Rep. Rick Boucher (D-Va.) is in a tough spot when it comes to overhauling the nation's healthcare system. Major hospitals in his largely rural district have told him the bill pending in the House would cripple them financially. But Boucher also believes that the need for change is painfully obvious: When a free medical clinic was offered in a remote area of his district, some 2,700 people showed up.
"It put an exclamation point on the fact that we have 47 million uninsured Americans," said Boucher, who was one of five Democrats to vote against the bill when the House Energy and Commerce Committee approved it Friday night, setting the stage for a House vote in the fall.
"But there are clear practical problems for rural areas. This is not about philosophy. It's about the survival of hospitals."
Those political cross-pressures were evident when President Obama visited Boucher's district last week: There were demonstrators outside the event both supporting and protesting Democrats' plans to overhaul the nation's healthcare system.
During the August congressional recess, Democrats from across the country expect to be buffeted by those same cross-currents. Their meetings with constituents are sure to be dominated by the far-reaching healthcare legislation emerging from House and Senate committees.
The bill, which took a big step forward with the Friday committee vote, is designed to expand health coverage for the poor, cut costs, and improve coverage for people who already have insurance. It would also raise taxes on high-income people, mandate that businesses with more than $500,000 a year in revenue provide health insurance for their employees, and establish a government-sponsored health insurance option.
Critics, including some Democrats, fear the government plan could dominate the market and undercut private options. Hospitals in rural areas are especially fearful that a new reimbursement system would not adequately cover their costs.
Though Obama owed his 2008 election in part to his pointed critique of the healthcare system -- and many congressional Democrats won their seats on his coattails -- the issue now is a political live wire, and Democrats are treading gingerly.
"We are getting thousands of phone calls and e-mails, many deeply angry," said Rep. Jim Cooper (D-Tenn.). "Some want to do nothing, others want to do everything. We can't distinguish between what is just grumbling about change and what is a precursor of an earthquake."
For some politicians, the choice is simple: In Flint, Mich., unemployment is close to 30%, and Democratic Rep. Dale E. Kildee embraces government efforts to help cover the uninsured.
Republicans and other critics portray Obama's plan as a federal takeover of medicine, making it a much riskier issue for Democrats in more conservative districts. That includes the many Democrats elected in Republican-leaning districts in the 2006 and 2008 elections and the Blue Dog coalition of fiscal conservatives. That wing of the Democratic Party has bargained hard for concessions to help small businesses and rural areas, and to reduce the overall cost of the bill.
Rep. Allen Boyd, a Blue Dog leader, represents a district in northern Florida that exemplifies the mixed audiences that swing Democrats will play to: It stretches from conservative Panama City to Tallahassee, the more liberal state capital with a big academic community. "I plan to have a lot of town hall meetings," Boyd said. "The discussions will be spirited."
Another reason the issue is politically fraught: Healthcare touches virtually every constituent and interest group directly, unlike more abstract issues like global warming. And though 47 million people have no health insurance, most Americans do. Voters may have responded well to the general idea of improving healthcare during the 2008 campaign, but many are less sanguine about the legislation's effect on them as Congress begins to fill in the details.
A new poll by the Pew Research Center documented both the high level of voter interest and growing reservations about the legislation. Nearly a third of those surveyed said the healthcare debate was the most important story they were following in the news -- far more than the 19% who cited the economy.
But more Americans oppose than favor the proposals before Congress, 44% to 38%, the poll found. Opinions break sharply along partisan lines. But among independent voters, the trends are not encouraging for Obama: Independents who said they have heard a lot about the bills in Congress oppose them by 70% to 27%, Pew found.
Many congressional Democrats expect to spend a lot of this recess helping their constituents understand the pending proposals, as well as the current healthcare system, because both are so complex and so little understood.
Rep. Jason Altmire (D-Pa.) says the many senior citizens and military veterans in his district are already enjoying the benefit of federal health programs, but some hardly seem to realize it. He cites an 80-year-old man who told him to "keep the government out of healthcare" -- even though Medicare had paid for his successful heart surgery 15 years ago.
Altmire, one of only three Democrats who voted against the healthcare bill in the House Education and Labor Committee, said the cost-cutting changes made last week in negotiations with conservative Blue Dogs would help make it easier for him to sell the legislation in his district, a GOP-leaning region he won from a Republican incumbent in 2006.
Democratic leaders are arming their rank and file for conversations with constituents. Rep. Chris Van Hollen (D-Md.), chairman of the Democratic Congressional Campaign Committee, met with first- and second-term lawmakers recently to brief them on the issue.
His political advice: Define the issue yourself -- before your opponents do it for you.