Spurred on by President Obama and an array of businesses, medical providers and consumers clamoring for change, congressional Democrats have begun to lay out specific plans for overhauling the nation's healthcare system -- proposing changes that would affect almost every American, old or young, sick or well, rich, poor or middle-class.
Despite a looming brawl over key details, the Democratic majority is expected to pass a bill that will make ordinary Americans the ultimate stakeholders who must live with the system, adjust to changes and -- one way or another -- absorb the costs.
For laid-off autoworkers, there could be a new guarantee that they won't lose their family health insurance. A patient with heart disease could receive more advanced treatment to avoid hospitalization. Small shop owners could get help figuring out coverage for employees. An overweight teenager might find a new slim-down program at school.
And for some Americans, especially the affluent and those with traditional job-based medical insurance, there could be new or higher taxes.
After months of spadework and consultation with the interested parties, lawmakers begin the most sweeping healthcare debate in a generation with broad agreement on the need to control costs, improve the care Americans receive and expand coverage to nearly everyone.
But shadowing the debate, which is expected to dominate Washington's summer and extend into the fall, are the same vexing controversies that have derailed almost all previous efforts to reshape the U.S. healthcare system.
There is still no consensus, for example, about how large a role the federal government should play. Nor is there agreement on who should bear the cost, which could surpass $1.5 trillion over the next decade.
Obama's proposals include higher taxes for the wealthiest Americans. But that idea has generated widespread opposition in Congress.
Other financing schemes may be just as unpopular, such as taxing employer-provided health benefits or putting new levies on sugary beverages to raise revenue and encourage healthier behavior.
The first concrete legislation emerged Tuesday as Sen. Edward M. Kennedy (D-Mass.) filed a mammoth bill that, among other things, outlines a dizzying new government regulatory structure to ensure that every American gets health insurance.
Other bills are expected to follow from a trio of senior House Democrats, including Rep. Henry A. Waxman (D-Beverly Hills), and Senate Finance Committee Chairman Max Baucus (D-Mont.), whose bill may offer the best hope for gaining Republican support.
In addition, a phone-book-size catalog of amendments and less-detailed alternatives -- including many from Republicans seeking to shape the debate themselves -- are expected to compete for attention.
Though they differ on important details, the Democrats' plans all focus on three broad goals, each of which has contributed to stalemate in the past:
* Improving the quality of care for everyone by encouraging doctors, hospitals and others to adopt the best, most effective courses of treatment. Research shows that many doctors fail to adopt advances in treatment and that more than 25% of all treatment may be medically ineffective or unnecessary.
Achieving this goal moves the government into the sensitive area of relations between individual patients and their doctors.
But many health policy experts say such changes could do the most to reduce medical costs and improve care.
"At the end of the day, that may be the most important thing we end up doing," said Ken Thorpe, a healthcare economist at Emory University.
* Curbing the explosive growth in costs by prodding the medical system to make more cost-effective decisions and to increase efficiency by moving to computerized medical records.
The public and employers are staggering under the cost of the present system -- rising at more than twice the rate of inflation and expected to surpass $2.2 trillion this year. But reining in prices can narrow freedom of choice and impose changes on providers.
* Making health insurance readily available to the 46 million people who don't have it, as well as more affordable and less burdensome to those who do, and to the employers who still deliver the bulk of medical insurance to workers.
In one of their most controversial proposals, Obama and congressional Democrats want to create an optional government insurance plan that individuals could choose instead of a private plan. Supporters argue that such a plan would curb costs and improve quality by creating competition for the handful of private insurance companies now dominating the market.
Few proposals ignite hotter partisan passions.
"It's just very, very difficult," a frustrated Sen. Charles E. Grassley (R-Iowa) said after emerging from one meeting with fellow lawmakers last week.
Grassley, the senior Republican on the Senate Finance Committee, is a leading member of a bipartisan group that has been working for months on healthcare legislation with input from dozens of interest groups.
This is the seventh major push over the last century, and senior senators from both parties say they are trying to find common ground.
"I think we have been surprised at the amount of agreement there is," said Wyoming Sen. Michael B. Enzi, the senior Republican on the Senate Health, Education, Labor and Pensions Committee.
One thing lawmakers in both parties have agreed on is that people's existing healthcare arrangements should be disrupted as little as possible. In particular, people should be able to keep their insurance and their doctor if they want to.
"For lots of Americans, there won't be much change right away," said Drew Altman, an expert on healthcare politics and president of the nonprofit Henry J. Kaiser Family Foundation.
"That is inherent in the strategy."
Altman said that approach reflected the fact that most Americans report high satisfaction with their own care, even as they worry about rising costs.
In the same spirit, senior lawmakers and the administration are working to preserve the current employer-based system through which most Americans get insurance, while rejecting a single-payer system favored by some liberals, as well as a more free-market system favored by conservatives.
But signs of tension are already emerging, especially over provisions that Republicans charge would lead to government intrusion into the private relationships between patients and care providers.
Sensitive as those issues may be, many healthcare analysts worry that paying the bills may ultimately be where cooperation breaks down.
"The stars are aligned. The signs are promising," said Jacob Hacker, a political scientist at UC Berkeley who has studied previous efforts to overhaul the nation's healthcare system.
"But so far there has not been much congressional willingness to consider even relatively modest revenue-raising ideas," he said. "And in the healthcare debate, time is one of the greatest dangers. It gives people a chance to decide they are against whatever is on the table."