes a handful of moderates whose votes on President Obama’s signature domestic initiative are not a given.

And already at least one of Reid’s fellow Senate Democrats, New York’s Charles Schumer, is agitating for a final bill that includes a public insurance option – something missing from the measure passed this week by the more conservative Senate Finance Committee.

“In one sense, the debate begins all over again,” says Bob Moffit, director of health policy studies at the conservative Heritage Foundation.

The long-awaited $829 billion proposal approved Tuesday by the Senate Finance Committee with a single Republican vote “concludes one big chapter of the health care debate,” Moffit says. “But you’re not going to see that bill again.”

Opposition Pumps Up The Volume

Schumer wasn’t the only one stirring the pot in the wake of Tuesday’s vote.

Interest groups have ratcheted up their message machines this week – from insurers denouncing the Finance Committee proposal for failing to require that all Americans obtain coverage to unions balking at proposed taxes on generous benefit packages.

So Reid, with a tough re-election battle back home in Nevada and a looming showdown with House Speaker Nancy Pelosi over her chamber’s competing legislation, has to devise a strategy that not only melds the Finance Committee’s bill with the more liberal offering from the health committee but still gives the president a win.

There are a few certainties: There is little doubt that the ultimate Senate bill will include changes that prohibit insurers from denying coverage to Americans with pre-existing health conditions or canceling coverage when a policyholder gets sick.

And both Senate bills contain similar provisions for creating state-based insurance exchanges – or pools – that can be used by poor and low-income individuals and families, and small businesses, to purchase more affordable coverage.

The Finance Committee’s plan to expand Medicaid coverage to more poor Americans is also expected to make the final bill, though details on how to pay for it – and for many other bill provisions – have yet to be worked out.

But the Finance Committee bill is the only proposal that does not include a government-run plan, and it does not require employers of a certain size to offer coverage to its employees.

“Do you impose an employer mandate that unions want, but employers will fight to the death?” Moffit asks. “Do you include a public plan that moderate Democrats don’t want? Do you impose an individual mandate?”

Those big, fundamental questions are unanswered, says Michael Tanner, a senior fellow at Cato Institute. “There are real problems yet to be resolved,” he says. “This is not even halfway there.”

Different Mandates, Different Parameters

The Senate Finance Committee bill would require that most individuals obtain insurance, but its proposed phased-in penalties for failure to comply are nominal and would do little, critics argue, to encourage insurance purchase.

It proposes that penalties of $200 per adult begin in 2014 and reach $750 by 2017. The Senate health committee has proposed a penalty of up to $750 a person, with no phase-in period.

The insurance industry had banked on a vastly increased pool of potential clients under a mandated-coverage plan. Now the industry is attacking the Finance Committee’s proposal as guaranteeing an increase in the cost of premiums.

Also at odds are the competing Senate committee proposals for employer mandates, which have emerged as one of the stickiest issues Reid faces.

The Finance Committee would require that businesses with more than 50 employees foot the bill for government insurance subsidies for which their workers may qualify. The health committee bill demands that employers pay for part of the cost of worker coverage or face a penalty. Both bills include exemptions for small employers.

A merged Senate bill will very likely include both an individual and employer mandate, but just who will be exempted is expected to be one of the issues dominating closed-door sessions over the coming days.

Meeting Obama’s Objectives Without A Public Option

Schumer may be pushing hard again for a public option to be included in the final Senate bill, but Obama suggested Tuesday that the Finance Committee bill – sans public option – brought Congress closer to achieving the president’s core objectives: dramatically expanding the number of Americans covered by insurance, and bending the cost curve.

Len Nichols, director of the health policy program at the nonpartisan New America Foundation, said there has been “fertile thought” around an alternative to a full-blown public option.

That alternative, he says, could be some kind of a melding of so-called trigger proposals advocated by both Democratic Sen. Tom Carper of Delaware and Sen. Olympia Snowe of Maine, the only Republican on the Finance Committee to vote for the proposed overhaul plan.

Under a trigger plan, a public insurance option would kick in if a state fails to meet federal insurance coverage goals.

“I would not be surprised at all to see that emerge” from the Senate’s bill-merging discussions, Nichols says.

“Some kind of trigger is the best way to square the circle,” he says. “It shows the right that there’s no government takeover going on here, and moderate Democrats can get onboard.”

But on Capitol Hill Wednesday, Reid said he wanted to note where he stands at the start of bill negotiations.

“I believe in a public option,” he said, adding, pointedly: “Remember: I said I do.”

A Win For Obama?

And that may be the path to what Obama could define as success on his signature domestic issue.

Even with a plan emerging that would contain an alternative to a full-blown public insurance option, and with considerably watered-down mandates for individuals to buy insurance and employers to pay for at least some coverage costs, the White House would most likely declare victory.

“The reason this is historic has almost nothing to do with the specifics,” Nichols says, “but [with] the commitment now on the part of five congressional committees to make health insurance and health care affordable for all Americans – and to simultaneously bend the cost curve.”

“We’ve never gotten this far before,” he said.

But, for overhaul opponents, the game has only begun – and it will play out in the home districts of members of Congress facing re-election in 2010.

“If this is defeated, it will be defeated at the grass-roots level,” says John Goodman, president and CEO of the National Center for Policy Analysis, which has gathered the signatures of more than 1.3 million who oppose the “nationalization” of health care.

“There is,” Goodman says, “a real intense battle going on out there.”

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A few months ago, Republican Sen. Chuck Grassley of Iowa positioned himself to be the key GOP player in negotiations to advance President Obama’s top domestic priority – overhauling the nation’s health care system.

As ranking minority member on the Senate Finance Committee, Grassley has been a leading voice in the committee’s bipartisan “Gang of Six” that had been struggling to hammer out a bill before Congress recessed for August.

But Grassley’s evolution – from legislator once complimented by Obama for his willingness to work across the aisle to one of the president’s chief critics on health care – is a sign that the chances for passing a bipartisan health care bill have all but disintegrated. And as Grassley has pivoted from defending bipartisan work on a Senate bill to criticizing a competing House bill, he has increasingly sown confusion over just where he stands in negotiations to overhaul health care.

In the process, the five-term senator criticized the president as “intellectually dishonest” and prompted some Democratic leaders to say efforts at a bipartisan deal are dead. He has also drawn sharp criticism himself for echoing in recent days the questionable argument that a Democratic plan would ration health care for seniors.

In an interview on Wednesday, Grassley insisted he is still interested in working toward a bill with broad-based appeal, though his assertion this week that he would vote against any bill – even one he supports – if it fails to attract wide GOP support has raised questions about his commitment to bipartisan negotiations.

What happened to Grassley the compromiser, who less than four months ago hailed the momentum Obama created for a health care overhaul and touted the promise of “bipartisan health reform proposal”?

Those questions make Grassley bristle.

“I’m sitting down talking with the idea that we come out with a product,” he told NPR Wednesday. “I’ve said that we’ve got to have a bipartisan bill, and bipartisanship is not three Republicans and 58 Democrats.”

“You asked me why I said lately that I would not be going with a bill that got a few votes,” Grassley said. “I’ve been saying that all year. You’re asking me a question like I just said it…”

“I’m not going to walk away from the table,” he said. “If I get away from the table, it’s because I’m pushed away from the table.”

But in recent days, Grassley’s comments suggest that he’s doing some of the pushing. During town hall meetings in Iowa, he alluded to government programs that would “pull the plug on Grandma.” He recently engaged in a tit-for-tat Twitter argument over health care “death boards” with Sen. Arlen Specter, a Pennsylvania Democrat. And he invoked gravely ill Sen. Edward Kennedy when inaccurately suggesting that under a British-style, state-run health plan, the Massachusetts Democrat would have been denied treatment for cancer because of his advanced age.

“I regret using Sen. Kennedy’s name,” Grassley told NPR. But he said he has no regrets about comments he made about British-style health systems, or addressing concerns – real or imagined – about end-of-life issues under a government plan.

Pressure And Pushback

Partisan and ideological pressure pushed Grassley back from working too closely with Democrats on a health care bill, says political analyst Charlie Cook, along with an altered political world where the public’s appetite for systemic change has receded dramatically over the past year.

“The pressure has been really intense to hold ranks and not give Obama a victory,” says Cook, the publisher of The Cook Political Report. “And, ideologically, this health care overhaul has been tough for conservatives to swallow.”

When Grassley said that he would not back a bill that didn’t attract wide GOP support, he was simply engaging in an unusual moment of political candor, Cook says.

“If he can’t bring along the Dick Lugars, the George Voinoviches and other Senate Republicans who might be open to something,” Cook says, “he’s wasting his time.”

Says Grassley: “We’re restructuring 16 percent of the gross national product. Health care is a life-or-death issue for every person in America, and my principle has been the same as [Montana Democratic] Sen. [Max] Baucus’s during this whole year of discussion of health care – that it ought to be done on a broad, consensus basis, which we’ve always signaled is 70 to 80 votes.”

A Target For Upset Conservatives

Back home in Iowa, long before the boisterous town hall meetings of summer, Grassley was kicked around by conservatives after he attended the president’s spring health care forum at the White House. Though he argued that it was better for his party to have a seat at the table than not, critical letters to the editor began appearing in local newspapers, and conservative pundits on cable television made Grassley, up for re-election next year, a favorite target.

“He’s an example of a leader who is genuinely trying to make something happen and winds up getting hit from both sides,” says David Yepsen, the former Des Moines Register political reporter who followed Grassley for decades.

“But he understands his state and has a very tough chasm to bridge back there,” says Yepsen, now director of the Paul Simon Public Policy Institute at Southern Illinois University, Carbondale.

Though Iowa went for Obama over GOP nominee John McCain in the presidential election last fall, the state’s Republicans earlier made former Arkansas Gov. Mike Huckabee – who stressed his Christian conservative credentials – their top choice in the statewide caucuses. And last year, they ousted their longtime national party committee members and replaced them with more conservative picks.

Iowa remains a largely conservative place, says Diane Bystrom, director of the Catt Center for Women and Politics at Iowa State University. Grassley increasingly felt the heat, she says, as opposition to health care became entrenched on the right, and more false rumors and innuendo spread about plans being considered in the House and Senate.

“Sen. Grassley’s conservative credentials were being questioned at town meetings, and his pushback was to make sure his meetings were crowd pleasers,” Bystrom said.

No Peril At Home

Though part of Grassley’s strategy may be electoral self-preservation, there are no indications that he’ll face any serious challenge next year if he runs for a sixth term, as he has said he will.

“Charles Grassley isn’t in danger in this state,” says Bystrom, noting that the senator has been elected with more than 65 percent of the vote since his second term and pulled in 70 percent in 2004.

So, just what will Grassley do when Congress reconvenes in September and will again take up health care negotiations?

“The short answer is, we just don’t know,” Cook says.

With the president’s proposal for a public insurance option withering on the vine, Grassley says he is among Republican senators more amenable to the alternative of yet-to-be-defined health care co-ops, owned and managed by members. The concept is familiar in rural states, where agriculture and utility co-ops have been around for decades.

“I can support co-ops if they want to do it as we’ve known co-ops in America for 150 years – where they serve the purposes of the consuming public, whether it’s health care or whether it’s co-ops as we know them in the Midwest, providing electricity or to sell supplies to farmers,” Grassley said.

He opposes suggestions by Democrats like New York Sen. Chuck Schumer to create a national co-op, characterizing it as moving “right back to a public option.”

The Future Of Bipartisan Progress

Grassley’s commitment to bipartisan negotiations may become clearer Thursday evening when Baucus, chairman of the Senate Finance Committee, has scheduled a teleconference with his fellow Gang of Six members. Baucus said the group will meet again before Congress reconvenes.

Grassley says any deal will have to reflect the position of the GOP caucus: “No public option, no pay-or-play, no things that are going to lead to any rationing of health care, no interference with doctor-patient relationships, and tort reform.” A pay-or-play mandate would require employers to either provide employee health coverage or pay a tax to a national fund that would provide coverage.

The ball, as Grassley sees it, is in the Democrats’ court.

“Have you ever stopped to think that maybe 40-45 percent of the Democrats are so liberal they think that Baucus shouldn’t be talking to any Republican?” Grassley said. “So it seems to that [Baucus] has some problems. It seems to me that [House Speaker Nancy] Pelosi has signaled problems.”

“And I see a lot of stuff coming out of the White House this week that is very defensive,” Grassley said.

In a statement released Wednesday, Baucus asserted that “bipartisan progress continues.”

“The Finance Committee,” he said, “is on track to reach a bipartisan agreement on comprehensive health care reform that can pass the Senate.”

Whether Grassley will be part of that deal is anybody’s guess, but the odds, this week any way, appear long.

From The Senator

NPR caught up by phone with Grassley on Wednesday, while the senator was on a bus tour of his home state. Here are some excerpts from that interview, about the ongoing health care overhaul negotiations:

On the circumstances in which he would stop negotiating with the other members of the Senate Finance Committee’s bipartisan “Gang of Six”:

“I’m at the table to represent the interests of my party in overall reform. … I’m also at the table because Iowa … has high quality and low reimbursement under Medicare. I’ve got to be at the table to represent Iowa’s interests to see that we don’t continue to get screwed by Medicare. And so I’m at the table for those reasons. And I’ve always said I’m not going to walk away from the table. If I get away from the table, it’s because I’m pushed away from the table.”

On whether the public insurance option is dead, given Health and Human Services Secretary Kathleen Sebelius’ suggestion Sunday that the public option is “not the essential element” of a health care overhaul:

“I believe it is. There again, you send up a trial balloon like [Sebelius] did last Sunday on talk shows and you think, yeah, well, maybe the president is taking my advice when I gave it to him a week ago. … I said something like, ‘Can you make a public statement that you would sign a bill without a public option?’ He didn’t answer me, but I saw [Sebelius’ comments] as a trial balloon. And then the next day I saw him backpedaling.”

On whether, absent a public option, he could bring any more Republicans onboard:

“I can’t really answer that question until you have a product to show them. Don’t forget, there’s no point in my talking to Democrats if I can’t get Republican support – because that’s my goal.”

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No matter which side of the issue members come down on, they will find that the people who put them in office remain deeply confused about what the still-being-written overhaul might bring.

And most Americans are equally suspicious of – and confused by – claims being made by both supporters and opponents of President Obama’s most ambitious domestic initiative.

With Congress still struggling to fashion legislation and Obama letting the details take shape on Capitol Hill while he sells its broader parameters during appearances that include town hall meetings, most outside Washington have no idea what the overhaul will look like, what it will cost and how it could affect them personally, says Mark Blumenthal of Pollster.com.

“Much of this story has been a big, inside-Washington debate about cost and bending the cost curve,” he says. “It’s a remote, technical discussion.”

Polls show that the delays in reaching agreement on a bill – coupled with growing concern about the billions already spent on bailouts and the stimulus package – have spurred skepticism about whether Obama’s biggest domestic initiative will help the country, and who it will benefit.

‘Babble’ From D.C.

Iowa’s senior Sen. Chuck Grassley, a Republican, has been one of a half-dozen Senate Finance Committee members who have been struggling to piece together a bipartisan bill.

But that proposal, senators have said, won’t be ready until after the August recess. That means voters back home, desperate for concrete information about the overhaul, will have to wait longer for clarity.

And after the Senate leaves for recess this week, Grassley is guaranteed to face the same questions back in Iowa that Congress members will face across the country. That group includes Grassley’s fellow Iowan Rep. Bruce Braley, who is part of a group of House Democrats fighting for a fix in disparities in how Medicare reimburses rural and urban health care providers.

“There is intellectual acceptance that health care is a problem and that it costs too much,” says Graham Gillette, who runs his own public relations strategy company in Des Moines, Iowa. “But for most Americans, the confusing babble that’s coming out of Washington sounds worse.”

“And after the fear-mongering and mud-throwing of the last few weeks,” he says, “that’s not hard to understand.”

In Iowa, a national labor union has aired television advertisements that targeted Grassley’s support for a proposal that would tax health care benefits. The state’s Democratic and Republican parties have stepped up their rhetoric in anticipation of the August recess. Volunteers who helped Obama win the Iowa caucuses last year are being recruited to make phone calls to remind supporters that a national health care overhaul was one of the reasons they voted for him.

The Need Is Clear

For the past decade, David Lind’s company, based in Clive, Iowa, has conducted an annual survey assessing the state of health insurance in the Hawkeye State. It’s meant for his clients in the employee benefits sector.

What his surveys have found, he says, reflect not only conditions in Iowa but around the country. The numbers are sobering.

“We have found in the past 10 years, health insurance premiums have basically doubled,” he said. “That mimics what we’ve seen on a national basis.”

Employers facing these dramatic increases in premiums have increasingly had to pass costs to their employees, Lind says, by increasing deductibles that employees pay and hiking co-pays for office visits and prescription drugs.

The average deductible for a single person in Iowa has increased 200 percent over the past decade; family deductibles have gone up 180 percent over the same period, his data show. And the smaller the employer, Lind says, the higher the employee deductibles and copay requirements.

“Rather than drop health insurance, employers are reconfiguring plan design and ratcheting the [employees’] cost share upward,” he said. “But employers are still taking the brunt of the increases in premiums.”

Frog In A Pot

Des Moines-based pollster J. Ann Selzer likens the situation to the old frog-in-the-kettle analogy: “People are like frogs in a pot of warm water, with the temperature slowly rising,” she says. “It feels warm now – but they don’t realize how hot it’s getting.”

For many, she says, the status quo holds appeal – particularly in the face of heavy push-back from Republicans opposed to the tenets of Obama’s overhaul goals.

Lind says his clients are particularly concerned about the status of a proposed public insurance plan that would compete with private insurers.

“There needs to be a meaningful discussion about what it means to actually have a public plan next to a private plan, so there isn’t a hidden tax,” he says.

“The dialogue seems to be more about politics than what’s really happening,” Lind says. “Let’s get all the facts out there, have complete transparency of what it looks like, and then we can apply the facts to it.”

A Message Problem

When pollsters ask straight-up questions about whether people favor or oppose revamping health care, there is a little more opposition than support, Blumenthal says.

But when the surveyors ask more specific questions about what the plan might include, there is “remarkably consistent support in the 50-55 percent range,” he said.

What hasn’t been communicated well enough to the folks back home is what an overhaul could do – including guaranteeing that you won’t lose your insurance if you change jobs, for example, or if you have a pre-existing medical condition, Blumenthal says.

“I don’t get a sense that Americans have a very good idea of what the ‘it’ is,” he says. “In the absence of a real strong case being made for this [what’s happening] is that people are hearing and processing messages from the other side.”

The Politics Of Confusion

People are confused, and there’s the fear of the unknown, says Gillette, who volunteered for Obama in Iowa during his presidential run. And that uncertainly is compounded by the complexities involved in the administration’s push for sweeping changes in one big overhaul bill.

“If Washington could have broken the problem into pieces – cost containment, for example, and insurance portability – they could have hammered out some agreements and given people some confidence that progress was being made,” he said.

“The approach they took was almost all-or-nothing,” he says. “That is confusing, and, to many, scary.”

And that’s what Grassley and his congressional colleagues will face in coming weeks: confusion, skepticism and the still-lingering question of what the overhaul will look like and what will it mean for households in Iowa and beyond.

“The play’s not over yet,” Blumenthal says. “But proponents will be in a much better position to sell it when they have something concrete.”

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