More than anything else in Barack Obama's presidency so far, health reform has exposed a get-a-deal-at-any-cost side of Obama that infuriates his party's progressives.
And as Democrats tried to salvage health reform Tuesday, some liberals could barely hide their sense of betrayal that the White House and congressional Democrats have been willing to cut deals and water down what they consider the ideal vision of reform.
"The Senate version is not worth passing," former Democratic National Committee Chairman Howard Dean told POLITICO, referring to plans to strip the latest compromise from the bill, a Medicare buy-in. "I think in this particular iteration, this is the end of the road for reform."
Dean said there are some good elements in the bill, but lawmakers should pull the plug and revisit the issue in Obama's second term, unless Democrats are willing to shortcut a GOP filibuster. "No one will think this is health care reform. This is not even insurance reform," he said.
The White House pushed back hard at liberals' complaints Tuesday, with Obama talking up what's in the plan but not saying a word about what's been left out:
A single-payer plan, a public option, a state "opt-out" of the public option, a trigger and a Medicare buy-in - all ideas pushed by Democrats and blessed by Obama at various times but now gone from the bill.
But it's not just the liberal base that's feeling unsettled. Obama has also proved frustrating to moderates, who simply wanted to know where Obama's core principles on health care stood, all the better to cut a deal to the president's liking.
Time and again, he rebuffed Democrats' requests to speak up more forcefully about what he wanted - a strategy that allowed Obama to preserve maximum flexibility to declare victory at the end of the process, no matter what the final bill looked like.
He began that process in earnest Tuesday after a meeting with Senate Democrats, who are resigned to dropping a Medicare buy-in compromise to win the vote of Sen. Joe Lieberman (I-Conn.) and get the 60 votes needed to pass a bill.
Obama hinted at the Democratic retreat on the plan - saying not every senator's favorite ideas can be included in any bill - while staunchly defending what Senate Democrats can accomplish in a bill, including making coverage more affordable for 30 million uninsured Americans, cutting insurance premiums and reducing the budget deficit.
"These aren't small changes. These are big changes. They represent the most significant reform of our health care system since the passage of Medicare. They will save money. They will save families money. They will save businesses money, and they will save government money. And they're going to save lives," Obama said.
In the White House meeting, there were signs of tension within the Democratic Caucus. Sen. Sherrod Brown (D-Ohio), a proponent of the public option, challenged Lieberman's arguments that allowing people ages 55 to 64 to buy in to Medicare would add to the deficit and hurt the program.
"I made a direct appeal to him ... and answered the arguments I've heard him make," Brown said. "We're not giving up. It's going to conference."
But in the end, Brown said he would vote for the bill. "I can't imagine I wouldn't. There is just too much at stake," he said.
Obama's need to pass a reform bill ahead of the 2010 elections drove the political calculus as the calendar turned to December, when the days grew short and the pressure to sign something, anything, began to take precedence. Otherwise, Democrats risked facing voters next fall with little to show for a full year of twin congressional majorities. It's what drove White House chief of staff Rahm Emanuel to urge Senate Majority Leader Harry Reid to cut a deal with Lieberman.
The final bill isn't even close to a bill then-U.S. Senate candidate Obama spoke of in 2003, when he said, "I happen to be a proponent of a single-payer, universal health care plan," using the terms that commonly refer to a government-run health insurance system.
But whatever Democrats can pass now - if they can pass anything at all - also will fall short of ideas Obama discussed during the year to create a public health insurance plan to provide competition to private insurance companies and keep them honest.
Yet perhaps what angers liberals the most is that Obama himself never seemed willing to push hard enough for the public option - and, in fact, all but took it off the table in August when he said he could sign a bill that didn't include it.
Once Obama said he didn't need a public option, these progressives argue, there was no cost or penalty to be paid by a Lieberman or a Sen. Blanche Lincoln (D-Ark.) or a Sen. Ben Nelson (D-Neb.) for taking to the Senate floor and opposing it, too.
Progressives feel betrayed, but are not surprised, by the Senate's move to drop the Medicare buy-in and the public option. They blame Reid and Obama for not exercising their power to fight for the provisions.
Obama's failure to demand a public option and Reid's decision to take reconciliation off the table emboldened moderates who might have thought twice about challenging a popular president or a Democratic majority comfortable with using Senate procedure to pass a bill with 51 votes.
"They were very good at making it look like they wanted a public option in the final bill without actually doing anything to make it happen," said Jane Hamsher, publisher of the liberal blog Firedoglake. "It's hard to believe that the two most powerful people in the country - arguably the world - could not do more to achieve their desired objective than to hand the keys over to Joe Lieberman. They would not be where they are if they are that bad at negotiation."
Press secretary Robert Gibbs defended Obama against charges that he was caving in to moderates to get a final bill passed, even if it risked angering liberals who wanted more government involvement in the health care system.
"There's very little legislation that's passed that has each and every idea that each and every member of the Senate or the House wants to have in it," Gibbs told reporters Tuesday. "On balance, does this legislation make a big difference in the lives of everyday working men and women? It's not even a close call on that."
If Obama was hoping for a triumphant announcement out of a rare White House meeting with the entire Senate Democratic Caucus Tuesday, his measured tone and acknowledgment that differences remain showed how much work is still ahead for Democrats eager to wrap up by Christmas.
Reid was still awaiting a price tag on his bill from congressional scorekeepers, and Nelson said he still can't support the current version of the bill, which lacks the tough anti-abortion language he seeks.
But after leaving the White House meeting, even some of the staunchest public option advocates seemed resigned to passing a bill without it or the Medicare buy-in, a sort of public option for people ages 55 to 64 - a sign of a split between liberal elected officials and the activist base. Obama's argument that Democrats shouldn't pass up a once-in-a-generation chance to achieve reform appeared to be sinking in.
Brown, who has said several times throughout this process - including two weekends ago - that the president needed to get more involved, brushed aside any introspection about what the loss of the public option says about Democrats or the president.
"It says something about the math here," Brown said. "You've got to get all 60 Democrats and independents, and it is hard to do. I want to continue to talk to people. ... I like the bill. I just think we could make it better."
Sen. John Rockefeller (D-W.Va.), also a major advocate of the public option a few months ago, is a convert to the bill. He has a perspective that many of his colleagues lack: He was around 15 years ago when President Bill Clinton rejected compromises that fell short of his goal of providing universal coverage.
"If you think of what I don't get, and you think of what we do get, that's a pretty long list," Rockefeller said.
Carrie Budoff Brown contributed to this story.