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Next phase in health-care debate: The art of the deal

Most negotiations are taking place in private. But the tidbits that have emerged hint at the remaining contentious issues.

Some of the nation's largest employers have appealed to Reid and home-state senators to remove language that would require large firms to immediately enroll new hires in the company health plan. Corporate executives say the provision could add unnecessary burdens, because some employees receive coverage through a spouse, a parent or the government. Reid has not indicated how he will handle the request, industry sources said.

Labor unions are lobbying against a Senate proposal to tax higher-priced insurance policies. It is another tough call for Reid, who is engaged in a tight reelection campaign: Unions provide legions of campaign foot soldiers for Democrats, but the tax is a core element of financing health-care reform.

Physicians are still pressing for a technical change to Medicare payment formulas that would translate into an extra $250 billion over the next decade. Reid could not secure the money last week, leaving the powerful American Medical Association decidedly noncommittal about a broader overhaul.

"The doctor situation is a huge wild card," said Rep. Jim Cooper (D-Tenn.). Without the increase in Medicare rates, reform offers "pretty thin gruel from the doctors' perspective."

Even recent attacks by the insurance industry are "not so much an attempt to block the legislation," Altman said, but rather a "recognition the legislation is likely to pass, and they're trying to gain leverage on the fine points that really matter to them in the final bill."

He added: "All these details make people's eyes glaze over, but they mean billions to an industry."

Lobbyists are not the only ones flexing their political muscles. Lawmakers see an opportunity to rework the legislation more to their liking.

In the House, at least five groups have formed around particular concerns, said Cooper, who is among the contingent pushing for greater cost savings. The others include: antiabortion activists, small-business proponents, ardent liberals, and a band focused on reducing geographic disparities that often hurt rural areas.

In the Senate, where Reid needs every Democrat and the chamber's two independents to back him on procedural votes, each lawmaker holds enormous sway.

Sen. Ben Nelson (D-Neb.) drove home that point Sunday when he said it would be "reckless" to promise prematurely to stand by his party. "I can't decide about the procedural vote until I see the underlying bill," he said on CNN's "State of the Union."

Administration allies said Obama will return to his role as chief salesman when it becomes clear exactly what he is selling. Behind the scenes, he continues to nudge lawmakers without making explicit demands, Capitol Hill staff members said.

"He will have to determine when things are just bogged down temporarily and when they are more permanently stuck," said one Democrat close to the White House. The source, who discussed strategy on the condition of anonymity, said Obama still prefers to wait until the final negotiations, known as a conference committee, but that may not be possible.

With perhaps two full months of haggling to go, Obama's top policy goal is still far from reality. But both sides sense a shift in the political calculus.

"Democrats have concluded it would be to our political and policy detriment if we don't" enact reform this time, Jennings said, reflecting a theme sounded by the Obama White House. "With each step forward, it's harder to turn back."

Sen. John McCain (R-Ariz.) predicted that Democrats will have the votes to pass a bill.

"They don't want a repeat of the Clinton failure in 1994," he said on "Face the Nation." "So I think it's likely they will get something through. But it's not clear to me what it is."

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