Senior policy aides in the White House are scrambling to craft what they hope will be a game-changing speech on healthcare by President Barack Obama. He will present the proposals to an exceptional joint session of Congress next Wednesday in a speech to be broadcast on prime-time television.
While officials are hoping Mr Obama can pull off the kind of oratorical triumph that the nation witnessed at the most critical and precarious junctures of his election campaign last year, the impact of the speech will depend also on what he chooses to say – or not say – about possible compromise solutions to get a reform bill approved.
First indications seem to point to a willingness partially to pare back the President's original vision for ensuring insurance coverage for all.
Around 45 million Americans have no health insurance. But coverage for all would mean dropping a number of provisions currently included in versions of the bill circulating in Congress; these have have drawn special wrath from Republicans and some moderates in Obama's own party.
No conundrum is bigger than what to do about arguably the most incendiary provision in most of those bills: the creation of a government insurance entity that would compete with private insurers to offer coverage to consumers. Conservatives abhor the very notion, while progressives see it as a sine qua non of any overhaul package.
Indeed, as many as 80 Democrat members of Congress could withdraw their support if the public insurance option is not part of a final deal.
The mere fact of the President addressing a joint session on Capitol Hill is an indication of how badly things have gone for the White House since the reform effort began in the spring.
It also shows that Mr Obama has now taken heed of those who have assailed him for remaining too aloof from the process and allowing Congress to get itself bogged down with the reform proposals. In standing back, Mr Obama and his aides may have over-learned the lessons from 16 years ago, when then President Bill Clinton and his wife, Hillary Clinton, tried at first almost to dictate to Congress what should be included in an overhaul bill, only to see their efforts end in complete failure. Now the Obama White House is changing tack, it seems.
"Stay tuned for Wednesday," Vice President Joe Biden told a think-tank in Washington last night. "It's going to be a major speech, laying out in understandable, clear terms what our administration wants to happen with regard to healthcare and what we're going to push for, specifically."
But there are risks for Mr Obama also. Some inside the White House reportedly counselled against an appearance before Congress, lest history repeat itself. Mr Clinton made just such a pitch to a joint session in September 1993, when his reform push was in trouble. One year thereafter, the Bill-Hillary package was formally declared dead.
The Obama circle has been shaken by the events of August, when members of Congress returned to their constituencies and town-hall meetings where they found an extraordinary degree of resistance to reform, often expressed in the fiercest terms.
The tumult became a staple of the TV networks' nightly news bulletins. "I was expecting a lot of anger, but what really surprised me about the town meetings was the fear that people were expressing, afraid for the country," said Senator Chuck Grassley, a Republican from Iowa who earlier was involved in efforts to build bi-partisan support for a bill – something that now looks somewhat pie-in-the-sky.
Most Democrats will welcome Mr Obama's closer engagement. Indeed most think it is overdue. "This level of involvement from the President could well be a game-changer," Senator Charles Schumer of New York said.
"There is no better way to turn public opinion around than to have someone as popular as President Obama addressing the American people directly, without intermediaries interpreting – or misinterpreting – his ideas." Joint sessions of Congress are usually convened just once a year, to hear the President's State of the Union address. The only exceptions in recent times have been the appearance by Mr Clinton on healthcare in 1993, and the speech by then President George Bush in late 2001, in the wake of the 9/11 terror attacks.
Critics say Mr Obama will have to be clear about his aims.While he will assuredly be seeking to consolidate support for reform among the more conservative and hesitant elements of his own party, he may or may not decide it is still worth wooing some of the more moderate Democrats.
The White House has its eye on Senator Olympia Snowe, a Republican from Maine, who wants to alter the provisions for the public insurance option so that it would only happen if the insurance companies had after a certain time proved themselves unable to serve consumers better, by, for example, lowering costs and ending their practice of refusing coverage to people with pre-existing conditions.
Beyond Congress, Mr Obama will also be seeking to reassure the public – which according to opinion polls has become progressively less convinced that it is really necessary to change anything.
The proposals: And what they would cost
The main aims:
* Providing health insurance to all Americans (not illegal immigrants).
* Cutting the costs of healthcare in America while improving quality.
How it would work:
* All Americans would be required to buy insurance and nearly all businesses, except for the smallest, would be obliged to offer it to employees. Those who decline would face tax penalties.
* Subsidies would be offered to help consumers and business cover those new insurance costs.
* A public, government-run entity may be created to compete with private insurers, in the hope that it would make them lower costs.
* Private insurers would no longer be allowed to decline coverage to people with pre-existing health conditions.
* Expand the existing Medicaid insurance programme for the very poor.
The cost and paying for it:
* One battle in Congress is to keep the cost of the reforms over 10 years to less than $1 trillion. Not easy.
* New surtax for wealthier Americans to help pay for universal coverage.
Obstacles to reform: Obama's plans might have fared a lot better but for...
* Their launching just after the passage of the $787bn economic stimulus package. Budget deficit fright began to grip the public.
* The Congressional Budget Office saying it saw nothing in the bills being proposed that would actually curb federal spending on healthcare.
* The concern of those Americans who actually do have health insurance that the changes being proposed would dilute the level of care they are already getting. Never mind the 46 million-odd folk who don't.
* Barack Obama deciding to stay aloof from the negotiations on Capitol Hill until now, apparently remembering how things ended when Bill Clinton tried to tell Congress what to do last time – badly.
* Previously obscure conservative groups with names like Conservatives for Patients Rights springing up to run TV ads opposing reform and encouraging people to wail at summer town-hall meetings.
* The success of these groups, abetted by right-wing radio and TV jocks, in spreading skewed rumours about "Obamacare", for instance that "death panels" would determine when old folk would be left to die.
* Britain's National Health Service. The NHS, opponents claimed, is a model for government-run, rationed health no American could want.Reuse content