With hopes growing ever dimmer for a bipartisan accord, White House and Democratic leaders are considering a wide range of strategies for getting a health care bill passed when Congress returns from its summer recess.
Some are blunt. Some are complex and technical. All are problematic.
Insiders say it's impossible to confidently predict which plan, if any, will prevail after lawmakers return the day after Labor Day. Will Democrats simply try to roll over minority Republicans? Will they try such uncertain paths as asking moderate Democrats, or perhaps a retiring Republican, to let a bill reach the Senate floor even if they plan to vote against it?
Possible outcomes, according to congressional and White House officials:
A bipartisan agreement.
Still the preference of President Barack Obama and congressional leaders, prospects have dimmed this month as top Republicans have sharply criticized key Democratic goals. Most notably, the chief GOP negotiator - Sen. Charles Grassley of Iowa - signaled he would not support a bill, even if he liked it, unless most of his fellow Republicans signed on. That seems highly unlikely.
A truly bipartisan bill would draw significant numbers of House and Senate Republicans, and it surely would be among the least-ambitious scenarios under discussion. It might include widely supported measures such as barring insurers from refusing to cover pre-existing medical conditions, and allowing people to carry their insurance from job to job. But it would not include a public insurance option, hefty subsidies to help the poor buy insurance and other priorities of the left.
Political insiders see little hope for a truly bipartisan bill emerging from the current negotiations.
A 60-Democrats strategy.
This Democrats-only strategy presumably would produce the most robust, far-reaching changes to the health care system. Liberals say that if Republicans won't play ball, there's no point in compromising the agenda Obama campaigned for, including a public insurance option and coverage for nearly all Americans.
But this approach has many hurdles, and insiders consider it a long shot. Senate filibuster rules would force Democrats to persuade each of their 58 members and two independent supporters to vote down the 40 Republicans on issue after issue. Some moderate Democrats would balk on issues they oppose. And two liberal Democrats - Robert Byrd of West Virginia and Edward Kennedy of Massachusetts - are seriously ill and often absent.
Even if the Senate passed a bill with Democratic votes only, conservative House Democrats might band with Republicans to reject it as too expensive.
A Democrats-only approach would fuel Republican accusations of heavy-handed overreaching by Obama and his allies. But it would energize the president's liberal base.
A handful of Republicans.
Even if the negotiations involving Grassley collapse, it's possible that a tiny number of GOP senators will join nearly all the Democrats in passing a bill that includes most of Obama's priorities. Maine's Republican senators, Olympia Snowe and Susan Collins, are mentioned most often.
But they would face enormous pressure not to break ranks and provide the crucial 60th vote to overcome an otherwise solid GOP opposition. And if they did, the resulting bill still would be seen as a Democratic creation, undermining its acceptance by many Americans.
Handicappers give this scenario a less than 50-50 chance.
If they're willing to play true hardball, Senate Democrats still could pass a health care bill without amassing 60 votes on some contentious points.
The "reconciliation" process lets the 100-member Senate pass budget-related items, under tight restrictions, with a simple majority of votes. But items that arguably are unrelated to the budget could be challenged and possibly subjected to the 60-vote threshold.
Democrats could submit one big bill and fight to keep as many provisions as possible from falling victim to a 60-vote requirement. Or they could split the package in two:
One bill, dealing with spending questions, could pass under reconciliation rules with as few as 50 votes. The other bill would require 60 votes, and it would be subject to mischievous amendments. But it might include widely popular provisions such as protecting insurance buyers who have pre-existing conditions.
Senate experts differ on how many of Obama's priorities, such as a public insurance option, would fail under the reconciliation process. But everyone agrees the strategy would severely worsen the already testy relationships between Republican and Democratic senators.
Because it is complex, unpredictable and divisive, reconciliation is unpopular with many Democrats, not to mention Republicans. But Capitol insiders say Democratic leaders will use it before accepting full-blown defeat, and some see it as the likeliest outcome.
Modified all-Democrats approach.
This approach would require Democratic solidarity at some point, but it could be portrayed as a procedural matter rather than a more highly charged policy question.
The crucial votes would occur after the House and Senate had passed separate bills, sent them to a powerful conference committee and then prepared to give the reconciled (and possibly much-changed) product a final yes-or-no vote in each chamber.
The first key is to get the House and Senate to pass their own bills, even if they differ widely. The Senate version probably would be more constrained than the House version, in order to attract enough GOP support to overcome filibusters.
House-Senate negotiators might make the final package closer to the House's more liberal version. That would anger Senate Republicans, and perhaps some moderate Democrats, who could threaten a filibuster on the last showdown vote.
But Obama and his allies could urge the centrist Democrats, in the name of party loyalty, to reject a filibuster even if they plan to vote against the bill itself. If Byrd or Kennedy could not provide the crucial 60th vote, it might come from a retiring Republican who concludes that a huge issue such as overhauling health care deserves an up-or-down vote.
Such a senator might be George Voinovich of Ohio, said Norm Ornstein, who has written about Congress for years at the American Enterprise Institute.
This multi-pronged scenario would yield something "closer to a third or quarter of a loaf than the full package" that liberals want, Ornstein said. But with the Senate's 40 Republicans able to use the filibuster, and the House's conservative Democrats able to block a bill they consider too costly, that's probably the most Obama can hope for, he said.
All the above options may fail, and partisan clashes could kill the bid to overhaul health care altogether. Top lawmakers consider this unlikely. Democrats control the House, Senate and White House, and they should be able to produce at least a modest bill that Obama could tout as a victory, with hopes of coming back for more in later years.
Passing no bill at all would severely wound Obama's image, exasperate liberals and drag Congress' reputation for effectiveness lower. The political fallout might be hard to predict, however. The blame for failing to make even modest improvements to U.S. health care might stick to Republican critics of Obama as well as Democrats who used their majorities for naught.