Appearing before a White House audience of invited guests, many of them wearing white medical coats, Obama firmly rejected calls from Republicans to draft new legislation from scratch. "I don't see how another year of negotiations would help. Moreover, the insurance companies aren't starting over," the president said, referring to a recent round of announced premium increases affecting millions who purchase individual coverage.
While Obama said he wanted action within a few weeks, Senate Majority Leader Harry Reid (D-Nev.) seemed to hint a final outcome could take far longer. "We remain committed to this effort and we'll use every option available to deliver meaningful reform this year," he said.
The outcome will affect nearly every American, mandating major changes in the ways they receive and pay for health care or leaving in place current systems that leave tens of millions with no coverage and many others dissatisfied with what they do get. With Republicans united in opposition, there is no certainty about the final result in Congress - or even that Democrats will go along with changes Obama urged on Wednesday in what he described as a bipartisan gesture.
With polls showing voters unhappy and Democrats worried about this fall's elections, Obama also sought to cast the coming showdown in terms larger than health care, which is an enormously ambitious undertaking in its own right. "At stake right now is not just our ability to solve this problem, but our ability to solve any problem," he said.
Republicans dug in for another struggle on an issue that they agreed would echo into the fall campaign.
The Senate GOP leader, Mitch McConnell of Kentucky, said a decision by Democrats to invoke rules that bar filibusters would be "met with outrage" by the public. "This is really not an argument between Democrats and Republicans. It's an argument between Democrats and the American people," he said.
At its core, the legislation under discussion still is largely along the lines Obama has long sought and GOP critics attack as a government takeover of health care. It would extend coverage care to tens of millions of uninsured Americans while cracking down on insurance company practices such as denying policies on the basis of a pre-existing medical conditions.
A new "insurance exchange" would be created in which private companies could sell policies to consumers under terms fixed by the federal government. Much of the cost of the legislation, nearly $1 trillion over a decade, would be financed by cuts in future Medicare payments to hospitals and other providers and higher payroll taxes on individuals earning more than $200,000 and couples over $250,000.
The president's appearance marked yet another pivot point in a long, uphill effort by the Democratic Party to enact far-reaching changes to the health care system.
The president's appearance marked a presumably final pivot point in a long, uphill effort by Obama and other Democrats to enact far-reaching changes to the health care system - and with his own administration at an important crossroads. Eager to turn attention to efforts to stimulate the economy and create jobs, the president is seeking a victory on health care that can also give him a boost on other priority legislation.
At the same time, a defeat could damage Obama's ability to help fellow Democrats heading into the fall campaign. Failure on health care could well lead to a shake-up of the president's White House team, which has received criticism recently from Democratic lawmakers.
After nearly a year of struggle, the House and Senate passed separate bills late last year, and appeared on course for approving a final compromise version early in 2010. But those efforts were abruptly abandoned when Republicans unexpectedly won a special election in Massachusetts. Sen. Scott Brown's victory gave the GOP an ability they had lacked, the strength to sustain a filibuster, a form of opposition that requires supporters of a bill to post 60 Senate votes in order to cut off debate and force a final decision.
Democrats went into something of a political fetal position, and have begun to stir in recent days only as Obama asserted his determination with a bipartisan summit followed by a revised set of proposals.
Obama said the use of rules that deny the minority the right to a filibuster had been used numerous times in recent years, including on passage of welfare reform legislation in the 1990s and twice when President George W. Bush pushed tax cuts to passage. Health care "deserves the same kind of up or down vote" as those earlier measures, he said.
Under the rather complicated approach under discussion, the House would be asked to approve the bill that passed the Senate late last year, despite objections by many members of the rank and file to several provisions. Simultaneously, both houses would also vote for a companion measure whose purpose would be to make changes in the first bill sought by either House Democrats or the White House.
Obama said he was exploring GOP proposals for cracking down on fraudulent medical charges, revamping ways to resolve malpractice disputes, boosting doctors' Medicaid reimbursements and offering tax incentives to curb unnecessary patient visits to doctors.
The ideas include an experiment that would establish special courts in which judges with medical expertise would decide malpractice allegations. The idea has been criticized by the Center for Justice & Democracy, a consumer group that prefers the current system of awarding damages. It said health courts would be "anti-patient."
The White House and Democratic leaders said they hoped that Obama's maneuvering would at least win the votes of wavering conservative and moderates in their own party, even if it didn't entice Republicans.
But there was no guarantee of success, despite Obama's vow to do everything in his power to succeed - and a White House announcement that he would travel to Pennsylvania and Missouri next week to campaign for the legislation.