WASHINGTON - President Barack Obama faces near unanimous Republican opposition and a serious divide among his own Democrats as he prepares to make a highly unusual and high-stakes address to Congress on Wednesday to press for his version of health care reform, his top domestic policy goal.
The president took office vowing to overhaul a system whose costs are raging out of control while as many as 50 million Americans are without health insurance. Thousands of households talk bankruptcy daily because of medical bills, and health care consumes nearly 20 per cent of the gross domestic product.
But a failure among Obama's fellow Democrats to solidify their support behind his reforms, intense Republican attacks against the overhaul - including blatant falsehoods - and sagging poll numbers pushed the president into making Wednesday's speech.
An Associated Press-GfK poll released on Wednesday showed that public disapproval of Obama's handling of health care has jumped to 52 per cent from 43 per cent in July. The survey also found that 49 per cent now disapprove of the president's overall job performance. That figure was just 42 per cent in July.
So far, he has been unable to take full advantage of his party's significant majorities in both houses of Congress.
While polls show most Americans want to see the system changed, Republicans have inflamed the debate, and some moderate Democrats in so-called swing states - fearing punishment at the polls next year - have refused to back Obama on the government-run public health care option.
Other conservative Democrats are wary of the huge cost of overhauling the private system and offering a government coverage option. Congressional estimates say the plan would cost as much as a trillion dollars over the next decade.
Also, there is an instinctive reaction among many Americans to federal government involvement in their lives - an irrational fear of what some call "socialism" - despite their dependence on or expectations of programs such as Medicare, government run health care for the elderly, and Social Security, a government pension for nearly every American at retirement.
The Obama speech takes a page from the last Democratic president, Bill Clinton, who went before both houses as he sought during his second year in office to ram through health care reform. His plan, written largely under the oversight of his wife, Hillary Rodham Clinton, never got to a vote and the whole issue was dropped.
That was a significant political blow to Clinton, and Democrats suffered a major setback in the next midterm Congressional elections.
While Obama was quick off the mark in his presidency in winning passage of a $787 billion stimulus to reinvigorate the failing economy, other reform programs have stalled or are facing significant resistance. Perhaps most important is his attempt to get the Senate to take up a measure that would tax polluters and use those revenues to support and develop alternative and renewable energy resources.
Obama's troubles on health care overhaul have led some analysts to forecast bad political days ahead for Obama and big setbacks for fellow Democrats in next year's midterm congressional balloting, making it even more difficult to win passage of the rest of his reform agenda.
That's what makes his Wednesday speech so important. Obama needs to walk away from the lectern in the House of Representatives without having angered his liberal backers, who are determined to have a government-run health plan, while having also accommodated himself to centrists Democrats and Republicans who are dead-set against it.
Nevertheless, an Obama aide said Wednesday, the president will repeat his support for a government-run insurance option and make a case for why he believes it's the best way to introduce competition. But he will not outright demand it or issue a veto threat over it. The senior official spoke on condition of anonymity to discuss the speech before its release.
But it's appearing more and more likely that the president's bid to set up a government-run health insurance plan - one that would offer low-cost coverage to the uninsured and competition to the private insurance industry - has become politically impossible, for now.
The most likely substitute would be a system of non-profit health insurance co-operatives or a government system that would take effect in future years if the insurance industry doesn't mend its ways.
At this point, Obama now looks - at best - capable of winning legislation to reform private health insurance companies - a law that would forbid them from refusing coverage to people who have existing medical conditions and stop the practice of dropping coverage when someone becomes ill. At worst he would get nothing at all.
Even staunch allies like House of Representatives Speaker Nancy Pelosi, as she did after meeting with Obama Tuesday afternoon, are still insisting that jettisoning the public option is a line that liberals like her will not cross.