This time it's really going to happen. Or so they claim.
Senators get down to work this coming week on turning ideas into legislation to cover some 50 million people without health insurance and contain costs for everyone else. Hopes are high that Democrats and Republicans can find common ground for a bill to emerge by summer.
They will have to defy history.
Grand plans to revamp health care have a half-century history of collapsing. More focused proposals, such as the creation of Medicare in 1965, have succeeded.
Lawmakers far apart on issues
Lawmakers are far apart on some of the most important issues today, from the reach of government to the responsibilities of employers and individuals. And guaranteeing coverage for all could cost $1.5 trillion over 10 years, an eye-popping sum in a time of recession and mounting national debt.
Yet major constituencies often at odds are now clamoring for change. They range from consumer groups to insurers, from employers to doctors and hospitals. President Barack Obama has pledged to chip away at hardened ideological positions to find compromises.
"This is the toughest issue we have ever taken on — every part has got a chance of blowing up," said Iowa Sen. Charles Grassley. He is the top Republican on the Senate Finance Committee, which oversees government health programs and taxes, and plans to start work Tuesday.
Appealing to the middle
Grassley said he is reasonably confident that he and the chairman, Sen. Max Baucus, D-Mont., can produce a bill that appeals to the middle. "Our only hope is if we do it in a way that keeps the vast majority of both parties going in the same direction," Grassley said.
Sen. Ron Wyden, D-Ore., sees opportunity. "There is a very appealing philosophical truce within the Senate's grasp," he said.
"Democrats are right on the idea that we've got to cover everybody. Republicans have been right on the role of the private sector, not freezing innovation and staying away from price controls," Wyden said. "You meld those philosophical views and you are on your way to 68 to 70 votes."
Consensus is growing on many points: Changes should build on the current system, not scrap it; hospitals and doctors should be paid for quality, not quantity; insurers shouldn't be able to discriminate against people with health problems; small businesses need special attention.
But huge differences remain. Three of the hardest issues are:
Obama set aside $634 billion in his budget as a "down payment" for health care over 10 years. Many experts believe that represents less than half the cost. Covering the uninsured could cost $100 billion to $150 billion a year, or more.
Liberal Democrats want to follow Obama's example and get half the money from tax increases and half from spending cuts. Upper-income tax increases and sales tax increases on alcoholic beverages, tobacco products and even sugary sodas are being discussed.
But Republicans and fiscally conservative Democrats want most of the financing to come from spending cuts and from making the health care system less wasteful.
Health insurance is based on pooling risk: premiums from the vast majority of healthy people cover care for the sick. For the system to work, economists say, everyone should have health insurance from the outset so uninsured people don't end up going to the emergency room and driving up costs for everyone else.
Because insurance is expensive, requiring people and businesses to pay for it is politically difficult. Most people now get insurance from their employers, but companies aren't required to offer it and as the economy skids more have cut back.
Obama and Democrats are considering a combination of requirements on individuals, parents and employers, with exemptions for small businesses and sliding-scale subsidies for families making as much as $80,000 a year.
Republicans opposed an employer mandate in the 1990s, but have mixed views on an individual requirement. The insurance industry is supporting an individual mandate. Labor unions are pushing for employer mandates.
Obama and the Democrats want to give middle-class workers and families the option of joining a government-sponsored insurance plan that would be offered alongside private ones through a new insurance clearinghouse.
Supporters say a public plan could be a testing ground for innovations and a check on private insurers. Republicans see it as a thinly disguised step toward a government-run system. Insurance companies say they wouldn't be able to compete with a government plan.
Efforts are under way to find a compromise, maybe by limiting the scope of the public plan. But Rep. Dave Camp, who is playing a leading role in the House, said he doesn't think a deal is possible. "The public plan is a bright line for us," said Camp, R-Mich.
Senators begin their work in public Tuesday at a Senate Finance Committee meeting on how to change the health care delivery system to make it more efficient. They will meet the following week in closed session to consider specific proposals that would affect doctors, hospitals and other medical providers.
Similar sessions are scheduled on expanding coverage and paying for a revamped system. Leaders are hoping the committee can vote on a bill by mid-June.
Separately, the Senate Health, Education, Labor and Pensions Committee is working on a complementary bill, with the goal of merging the two in the full Senate. It's unclear whether Senate Republicans will offer their own bill.
In the House, the Democratic leadership aims to introduce legislation by late June. The bill will be considered by three committees that share jurisdiction over health care. Republicans are planning to offer their own measure.
Democratic leaders want the full House and Senate each to pass legislation before Congress leaves town for its August break.
Democrats probably will allow the use of a legislative device that would let them pass a health bill in the Senate with 51 votes, instead of the 60 needed to defeat a filibuster. Republicans say that would be an act of bad faith and could poison chances for a deal.