Many liberal health care advocates, who have embraced President Obama’s pledge to push for universal health care, are growing worried that Democrats in Congress will succumb to Republican pressure and sell the plan short.

A government-run health insurance plan for middle-class Americans that would supplement – or even replace – the private insurance industry appears less likely than only a few weeks ago, as Democrats grapple with the political realities of Republican opposition and a concerned public.

"No one knows what’s going to come out of this and people are more nervous that there will be too much compromise," said Dr. James Floyd, a health researcher with the left-leaning advocacy group Public Citizen.

Much of the left’s consternation lies with Senate Finance Committee Chairman Max Baucus, Montana Democrat, who has taken the lead on drafting a health care reform bill. Many view Mr. Baucus, an easygoing lawmaker who works well with Republicans, as too willing to compromise.

"The question is, is that the right profile for the lead architect on health care reform – that he would compromise to get a product that may be bipartisan but doesn’t have the details we need in order to have good health care reform bill?" said Jerry Flanagan, health care policy director for the liberal Consumer Watchdog group.

Mr. Baucus has frayed the nerves of many liberals by toning down his enthusiasm in recent weeks for a government-run, or public option, health insurance plan that would compete with the private sector.

While the senator has insisted that a government-run insurance plan is still on the negotiating table, he told a gathering of reporters last month, that "it might be a bit on the side of the table," hinting he instead may focus more on reforming the existing private insurance industry.

His comment is in sharp contrast to his white paper released in November, which called for a public option insurance plan to play a central roll in health care reform.

"It’s unclear what he means," Mr. Flanagan said. "I think there are some indicators in his public comments … that he’s willing to interpret public option pretty widely"

Yet even if a public option insurance plan is included in a final bill, many on the left worry it will be diluted to the point of being ineffective at best, or a burden to the health care system at worst.

"In much the same way (the) Medicare Advantage (program) was able to swindle money away from Medicare funds, I think private insurance can do the same with the public option," Dr. Floyd said. "However public option is defined upfront, it will almost certainly be watered down so that it becomes a dumping ground for patients who are constantly ill."

Other options

Many supporters of universal health care coverage also are upset that Democrats, including Mr. Obama, aren’t willing to at least consider replacing the current private health insurance system with a so-called single-payer plan – an option in which doctors, hospitals and other health care providers would be paid from a single national fund administered by the government.

By refusing to consider the single-payer option, Democrats would forfeit a crucial bargaining chip with Republicans, meaning that any compromise with Republicans would swing too far toward the center or right, liberals say.

"It’s striking that the issue of taxing employer-provided health benefits is considered to be a legitimate policy or financing option, but that a policy debate on the merits of single-payer, which has clear advantages, is off the table," said Michael Lighty, public policy director for the California Nurses Association and the National Nurses Organizing Committee.

"That’s why it looks like (Democrats) are moving so far to the Republican position because they’re not even considering the advantages" of a single-payer system.

But Democrats realize that opposition from Republicans and the powerful health insurance lobby have made the single-payer system a nonstarter, political analysts say.

Democratic leaders also have been eager to court Republican support for their health care reform efforts, knowing that voters may be reluctant to accept a plan that doesn’t appear to be bipartisan.

"I think there’s a strong desire on the part of members to work together," Sen. Christopher J. Dodd, Connecticut Democrat, said last week. "We are determined, if we can, to achieve a result that would produce 70, 75 votes in the United States Senate on this issue."

Democrats have a 59 vote advantage in the 100-seat Senate.

In order to standardize insurance costs nationwide, many Democrats seek inspiration from Massachusetts, which lets residents and businesses buy private, subsidized insurance though a state-run connector agency.

"I think the whole (health insurance) system should be more national, and the benefits have to be more national," Mr. Baucus said. "You can’t have benefits be one level in one state, and another level in other states."

But many liberals say the three-year-old Massachusetts plan is far from perfect. While the state has lowered the number of those without insurance, it hasn’t cut costs as expected. And critics argue that mandating residents buy health insurance without also having a government-run plan still gives the private insurance industry too much control over prices and coverage.

"There’s no effective guarantee that people are actually going to get health care even if they have insurance because those plans (purchased through the Massachusetts connector) have high deductibles and the benefits keep getting increasingly limited," Mr. Lighty said.

Discontent also is growing among liberal Democrats in Congress. Four liberal-leaning House Democratic groups this week sent joint letters to their party’s leaders in the House and Senate and to Mr. Obama demanding that a government-run insurance option be included in any health care reform package.

"There is strong evident that [a] private insurance-only approach will not provide equal access to health care for all consumers," said the letter that was signed by the leaders of the Progressive, Black, Hispanic and Asian Pacific American caucuses.

Kudos from some

Health Care for America Now, a coalition of labor unions and liberal advocacy groups pushing for affordable health care, says the public health insurance option is crucial to any meaningful health care reform. But group spokeswoman Jacki Schechner said she doubts Mr. Baucus would push reform legislation without it.

"It was in his white paper and we are confident it will be in the legislation that comes before the Senate Finance Committee," she said.

Ms. Schechner added that because Congress has several other health care reforms to consider, she isn’t concerned that Mr. Baucus hasn’t stressed the public option more in recent weeks.

"We also understand that Senator Baucus needs to make sure that with all the attention (the public option) is getting that his committee also focuses on other issues as well," she said. "You can take a look at the way he is trying to ensure that we look at the big picture also and not focus on just one component."

Service Employee International Union spokeswoman Lori Lodes also said she isn’t ready to label Democrats as traitors on the health care issue.

"You’ve had the president this week express his support for the public option," she said. "We’re extremely pleased with how this process is going."

Nervousness is normal

Many health care and congressional experts say that growing tensions on all sides of the health care debate is a normal part of the legislation process for an issue with such high stakes.

"We’re past kumbaya – we are now getting in the serious phase," said Len M. Nichols, director of the Health Policy Program at the New America Foundation, a centrist Washington think tank. "The closer you get to the details being revealed the more nervous you get."

Tom Miller, a health care expert with the conservative American Enterprise Institute, agreed, saying that liberal advocates will keep the pressure on Democrats until a final bill is passed.

"That’s the inevitable centrifugal dynamics of these issues, he said. " As much as (the left) will be disgruntled they’ll still get enough that they won’t walk away from any deal."

Mr. Miller added that, in the end, liberals stand to gain more than conservatives who support only modest tweaks to the national health care system.

"Those (conservative) folks will give more ground than the folks on the left feel like they’re sacrificing," he said. "But nobody gets their first set of dreams."