With Republicans unified in their opposition, Democrats are drafting plans to try on their own to pass a bill based on one Mr. Obama unveiled before his bipartisan health forum last week. His measure hews closely to the one passed by the Senate in December, but differs markedly from the one passed by the House.
That leaves Ms. Pelosi in the tough spot of trying to keep wavering members of her caucus on board, while persuading some who voted no to switch their votes to yes — all at a time when Democrats are worried about their prospects for re-election.
Representative Dennis Cardoza, Democrat of California, typifies the speaker’s challenge. The husband of a family practice doctor, he is intimately familiar with the failings of the American health care system. His wife “comes home every night,” he said, “angry and frustrated at insurance companies denying people coverage they have paid for.”
But as a member of the centrist Blue Dog Coalition, Mr. Cardoza is not convinced that Mr. Obama’s bill offers the right prescription. It lacks anti-abortion language he favors, and he does not think it goes far enough in cutting costs. So while he voted for the House version — “with serious reservations,” he said — he is now on the fence.
“I think we can do better,” Mr. Cardoza said of the president’s proposal.
Representative Frank Kratovil Jr., Democrat of Maryland, is also unconvinced. He voted against the House bill on the grounds that it is too big and too costly — a view that some constituents in his Republican-leaning district share. In case he did not get the message, one of them hanged him in effigy this past summer outside his district office on the Eastern Shore of Maryland.
“This system is broken; we have to do something,” Mr. Kratovil said. “But my preference would be to do smaller things.”
Under the Democrats’ tentative plans, the House would pass the health care bill approved in December by the Senate, and both chambers would approve a separate package of changes using a parliamentary device known as budget reconciliation.
The tactic is intended to avoid a Republican filibuster, but in the Senate, the majority leader, Harry Reid of Nevada, faces challenges if he tries to use it. He is having trouble persuading a majority of his caucus to go along.
In the House, lawmakers like Mr. Kratovil, Mr. Cardoza and other swing Democrats will come under increasing scrutiny from leadership as a vote draws near. Of the 219 Democrats who initially voted in favor of the House measure, roughly 40 did so in part because it contained the so-called Stupak amendment, intended to discourage insurers from covering abortion.
Some, notably Representative Bart Stupak, the Michigan Democrat for whom the amendment is named, will almost certainly switch their yes votes to no because the new version being pushed by Mr. Obama would strip out the House bill’s abortion restrictions in favor of Senate language that many of them consider unacceptable.
An additional 39, like Mr. Kratovil, are fiscal conservatives who voted no the first time around. Ms. Pelosi is hoping that she can get some to switch those no votes to yes in favor of Mr. Obama’s less expensive measure.
But persuading Democrats who are already on record as opposing a health overhaul to do a turnabout will not be an easy task, especially during a midterm election year in which Democrats’ political prospects already look bleak. Of the 39 Democrats who voted against the House measure, 31, including Mr. Kratovil, represent districts that were won in 2008 by Senator John McCain of Arizona, Mr. Obama’s Republican rival. Fourteen, including Mr. Kratovil, are freshmen, who are generally considered more politically vulnerable than more senior lawmakers.
“The concern among Democrats right now is that there are more yes votes reconsidering than no votes,” said David Wasserman, who tracks House races for the nonpartisan Cook Political Report. “My sense is that for Democrats to pass this bill, they would have to convince several members who are already in serious jeopardy, even after voting no on the first health care bill, to put passage of the bill ahead of their own chances of being competitive in the fall.”
But politicians do not want to be martyrs. They want to hold onto their seats.
Carl Hulse contributed reporting.
I'm more confident in the Speaker than the President's efforts on this. I hope PBO surprises and finally goes all out to get the last few votes.