The fierce national debate over health care is entering a new phase, with advocates on all sides focused on a handful of legislative bottlenecks that will determine the ultimate overhaul of the $2.5 trillion medical care system.

President Barack Obama’s prime-time address to Congress on Wednesday reassured some nervous Democratic lawmakers, and he aligned himself more closely with certain proposals.

While Obama’s words seemed to halt and possibly reverse the momentum that conservative groups had gained in August, they did not resolve all the concerns of centrist Democrats who will play pivotal roles, especially in the Senate.

“Obama’s speech was a game-changer when it came to the message,” said Sen Ben Nelson, D-Nebraska, one of the moderates. “But it is not an automatic change on the legislative side.”

Some version of a health care overhaul must squeeze through five key gates this fall if a final package is to become law by year’s end.

Advocates would be shocked if the Democratic-controlled Congress failed to pass some version of revamping the nation’s health system. At a minimum, they say, it would bar insurers from dropping customers who become sick and require them to cover people who have pre-existing medical conditions.

Greater competition

But Obama and most congressional Democrats want more: granting subsidies to help low-income people buy health insurance; requiring nearly all US citizens to have insurance, and requiring large employers to contribute; creating greater competition for private insurers, possibly through a government-run option; and imposing more efficiency in Medicare and other programmes, where experts say too much money and effort are wasted
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Obama is campaigning throughout the nation, with an appearance on Sunday on CBS’ ‘60 Minutes’ and trips next week to New York, Ohio, Pennsylvania and Maryland.
But the health care issue is mainly in Congress’ lap.

Knotty issues include whether to establish a government-run insurance plan and how to control costs. Perhaps the easiest early hurdle will be in the House. But even there, divisions between liberal and conservative Democrats worry leaders, and Republican opposition appears absolute.

Three House committees have approved portions of a far-reaching health care bill, but it will undergo changes before it reaches the full House.

In essence, Obama encouraged House leaders to tweak their bill when he embraced several Senate proposals absent from the House version. He also set a 10-year spending target of $900 billion, which may prove hard to meet. House officials said leaders will send to the Rules Committee a modified health bill reflecting some of Obama’s newly identified priorities.

Conservative Democrats may try to remove the government-run insurance option, which is dear to liberals. Still, many lawmakers expect the public option to stay in the House bill
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Procedural rules

Things are more complicated in the Senate, where procedural rules make it much harder for the majority party to impose its will. Obama’s remarks revitalised efforts by Finance Committee negotiators to shape a compromise bill that can attract at least one Republican’s support.

The first Senate showdown is expected in about two weeks, when the full Finance Committee debates and votes on the bill.