By Ceci Connolly
Washington Post Staff Writer
Friday, September 11, 2009

One day after President Obama pitched his plan for comprehensive health-care reform to a joint session of Congress, administration officials struggled Thursday to detail how he would achieve his goal of extending coverage to tens of millions of uninsured Americans without increasing the deficit.

In two public appearances and private meetings with a dozen lawmakers, Obama promised a "full-court press," saying, "We have talked this issue to death." He also argued that new Census Bureau figures showing a slight uptick in the number of uninsured Americans only underscores the urgency of enacting major legislation this year.

The 10-year, $900 billion proposal Obama envisions borrows heavily from concepts circulating on Capitol Hill, but there was little evidence that the broad ideas are sufficient to break a congressional logjam.

After declining for months to identify himself with the details of emerging legislation, the president for the first time Wednesday embraced a set of ideas as "my plan." But the White House released scant specifics on legislation advertised as including new taxes, changes in malpractice law, a new national high-risk insurance pool, a commission on eliminating Medicare fraud, and tax credits for individual consumers and small businesses that cannot afford insurance.

"His speech was very specific and, as promised, answered the big questions about how we should proceed on providing a secure and stable health system for all Americans," White House spokesman Dan Pfeiffer said. "Many of the details will be worked out in the legislative process."

Even the president's efforts to bridge the partisan divide -- in his speech, he endorsed two ideas developed by Republicans -- were met with skepticism.

Sen. John McCain (R-Ariz.), who grinned Wednesday night when Obama embraced his idea for a high-risk pool that would serve as a safety net for people who are currently difficult to insure, was collecting signatures Thursday on a petition in opposition to the president's entire plan.

The Obama proposal is an "egregiously expensive and expansive form of government-run health care," McCain said in an online letter to supporters.

More troubling for Obama were the mixed signals from Democrats who, absent any signs of significant Republican support, have increasingly become the focus of the president's lobbying effort. After a White House meeting with Obama, Sen. Herb Kohl (D-Wis.) voiced concerns that the most prominent health-care proposals fall short.

"We all understand that we want to move toward universal coverage, but I don't think we're focusing enough on costs," he said.

Although virtually every Democrat found something to like in the president's 47-minute address, the interpretations of what he meant varied widely, suggesting more difficult negotiations ahead. On the controversial question of whether to form a new public insurance option, many liberals characterized what was widely interpreted as Obama's neutral stance to be unwavering support for the idea.

"We were pleased you explicitly expressed your support for a public option as a central piece of achieving true reform," leaders of the House Progressive Caucus wrote in a letter to Obama.

Ways and Means Chairman Charles B. Rangel (D-N.Y.) said the bill that will be sent to the House floor for a vote will have a public option "of course." But other high-ranking Democrats suggested the idea could be left out.

Senate Majority Leader Harry M. Reid (D-Nev.) said he could support nonprofit, member-run cooperatives as an alternative.

Acknowledging that different wings of the party were focusing on the parts of Obama's speech that fit their own preferences, House Majority Leader Steny H. Hoyer (D-Md.) nevertheless said the current state of affairs is far better than the infighting that led up to it. "Are you surprised that people are focused on the part of the speech they liked best?" he asked reporters. "That always happens, and we all do that. But I think we are making progress."

Democratic pollster Stan Greenberg said Obama's speech soothed voter unease over cost and probably resonated with middle-class insured Americans. "The critical step now is for Congress to move," he said.

R. Bruce Josten, a vice president at the U.S. Chamber of Commerce, however, said: "I don't think we heard anything from the president that sets Congress back on track."

The broad concepts sketched out by Obama would move the country to a health-care system in which individuals and employers share the burden of medical costs. Obama wants to give tax credits to working Americans and some small businesses to buy insurance, but he has yet to identify who would be eligible for the credits, how large they would be or how much they would cost.

Obama did specify one policy change to help pay for reform, singling out the proposal of Sen. John F. Kerry (D-Mass.) to tax insurance companies on high-priced "Cadillac" policies. Aides could not say at what level the tax would begin or how high it would be, but Pfeiffer noted that Obama has previously endorsed other financing ideas.

"From Day One, we have laid out several very specific options from within the system and to raise revenue to pay for health care. He outlined another proposal last night," Pfeiffer said. "What should be crystal clear is that the president is 100 percent committed to signing a health reform bill that does not add a dime to the deficit."

In a 3 1/2 -page document posted on WhiteHouse.gov, the administration proposes a new commission to ferret out waste, fraud and abuse in Medicare. But some aides said the proposal would give the panel authority to advance much broader changes in coverage and reimbursement rates.

The high-risk pool inspired by McCain would use federal money to help high-cost patients buy insurance while other reforms are put in place. White House aides said Congress would work out the specifics.

Many of the Obama concepts are similar to those in a blueprint drafted by Senate Finance Chairman Max Baucus (D-Mont.). The panel's bipartisan "Gang of Six" negotiators still appears to be struggling to settle basic questions, such as how much health coverage uninsured people should be required to buy, and how much the government should help to pay for it. That topic has dominated discussions in the group for at least two months.

For weeks, the group of senators has debated a proposed Medicaid expansion and whether a bill should include explicit language that would ban both abortion coverage and benefits to illegal immigrants. Baucus hopes to release his bill on Sept. 18.

"The ideal bill would be one that takes the president's specifics, mixes that with what Democrats can agree to in the Baucus plan and stretch it to hold Snowe," said Len Nichols, head of health policy at the New America Foundation.

Obama, who is emerging as the lobbyist in chief for health-care reform in what are becoming almost daily sessions with lawmakers, expressed patience -- up to a point.

"I continue to be open to suggestions and ideas from all quarters -- House members, Senate members, Democrats, Republicans, outside groups," he said after a Cabinet meeting Thursday. "What we cannot do is stand pat."

Staff writers Paul Kane, Ben Pershing, Shailagh Murray and Perry Bacon Jr. contributed to this report.