WASHINGTON — President Barack Obama and Democrats claim a voter mandate to reinvent the nation's health care system, but the path has been rutted by philosophical differences, insurance industry muscle and political survival instincts.
To understand how monumental and complicated the task has become, look no farther than Florida.
The fractured Democratic congressional delegation reflects wide-ranging opinion on how to proceed with reform and how to cover the more than $1 trillion cost of extending coverage to 47 million uninsured Americans.
Some support a "public option" plan that would co-exist with private insurance. Some don't. Some think the wealthy should be taxed. Some don't.
And some lawmakers, most prominently Sen. Bill Nelson, are avoiding saying much at all as details are hammered out to meet Obama's early August deadline.
But even as the president persists in rallying the Democratic majority — "Now is not the time to slow down," he sternly told lawmakers Friday — the problem remains so complex and costly that anything can happen over the next few weeks.
Nelson's cautious posture has brought the scorn of fellow Democrats, who this week launched TV ads, phone banks and door-to-door campaigning to rally him and others to get behind Obama.
The pressure mounts, even as many in Congress are still trying to formulate positions amid fast-moving developments.
"This is historic public policy change, so it's not going to be easy," said Rep. Kathy Castor, D-Tampa. "But based on what folks are saying at home, they are ready and want us to stand up to insurance companies and get it done."
Castor, who as a member of the Energy and Commerce Committee is helping shape the House package, is a proponent of the public option, which would create a government-run program for those who cannot get or afford private health coverage.
"That is the key to lowering the cost of health care for families and businesses," Castor said.
But of the proposed surtax on wealthiest Americans, Castor is more reserved. "I don't love it. I hope there will be some other options in the end."
Rep. Debbie Wasserman Schultz, D-Weston, supports the idea, saying the rich can "well afford to part with a little more of their tax dollars," to help those without insurance. Wasserman Schultz, who is from a solidly Democratic district and can comfortably take that stance, is concerned that the public option could be watered down.
The idea is under considerable pressure from a group of 52 moderate-conservative House Democrats known as the Blue Dogs. Among them is Rep. Allen Boyd of Monticello, who thinks a public option should only be implemented if other changes in the private insurance market don't succeed in lowering costs.
"We don't need to copy the Great Britain system or the Canadian system," said Boyd, who also worries about the cost to small businesses.
Because of its size, the Blue Dog coalition poses a significant hurdle to House Speaker Nancy Pelosi and Obama. "I think that it would be such a mistake for any group of Democrats to bring down this legislation and give the president a defeat, especially those in marginal districts," Energy and Commerce Committee chairman Henry Waxman told reporters Friday after a GOP amendment was approved with Blue Dog assistance.
Even those outside the coalition are reluctant. Take Democratic Rep. Suzanne Kosmas, who represents a broad swath of Central Florida. Last year, Kosmas took the District 24 seat from Republican Tom Feeney, a major coup even though Feeney's ethical problems played a role. But the district remains favorable GOP territory.
So concerned is Kosmas with her electoral prospects, it seems, that she blew off a Financial Services Committee meeting this week to attend a Capitol Hill fundraiser hosted by a mortgage banker lobbyist.
Kosmas' spokesman said she was too busy this week to discuss health care but said she supports the broad reform goal. When asked about the public option and surtax, spokesman Marc Goldberg replied simply: "Congresswoman Kosmas is reviewing the bill carefully and evaluating all the details."
To fully embrace the House leadership plan would make Kosmas vulnerable back home. The best she can hope for is that less palatable provisions are stripped out, or that Democratic leaders give some rank-and-file members a pass on supporting the plan.
Then there is Nelson, Florida's senior senator, who does not face re-election until 2012. Nelson is a member of the Finance Committee, a critical player in the debate.
But Nelson does not appear to support a government-run health insurance plan. Several attempts to reach him this week were unsuccessful. His spokesman Dan McLaughlin characterized Nelson as "cautious" toward public option given worries that insurers could use it to offload high-risk clients.
Paying for it is another concern. "His goal is to make sure folks who already are being squeezed in this economy don't get hammered," McLaughlin said.
Nelson's reticence has upset liberal Democrats and those who feel there is no better time to create change. Nelson has been buffeted with letters, calls and on blogs. "Come on, senator. We who put you in office are in a big majority for strong health care reform with a strong public option. Why waffle?" asked a Miami blogger.
Then this week, campaign-style ads were launched in Florida by the Democratic National Committee. The spot does not mention Nelson by name, but it is clearly designed to get him on board.
Three people featured in the ad intone, "It's time."
Alex Leary can be reached at [email protected]