WASHINGTON - Mindful of how delays sapped the political will to overhaul healthcare during the Clinton administration, health advocates hoped to get a major bill during the new administration's first 100 days. Now, it looks like it will take longer, and some observers fear that a historic opportunity could be missed.
"The waters are very perilous, and whether the healthcare boat can traverse them given everything else that is going on, is, I think, very much an open question," said Robert Reischauer, president of the Urban Institute and the head of the Congressional Budget Office during the Clinton administration.
The economic downturn - which some say highlighted the burden of rising healthcare costs on businesses - has worsened to the point where deficit projections are already beyond $1 trillion. The stimulus bill and financial bailout are devouring the fledgling administration's political energy and kicking up considerable partisanship in Congress.
Meanwhile, President Obama conceded earlier this month that his campaign proposal to pay for healthcare by repealing the Bush tax cuts for the rich would not work. Senator Edward M. Kennedy, the Senate's most driven leader on healthcare, is in Florida following a seizure related to his brain cancer, and it is unclear when he will return. A major healthcare bill his aides had hoped to have ready early this year is still in progress.
The House, meanwhile, has contributed little to the discussion of a major reconception of the health system. In an interview last weekend, House majority whip James Clyburn said he did not expect to pass a major health-reform bill this year, prompting House Speaker Nancy Pelosi to tell a Capitol Hill newspaper that she expected "a major step" forward.
Those developments are alarming to some advocates of universal healthcare, even though key senators and the administration insist that healthcare remains a priority.
If Congress does not act between the expected approval of a stimulus package in mid-February and the start of campaigning for the midterm elections a year from now, "a rare window of opportunity" will be lost, warned Drew Altman, president of the Kaiser Family Foundation, a leading health policy organization, on the group's website this month.
In that brief span, Congress must consider a vast array of interest groups, and devise a way to fund a plan that could cost more than $100 billion a year.
"Maintaining support through a lengthy national debate may be even more difficult in the modern era where public opinion can be influenced by interest groups waging ad wars on TV, or now on YouTube, much like in political campaigns," Altman wrote.
Senate Finance Committee chairman Max Baucus dismissed such worries yesterday. Baucus, who put out a detailed policy road map in November, and whose aides are working closely with Kennedy staff on a health bill, chuckled at the suggestion that the stimulus bill - which he is also overseeing - might crowd out healthcare.
"It's just so important," he said. "The cost of not doing something on health reform is much greater than the cost of taking on health reform."
Kennedy, in an e-mailed statement, said: "Naysayers always find reasons not to take action. But the American people and American business know that we cannot afford inaction. The president and the Congress know it too. We are moving swiftly and deliberately to pass much needed healthcare reform. The president is committed to it and so am I."
Many healthcare advocates say the outlook for a significant change is still better than it has been in a generation. Business groups are demanding change, and insurers have indicated some willingness to make concessions. Unions and liberal advocacy groups have set aside millions to wage a ground campaign for a bill.
In the Senate, aides to Baucus and Kennedy have been working intensively on laying the groundwork. Obama appointed Tom Daschle, a former Senate majority leader who recently wrote a book on healthcare, as his point man. Obama in his inaugural address dismissed those "who suggest that our system cannot tolerate too many big plans. Their memories are short."
Many healthcare advocates also see the economic stimulus package as a first installment on a healthcare overhaul, since it will spend billions of dollars on technological infrastructure that could support the health system of the future.
Health Care for America Now, a liberal coalition, is urging a quick passage of the stimulus in hopes of creating momentum. Richard Kirsch, the group's director, said he was confident that the president "would [tend to] the short-term economic crisis and then move on to the larger issues affecting our economy."
John Rother, a lobbyist for AARP, said that as long as a bill gets through both houses of Congress by early fall, the effort will be on track.
Still, he said, timing is critical: "The farther away we get from that presidential honeymoon, the more difficult this is going to be politically."