When the long-awaited Senate health care bill is revealed today, the guillotine will drop on a government-run insurance plan.
Sure, some Democrats will continue to fight for the "public option," but it's likely the beginning of the end for the controversy magnet. Instead, Senate leaders will move toward nonprofit health care cooperatives, a largely unknown and untested concept.
To Florida Sen. Bill Nelson, the shift is a significant breakthrough, one that can secure enough Democratic support of an overall reform bill.
"If I had talked to you one week ago I would have had a whole different attitude. I think a lot's changed. So I'm an optimist now," the Orlando Democrat said Monday in his most extensive comments on the emerging health care proposal.
Senate Democrats' quest for a bipartisan compromise on health care collapsed Tuesday, though, as Finance Committee Chairman Max Baucus, D-Mont., announced he would move ahead with his long-delayed proposals without any guarantee of Republican support after a negotiating session broke up.
Nelson, who has been under fire for his low profile on the pressing issue, thinks health care co-ops will achieve the same goal of extending coverage to more people and lowering costs for all.
Under a cooperative, people would band together and form nonprofits that provide health care, not unlike electric co-ops that provide power in some rural parts of the country. Though the co-ops would get government funding at the outset, they would not be government-run, alleviating at least some concerns from Republicans and moderate Democrats like Nelson.
"They have every incentive to hold the cost down and to make it as cheap and as stable and as available as possible," Nelson said. "That's a pretty good competitor to the private insurance companies."
But health care co-ops are largely unknown in the United States and could take a long time to get started.
"They've taken many, many years to develop into a significant size and weight to make a difference in terms of quality and value of health care," said William Peck, a physician and director of the Center for Health Policy at Washington University.
"This isn't to say they are a bad idea," Peck added, "but they aren't going to be a short-term solution by any means."
And Nelson's support of co-ops will likely not quiet Democratic critics who say his relative silence on the issue has been part of the problem in enacting meaningful reform. Nelson is a member of the Senate Finance Committee working on the new proposal but is not part of the "gang of six" that has been hammering out the details.
Activists have demonstrated outside his Florida offices and sent him petitions demanding a government-run plan. Nelson further irritated critics by telling a crowd in Daytona Beach recently that he favored an "incremental" approach to health care reform.
Nelson said most of the public option advocates "don't have a clue," about what it would take to create such a plan. "The whole thing is so complicated you can't expect them to understand."
"If a co-op serves the same purpose, what's the big deal?" Nelson added.
Nelson said he is encouraged by President Barack Obama's willingness to accept something else - a point he made clear in a prime-time speech to Congress.
In addition to co-ops, the Senate plan may allow people to shop for private plans that meet government standards on benefits, co-pays and premium prices.
The details of the Finance Committee proposal could be released today and will go through a "mark up," or formal workshopping, next week.
Even from Democrats, support won't come easily. On Tuesday, Sen. John D. Rockefeller IV, D-W.V., said he could not vote for the plan because it lacks a public option. "It's not how can you get the best plan, it's how can I get at least a Republican vote or two Republican votes. Which is not the way you go at a serious policy," Rockefeller said.
Many House Democrats also believe in a public option. The House plan includes the option and, if the Senate passes its own version, one side will have to bend to the other.
The Senate proposal may not satisfy Republicans, either. Some lawmakers, including Sen. John McCain of Arizona, say co-ops are a "back door" way to create a government-sponsored program, like Fannie Mae and Freddie Mac.
Trying to counter his critics, Nelson said he has been working behind the scenes to get a bill that will gain enough support in the more moderate Senate.
"You can't get 60 votes in the Senate," Nelson said of a public option. "I'm trying to get something passed."
Additionally, Nelson said he is pressing Baucus to scale back on a plan that would limit benefits some seniors get under private Medicaid Advantage plans.
The current proposal would cut Medicare payments to insurers and, Nelson and others fear, would mean diminished extras such as eye care and health club memberships.
"You can't go away and take something that our senior citizens have," Nelson said, adding he voted against creation of the advantage plans.
Nelson said he will also seek an amendment requiring that Medicare is afforded the same prescription drug rebates as Medicaid. President Obama has already struck a deal with the drug industry for about $80 billion in savings over a decade, so further cuts would meet strong resistance.
"It's going to be very difficult to win this fight," Nelson said, "but I'm sure going to give it the old college try."
Alex Leary can be reached at firstname.lastname@example.org. Information from the Los Angeles Times was used in this report.