Article from the NYTimes.com
By SHERYL GAY STOLBERG
 

WASHINGTON — After months of insisting he would leave the details to Congress,
President Obama has concluded that he must exert greater control over the health
care debate and is preparing an intense push for legislation that will include
speeches, town-hall-style meetings and much deeper engagement with lawmakers,
senior White House officials say.
 

Mindful of the failures of former President Bill Clinton, whose intricate
proposal for universal care collapsed on Capitol Hill 15 years ago, Mr. Obama
until now had charted a different course, setting forth broad principles and
concentrating on bringing disparate factions — doctors, insurers, hospitals,
pharmaceutical companies, labor unions — to the negotiating table.
But Mr. Obama has grown concerned that he is losing the debate over certain
policy prescriptions he favors, like a government-run insurance plan to compete
with the private sector, said one Democrat familiar with his thinking. With
Congress beginning a burst of work on the measure, top advisers say, the
president is determined to make certain the final bill bears his stamp.
“Ultimately, as happened with the recovery act, it will become President Obama’s
plan,” the White House budget director, Peter R. Orszag, said in an interview.
“I think you will see that evolution occurring over the next few weeks. We will
be weighing in more definitively, and you will see him out there.”
On Saturday, while Mr. Obama was traveling in Europe, he used his weekly radio
and Internet address to make the case that “the status quo is broken” and to set
forth his ambitious goals.
 

Broadly speaking, he wants to extend coverage to the 45 million uninsured while
lowering costs, improving quality and preserving consumer choice. His budget
includes what he called a “historic down payment” of $634 billion over 10 years,
accomplished mostly by slowing Medicare growth and limiting tax breaks for those
with high incomes.
 

“We must attack the root causes of skyrocketing health costs,” Mr. Obama said,
pointing to the Mayo Clinic in Minnesota and other institutions as among those
that offer high-quality care at low cost. “We should learn from their successes
and promote the best practices, not the most expensive ones. That’s how we’ll
achieve reform that fixes what doesn’t work and builds on what does.”
The radio address was the start of a public relations campaign coinciding with a
50-state grass-roots effort that Organizing for America, the president’s
political group, began Saturday to promote a health care overhaul. His hope is
to provide what his chief of staff, Rahm Emanuel, called “air cover” for
lawmakers to adopt his priorities. It is a gamble by the White House that Mr.
Obama can translate his approval ratings into legislative action.
“Obviously,” Mr. Emanuel said, “the president’s adoption of something makes it
easier to vote for, because he’s — let’s be honest — popular, and the public
trusts him.”
 

But as Mr. Obama wades into the details of the legislative debate — a process
that began last week when he released a letter staking out certain specific
policy positions for the first time — he will face increasingly difficult
choices and risks.

Aides say he will not dictate the fine print. “It was never his intent to come
to Congress with stone tablets,“ said his senior adviser, David Axelrod. But he
will increasingly make his preferences known.

If he embraces a tax on employee benefits, an idea he attacked when he was
running for president, he may infuriate labor and the middle class. If he
insists on a big-government plan in the image of Medicare, he could lose any
hope of Republican support and ignite an insurance industry backlash. If he does
not come up with credible ways to pay for his plan, which by some estimates
could cost more than $1 trillion over 10 years, moderate Democrats could balk.
Many Republicans are already angry over the emphasis Mr. Obama placed on the
public plan in last week’s letter. Senator Mitch McConnell, the Republican
leader, said Friday that “the key to a bipartisan bill is not to have a
government plan in the bill.”

Mr. Obama is well aware of these risks, advisers say. “This is what he is now
very focused on,“ Mr. Orszag said. “What are the key things that are
nonnegotiable? He is asking those sorts of questions: What are the drop-dead
things that we need to have in order to have some hope of addressing long-term
cost growth?”

Senator Charles E. Grassley of Iowa, the senior Republican on the Finance
Committee, recalled how Mr. Obama made a personal pledge of bipartisanship when
he and Senator Max Baucus of Montana, the committee’s Democratic chairman,
joined the president for a private lunch at the White House last month.
“I said, ‘Yeah, it’s a problem,’ ” Mr. Grassley said of the public plan, “and he
said something along the lines of, ‘If I get 85 percent of what I want with a
bipartisan vote, or 100 percent with 51 votes, all Democrat, I’d rather have it
be bipartisan.’ ”

On Friday, Mr. Grassley said he viewed the letter as “a political document, not
a policy document,” intended to shore up Democratic support while letting Mr.
Obama remain flexible.

Senator Ron Wyden, an Oregon Democrat who is a longtime proponent of revamping
health care, said Mr. Obama seemed to be wrestling with how far he could push
Congress.

“The president is very much aware that to bring about enduring change — health
care reform that lasts, gets implemented, wins the support of the American
people and does not get repealed in a couple of years — you need bipartisan
support,” said Mr. Wyden, who was among two dozen Senate Democrats who met with
Mr. Obama about health care last week. “So he’s grappling with, how do you do
that?”

Mr. Obama began taking steps to make his case early in his administration. He
convened a “fiscal summit” where health care was a major topic, followed by a
“health summit.” Not long ago, he invited industry leaders to the White House,
where they pledged to cut $2 trillion in health care costs over the next decade.
But he has been restrained in his dealings with Congress.
He has, however, shown himself willing to exercise his presidential muscle when
he thinks it is necessary. In April, Senator Kent Conrad of North Dakota, the
Budget Committee chairman, balked at the idea of having the Senate consider
health legislation under the fast-track process known as reconciliation, which
could avoid a Republican filibuster. At a private meeting, Mr. Obama pressed him
on it.

“ ‘I want to keep it on the table as an option,’ ” Mr. Conrad recalled the
president saying. Not long after that, Mr. Emanuel, the White House chief of
staff, visited Mr. Conrad on Capitol Hill. Mr. Conrad was not convinced, but
decided not to stand in the way. “The Budget Committee chairman does not top the
president of the United States,” he said.

Going forward, Mr. Emanuel said, lawmakers could expect “quiet one-on-one
discussions” with the president.

But Republicans like Mr. Grassley say that after promising to leave the
legislative process to Congress, Mr. Obama must be cautious about his words, and
about the appearance of meddling.

“He’s doing good by staying out of it as much as he is,” Mr. Grassley said.
“He’d better use kid gloves at the start.”