WASHINGTON — Why is it so difficult to get an agreement on overhauling America's health care system?
There's a simple answer: "It's going to affect everybody," said House Education and Labor Committee Chairman George Miller, D-Calif.
The changes also could have a long-lasting effect on the federal budget and the economy, and the debate involves high-stakes politics that pits President Barack Obama against Republicans.
Next week is the last week that the House of Representatives is scheduled to meet before leaving for a five-week summer recess. House Speaker Nancy Pelosi, D-Calif., hasn't ruled out a vote on health care legislation, even though an estimated 40 to 45 moderate Democrats say they won't vote for the leadership's plan unless major changes are made.
"We will take the bill to the floor when it is ready, and when it is ready we will have the votes to pass it," Pelosi said. "I don't know that we would even have to stay any longer than our regularly scheduled departure."
The Senate, though, won't take a final vote until September at the earliest. If the two houses pass legislation, a negotiating committee then would reconcile differences, pushing final passage into late fall, if then.
That's a long timetable for the major initiative of a president who was elected with 52.9 percent of the popular vote, who until two weeks ago sought action by the August recess. Ronald Reagan won approval of his major tax and spending cuts in 1981 before Congress left for the summer, and 20 years later George W. Bush got his tax-reduction plan approved by Memorial Day.
Those were very different kinds of bills, however, because while they could change consumer and business behavior, they didn't have the potential to affect daily lives the way health care changes can.
"Health care is the one thing in American life people really don't budget for," explained Rep. Gene Taylor, D-Miss. "You buy a house or a car you think you can afford, but when it comes to health care, you do whatever it takes."
While no final legislation has been written, key Democrats agree on some provisions.
There's strong support for creating health insurance "exchanges" where people could compare the costs and coverage of different private plans and would be offered a government option. Most employers would have to offer coverage or pay a tax or fee. Individuals would have to buy coverage or pay a fee or fine, though hardship cases would be exempted.
The government would offer aid to people with lower incomes, generally $88,000 for a family of four and $43,000 for individuals.
However, the bills are massive — the House version is 1,018 pages — and despite Obama's repeated assurances that consumers will be allowed to continue getting their current care, lawmakers are nervous and are having a difficult time explaining the changes back home.
One reason is that people instinctively fear radical change, especially to a system they've grown to trust.
"When you walk around the hospital, you get the same feeling you do when you walk around a military facility. Some things may be really old, but some are the latest thing. They have the best stuff," said Rep. David Wu, D-Ore., an Education and Labor Committee member.
Then there's the fear that any plan will mean a big increase in taxes.
The House Ways and Means Committee wants to raise $544 billion from a surtax on the adjusted gross incomes of America's wealthiest people. The provision has proved unpopular with Republicans and moderate Democrats, who fear that small businesses will be unduly hurt.
They want to find more cuts and savings, but doing that could alienate liberals and members of the Congressional Black Caucus, who fear that any more cuts would disproportionately affect people who have the toughest time affording care.
Even if these problems are ironed out, there are fiscal and political problems.
Moderate Democrats and Republicans don't want to go home and say that health care changes increased the already record-high federal deficit. A report from the nonpartisan Congressional Budget Office earlier this month said that the bill proposed by House Democratic leaders would add another $239 billion to the deficit over 10 years.
Pelosi tried to discount the report, saying that the CBO "will always give you the worst-case scenario." The report dampened enthusiasm for change even further, however, and gave Republicans fresh ammunition.
Democrats' plan, charged House Republican Conference Vice Chair Cathy McMorris Rodgers, R-Wash., is a "prescription for failure as it relates to actually controlling costs (and) making health care affordable; a prescription for failure in the impact that it's going to have on our economy."
Underlying all this criticism is the drama playing out daily on the issue: It's the biggest test so far of Obama's presidency. Even though the president says it isn't a personal challenge, it is.
His top lieutenants have been all over Capitol Hill, meeting behind closed doors with key members of Congress day after day, trying to work out a compromise, largely without success.
Republicans have stoked the fire. If the plan fails, said House Republican Whip Eric Cantor of Virginia, "This administration, this president, has no one else to blame. They have no straw men; they have no press conferences left."
Democrats pin their hopes on a broader argument: While people may like their doctors and appreciate their hospitals, they see the health care system as an expensive mess.
"People know the system is not well designed, because they've had a lot of personal experience," Miller said.
Change won't come easily, however, Wu added.
People may approve of 80 percent of the proposed changes, he said, but have trouble with the other 20 percent. The problem, he said, is that "Everyone has a different 80/20 split."
Doctors, nurses, consumers all want something different. "We think we're this close," Wu said, "but that last little bit is really, really hard."
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