Health Reform: Can the Democrats Cross the Finish Line?

After months of uncertainty, a road map for passing comprehensive health care reform is finally at hand, one that could send a bill to Barack Obama's desk by the end of March. But it is going to require House and Senate Democrats to put aside their mutual suspicions, join hands and take a political leap worthy of Butch Cassidy and the Sundance Kid.

Obama finally laid down his demand for action in a speech on March 3 at the White House. "No matter which approach you favor, I believe the United States Congress owes the American people a final vote on health care reform. We have debated this issue thoroughly, not just for a year but for decades," he said. "I have therefore asked leaders in both houses of Congress to finish their work and schedule a vote in the next few weeks." (See the top 10 players in health care reform.)

The path to enactment, as it is envisioned now, requires two steps. First, the House would pass the exact bill that cleared the Senate on Christmas Eve — even though it is loaded with provisions that many in the House say they would not accept in a final product. Next, the two chambers would fine-tune that bill with a set of compromises that they would pass under a filibuster-proof procedure known as budget reconciliation, which requires only 51 votes to clear the Senate.

Republicans are promising that Democrats will pay a price this fall for passing such a sweeping and controversial bill this way — and they may be right. "A raw exercise of legislative power," Senate minority leader Mitch McConnell called the emerging game plan. He vowed, "It will be the issue in every race in America this fall." Yet this use of the reconciliation procedure — ironically misnamed, given the antagonism it has stirred — would not be as radical a maneuver as Republicans claim. Created in 1974, reconciliation has been used 21 times, mostly by Republicans, who employed it to, among other things, pass two sets of George W. Bush's tax cuts. Reconciliation has often been the way that Congress has made major rewrites to health care policy; for instance, the COBRA program that allows people to continue buying their employers' coverage after they leave their jobs gets its name from the acronym for the Consolidated Omnibus Budget Reconciliation Act of 1985. (See the top 10 health care reform ads.)

The choreography on health care has been difficult in no small part because of the long-standing animosity between the two chambers of Congress. An old joke among House Democrats has it that the Republicans are merely adversaries; the Senate is the enemy. That tension has grown in the past year as House Democrats have cast a series of politically treacherous votes on such issues as health care and climate change, only to be left exposed as the measures have been shredded or buried altogether in the procedural thicket of the Senate. So it's no surprise that the inclination of House Democrats toward this most perilous vote of all has been to tell the Senate: You go first.

House Democrats are unlikely to agree to pass the Senate bill without some kind of ironclad guarantee that the Senate will actually follow through on its promise to make changes to its original measure. Among those: scaling back the so-called Cadillac tax on very expensive health care policies and stripping the bill of sweetheart deals for individual Senators, such as the now infamous "Cornhusker kickback" that Nebraska Senator Ben Nelson arranged to exempt his state from having to pay additional costs for expanding Medicaid. One possibility under discussion would have at least 51 Senators signing a letter promising to uphold their end of the bargain. (Watch TIME's video "Uninsured Again.")

But even if all these pieces fall into place, there's still no assurance that the Democrats can find the votes to pass the bill in any form — especially in the House. Speaker Nancy Pelosi has virtually no room to maneuver: since her chamber adopted its original measure in November, a death, several retirements and the defection of the bill's lone GOP supporter have cut her five-vote margin to zero. She's facing revolts in her caucus on a number of fronts; dozens of Democrats, for instance, have given notice that they will not accept the Senate's more liberal language on abortion coverage — something that cannot be fixed through reconciliation.

Ultimately, Pelosi may have to change the votes of a handful of conservative Democrats who voted against the original House bill in November. She'll argue that the newer version is smaller and less expensive. It also does not include a government-run public option for providing coverage to the uninsured — a provision of the original House measure that had been anathema to those who saw it as the leading edge of what they feared would be a government takeover of health care.

Voting for health care may well end the careers of some House Democrats; their opponents already have attack ads ready. But having come this far, Obama believes, there is something that would be even worse for the Democrats. And that would be to fail to finish the job.

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