Barack Obama unveils his final strategy for pushing health reform in America

“EVERYTHING there is to say about health care has been said and just about everyone has said it…now is the time to make a decision.” So declared President Barack Obama on March 3rd to an audience of doctors and nurses gathered at the White House. After a year of dithering, he is now leaping into action.

His speech contained no policy surprises, but is worth noting for three reasons. First, he instructed congressional Democrats to embrace several Republican proposals—for example, modest measures to reform malpractice laws and fight insurance fraud—that were put forward during last week’s bipartisan summit on reform. Second, he made it clear that he now wants Democrats to forge ahead with whatever procedural manoeuvres are necessary to pass his health bill. And finally, he declared that he wanted to see “an up-or-down vote” in the “next few weeks”.

Grand ambition aside, Mr Obama’s decision remains a huge gamble. The opposition remains unbowed. Representative Ron Kind, a Democrat, says his party is willing to incorporate those Republican proposals into any final reform package—but that prospect has not won over a single vote. John Boehner, the Republican leader in the House, still wants to scrap Mr Obama’s plan in favour of “step-by-step” reform. But Senator Ron Wyden, a bipartisan-minded Democrat, says incrementalism cannot work. The pieces of health reform are so interlinked that any such scheme simply “does less but costs more”.

Passing reform without Republican support will probably involve House Democrats passing an exact version of the health bill passed by the Senate before Christmas. Both houses must also pass a “sidecar ” or “corrections” bill to capture any other provisions. This latter effort relies on a loophole, used by both parties in the past, that allows budget-related provisions to pass through the Senate with just 51 votes rather than a filibuster-proof 60 (a margin the Democrats no longer enjoy).

There are several potential snags in the House. One is that the Democrats simply may not have the votes. The Senate bill contains no provision for a government-run insurer, which angers leftists; some want to revive this controversial notion. Abortion could also scupper things, as the Senate bill’s provisions on the matter do not please some conservative House Democrats. And since the House bill passed three Democrats have died or retired, while only one Republican has.

The Senate may also prove problematic. In theory only financial provisions can be passed using the reconciliation approach; abortion, for example, cannot. So all eyes are on the upper chamber’s parliamentarian (its official adviser on procedure, currently Alan Frumin), whose rulings carry great weight. It must be noted, however, that Republicans fired the previous Senate parliamentarian when they found his rulings inconvenient.

Despite these obstacles, Democrats now seem eager to push a package through. One reason, Mr Obama argued, is to prove to a cynical public that the federal government works: “At stake right now is not just our ability to solve this problem, but our ability to solve any problem.”

A bigger reason, argues Mark McClellan, a former Bush administration official now at the Brookings Institution, a think-tank, is the fact that Democrats are going to get attacked anyway for their past votes in favour of reform. “Why not pass it,” he asks, “since doing so now is clearly better for Democrats than failure?”