From the start of his presidency, Barack Obama made clear that his plan for enacting comprehensive health-care reform came down to three words: fast, broad and bipartisan.
That was then.
Now, as lawmakers begin to flee Washington for a month-long recess, the White House team is retooling its message and strategy, hoping a more modest approach will reinvigorate Obama's signature domestic policy initiative and give him a first-year victory for Democrats to carry into the 2010 midterm elections.
Legislative wrangling, a well-coordinated Republican opposition and the sheer complexity of an issue that consumes nearly one-fifth of the nation's economy have taken a toll on the president and his bold ambitions. Polls show that support for Obama's handling of health reform has declined as anxiety deepens about its effect on middle-class, insured Americans.
"There was a view that because of the recession this could be sold as an economic fix," said Howard Paster, President Bill Clinton's legislative affairs director in 1993. "That's not selling. The public has spoken loudly."
With the debate shifting from partisan-charged Capitol Hill to the kitchens, diners and churches of America, Democrats are under pressure to counter the GOP's "risky experiment" story line.
Four congressional committees have approved bills, largely on party lines, that would require that every person carry health insurance, would offer credits to families and small businesses that have trouble affording coverage and would begin to realign financial incentives toward performance-based care.
A key fifth committee in the Senate is negotiating a more centrist bill, which could pave the way for a less-ambitious compromise.
"Over the next few weeks, we must build upon the historic consensus that has been forged and do the hard work necessary to seize this unprecedented opportunity," Obama said Saturday.
Eyeing success
By leaving the bill-writing up to Congress, Obama is better-positioned to claim success no matter which bill is adopted. Already, he has abandoned his opposition to the proposed requirement that everyone have insurance, known as an individual mandate, and signaled a willingness to consider financing schemes -- including tax increases -- that originally were not on his agenda.
His patient, hands-off style -- reminiscent of his methodical primary campaign last year -- has frustrated some anxious Democrats but stands in stark contrast to Clinton's unsuccessful strategy of crafting a 1,300-page bill in secret and then pressing lawmakers to approve it.
Both political parties and dozens of interest groups intend to be heavily engaged throughout August with television ads, door-to-door campaigning, traditional town hall meetings and Internet-based, grass-roots activities.
Health and Human Services Secretary Kathleen Sebelius, previewing a hectic month of travel for the entire Cabinet, makes appearances in Philadelphia on Sunday and Connecticut on Monday. Obama, too, will strike out beyond the Beltway with large rallies to energize supporters.
Emphasizing market reforms
Guided by polls, the administration intends to emphasize insurance market reforms -- prohibiting practices that have made buying coverage impossible or excessively expensive for many who are sick, older or had a prior illness. The theme of Sebelius's event Sunday with Sen. Arlen Specter (D-Pa.) and a webcast Friday is "Health Insurance Reform: What's in It for You?"
Those regulatory changes -- included in every bill in Congress -- address the most common frustrations of the 180 million people who have health insurance.
"If you're an American with insurance, you're saying, 'Where am I in this debate?' " said senior White House adviser David Axelrod. "We want to make sure that people understand" the many items in the legislation targeted to such individuals.
Axelrod acknowledged that two critical constituencies -- senior citizens and women -- need to be reassured that reform will translate into the "security and stability" that Obama promises. "That's work that we need to do," the adviser said in an interview.
For months, the White House assiduously courted industry trade groups, attempting to neutralize historically powerful opponents of change. But the talking points for the August recess have moved to a sharper critique of business interests. House Speaker Nancy Pelosi (D-Calif.) and top lieutenants have warned that they are not bound by deals the White House struck with drugmakers and insurers.
"The glory days are coming to an end for the health insurance industry," she said Friday.
The shift may be more than rhetorical.
Speaking of the 100 members of the Senate, White House health czar Nancy-Ann DeParle said: "I could get 100 votes" on the insurance changes being touted by Obama. If Congress enacted only the insurance provisions, it would still represent a significant achievement, though far less than the broad overhaul many expect.
Administration officials have also begun whispering a phrase used during the presidential campaign, speaking of putting the nation on a "glide path" to universal coverage rather than the insurance-for-all trumpeted by many Democrats. Though few remember, Obama never promised coverage to all 47 million uninsured Americans. A slower, phased-in attempt to cover everyone would help reduce the cost of legislation.
"A bill that gets us on a glide path is a win," said one Democratic strategist who recently visited the White House and spoke on the condition of anonymity because he is not authorized to comment on administration strategy.
Many of Obama's problems of the past six weeks mirror the natural course of a new president pursuing a broad agenda. Although some allies question the wisdom of Obama's get-it-done-now approach, Republican pollster Bill McInturff said it made sense. "The longer legislation is around, inevitably the more you focus on the pain part," he said.
Weakening his brand
The Obama brand -- long the envy of politicians of every stripe -- has weakened as voters examine a record that has thus far entailed huge government spending to help the economy, said McInturff, who was a key strategist in the defeat of the Clinton plan.
"This is not irrevocable, and it doesn't mean the fate of health care has been settled," he said. "We're going into this incredibly intense period where the fight for the hearts and minds of these members of Congress will be substantial."
Sen. Robert F. Bennett (R-Utah) said, "Voters will punish people if we don't move ahead." But he and other senators have voiced frustration at being shut out of the negotiations.
Splits
Democrats say they are concerned that they are losing the message wars and facing substantive disagreements within their ranks.
"Americans are asking what's in it for them, and I don't think the Democrats have responded as directly as we should on that," said Sen. Sherrod Brown (D-Ohio). With so much attention focused on the legislative brawls and missed deadlines, he said, "it looks like we're drifting."
Sen. Ron Wyden (D-Ore.) fretted that the debate has been "dizzying" for the average American and that "there's an awful lot of substance that needs to be fleshed out as well."
Sen. John D. Rockefeller IV (D-W.Va.) said that there is sufficient time for Congress to deliberate but that Obama should be "very aggressive" this month in rebutting attacks by well-funded interest groups. "He's got to get tough," Rockefeller said, "maybe tougher than he's ever been."
The tensions have prompted Senate Democratic leaders to revive threats to use a parliamentary procedure to force health-care legislation through on a simple 51-vote majority rather than a filibuster-proof 60 votes.
A month away from Washington may provide a much-needed "breather," as Rockefeller put it. But there are inherent risks for Obama when lawmakers who have yet to cast a vote are exposed to four weeks of intensive lobbying at home.
"He needs to make sure he doesn't have a lot of defections" by Democratic lawmakers or industry groups that could return in September with new demands, Paster said.
"His first year is going to be judged by how well he handles this issue," Paster continued. "If there is a health bill by Christmas, it will be deemed to have been a good first year."
More on: Health reform | Obama