‘A tough needle to thread’

President Obama’s spirited defense Wednesday night of his broad healthcare goals avoided making concrete commitments on some of the most contentious issues, reflecting a guiding principle of his legislative strategy: to put off the most controversial decisions until the very last moment.

It is a strategy born of political reality. At this stage of the process, when neither the House nor the Senate has even begun a floor debate, lining up firmly on one side or the other of the hot-button issues invites gridlock or even defeat.

And so, though some liberal Democrats have threatened to revolt if Obama does not insist on a new government insurance option -- the so-called public plan -- the president told the joint session of Congress that he would consider other approaches to making coverage affordable for the uninsured.

“The public plan is only a means to that end,” he said, “and we should be open to other ideas that accomplish our ultimate goal.”

At this point, Obama seeks to remain flexible because the House will not pass a healthcare bill that does not include the public plan, and the Senate will not pass a bill that does.

A final decision on the government insurance option will probably come only after each house has acted on its own bill and a conference committee has begun negotiations to resolve the differences. It’s in those negotiations, carried out behind closed doors, that a final compromise may be hammered out.

Much the same is true for other controversial issues, including the details of individual and employer insurance mandates, cutting back federal payments to Medicare Advantage plans, and levying new fees and taxes to pay for the overhaul.

When he told the joint session that “there remain some significant details to be ironed out,” the remark drew knowing laughter.

Obama’s careful combination of specific goals and less specific prescriptions for achieving them is designed to retain his freedom to compromise when the decision point is reached -- perhaps several months from now.

“It’s not critical that the president lock down every single outstanding question right now,” said Chris Jennings, a senior healthcare advisor in the Clinton administration. “In fact, going too far in one way or the other might actually mess things up.”

Nevertheless, there are drawbacks to the White House strategy.

Obama’s reluctance to publicly chart a more precise course for lawmakers and for the broader public is widely seen as one reason that Democrats appeared to lose control of the healthcare debate over the summer.

Before the speech, a poll conducted by Associated Press and GfK Roper Public Affairs & Media found that just 42% of Americans approve of the way Obama is handling healthcare, while 52% disapprove.

That was a major shift from April, when 53% approved of the president’s healthcare policymaking, while just 28% disapproved.

“There is high risk in being too specific,” cautioned Bruce Josten, a veteran senior lobbyist at the U.S. Chamber of Commerce. “But there is high risk in not being specific enough, too. . . . It’s a tough needle to thread.”

The chamber, which initially backed efforts to reshape the nation’s healthcare system, has become a leading critic of bills being advanced by congressional Democrats, running ads in 21 states opposing the plans.

Wednesday night, Obama backed a raft of proposals that already have broad support, including new regulations that would prohibit insurance companies from denying coverage to people with preexisting medical conditions.

He also spoke forcefully in favor of requiring individuals to get insurance and of requiring large businesses to provide benefits, but with loosely defined exemptions for small businesses and individual hardship cases.

Though much of his speech was aimed at reassuring ordinary Americans, Obama also had to remain sensitive to his congressional audience.

The House is dominated by liberal Democrats. In the Senate, though Democrats control 59 seats, including two independents who caucus with the party, a bloc of conservative Democrats holds the key to passing any healthcare bill.

Without these conservatives, few believe that Democrats would be able to cobble together the 60 votes necessary to overcome a Republican filibuster.

“The president has always been stuck in a situation where he does not want senators to think he’s not for their bill and he doesn’t want members of the House to think he doesn’t like their plan,” said Rep. Henry A. Waxman (D-Beverly Hills), the House Energy and Commerce Chairman and a leading architect of the House legislation.

That has left the president and his aides in the position of helping to guide a more liberal bill through the House of Representatives and a more conservative one through the Senate.

“Everything will be resolved in conference,” Waxman said.

Only then might Obama say precisely what kind of healthcare plan he really wants.

noam.levey@latimes.com

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(BEGIN TEXT OF INFOBOX)

The talking points

A look at key points in President Obama’s healthcare speech:

* Individuals would be required to carry basic health insurance. Those who couldn’t afford it would get a hardship waiver.

* Businesses would be required to offer their workers healthcare or chip in to help cover the cost. Ninety-five percent of small businesses would be exempt because of their size and narrow profit margin.

* Medical malpractice reform is not a “silver bullet,” but practicing “defensive medicine” can lead to unnecessary costs; demonstration projects will be reviewed to see what changes to medical malpractice insurance would work best.

* It would be against the law for insurance companies to deny coverage because of a preexisting medical condition.

* He promised to protect Medicare and reassured the elderly that Medicare funds would not be used to overhaul healthcare.

* A public option, or alternative to private insurance, needs to be available to the uninsured to “keep insurance companies honest.”

* The public option would not be subsidized by taxpayers, but would be self-sufficient and rely on the premiums it collects; the Congressional Budget Office estimates that fewer than 5% of Americans would sign up.

Source: Associated Press