Correction Appended

Now, the real work begins.

President Barack Obama and Congressional leaders have had their summits and their stakeholder meetings. Now they are starting to debate the actual details of health care reform.

It’s a top priority not only for Obama, but in Congress and among industry groups and patient activists. With 47 million Americans uninsured and millions more with inadequate amounts of insurance, and with health care and entitlement costs spiraling out of control, there is nearly universal agreement that something needs to be done.

But how — and how much and how fast — remains a topic of dispute.

The Obama administration has aimed for passing health care reform by the end of the year, and both chambers of Congress are working toward that goal. Senate Finance Chairman Max Baucus (D-Mont.) is planning to put the reform plan on the president’s desk during the summer. Senate Health, Education, Labor and Pensions Chairman Edward Kennedy (D-Mass.) is expected to have his language ready for a reform bill as early as Memorial Day.

Key House lawmakers, including Energy and Commerce Chairman Henry Waxman (D-Calif.), are working with the same timeline. Waxman and Rep. Frank Pallone (D-N.J.), chairman of Energy and Commerce’s Subcommittee on Health, are aiming to begin drafting language in April, in order to be ready to conference with the Senate in August, a House Democratic aide said.

But hard work lies ahead. While Obama and Members of Congress have already held a number of summits and other meetings and issued white papers to establish the basic principles, there are no legislative details at this point.

It’s time to move beyond the “happy talk— that has characterized the discussions so far, said David Introcaso, vice president of health care research for the Marwood Group, which specializes in financial services.

The next few weeks are crucial to getting reform done this year, as language needs to be introduced and debated, he said.

Without such details, stakeholders are merely “at the first pitch of a nine-inning game,— said Elizabeth Hall, vice president for public policy at Wellpoint Inc., a health benefits company.

Among the largest fights will be one over a proposed public health care coverage plan. Republicans and industry groups have already drawn a line in the sand, pledging to oppose a public option on the grounds that it undermines the competitiveness of private plans.

Specifically, conservatives say the government cost controls inherent in a public plan will make it difficult for private insurers to compete.

“Human nature and common sense will tell you that if you’ve got a government program competing with private programs, all of the factors weigh in favor of the government program— and individuals will leave the private-sector plans as a result, said Rep. Nathan Deal (R-Ga.), the ranking member of the Energy and Commerce Subcommittee on Health.

This is a “flash point— in the debate between the sides, a House GOP aide said. The issue is a potential deal-killer, Introcaso said.

While some stakeholders, including John Arensmeyer, the chief executive officer of the Small Business Majority, believe that compromise on the issue is possible, others doubt it.

It is “virtually impossible to guarantee fair competition because government can change the rules of the game at any time,— a House GOP aide said.

Another Republican insider showed his contempt for the proposal by likening a public option to a shark attack.

“Does the comely swimmer compete fairly, or at all, with the peckish shark? To be fair, the White House probably will start by proposing to eat only the lady’s foot,— the aide said. “People on the beach would then be expected to congratulate her on getting a compromise and wonder what the bloody thrashing was all about.—

But Democrats and activists argue that a public option is necessary to drive down costs and increase access to health care. Industry and Republicans’ complaints are “a confession of failure— on the efficiency and effectiveness of their plans, said Roger Hickey, co-director of the liberal group Campaign for America’s Future.

Many of the people involved in the debate who believe that compromise is possible are pointing to a paper by the New America Foundation as a solution. In the report, “A Modest Proposal for a Competing Public Health Plan,— Len Nichols, director of the group’s health policy program, and John Bertko, the group’s actuarial consultant, set conditions for fair competition between public and private plans.

These include requiring that the public plan must be actuarially sound by charging premiums to cover its costs, rather than letting those plans be subsidized by the government. Additionally, the government should not be able to leverage Medicare, or any other public program, to force providers to participate. Furthermore, the same insurance market rules and regulations should apply to both public and private plans, ensuring a level playing field. Also, public plans cannot be given an unfair advantage in enrolling uninsured or low-income individuals who would be eligible for government subsidies.

Despite this and other obstacles, all observers seem to agree that the chances for achieving reform are far better than they were when former President Bill Clinton tried to do so in 1993 and 1994.

“I have been working on health care policy for more than 25 years, and I have never been more hopeful about the prospect of reform — or more convinced about the overwhelming need for reform — than I am now,— Sen. Jay Rockefeller (D-W.Va.) told CongressNow.

One reason for their optimism is the poor state of the economy, which means businesses and workers alike are pushing to eliminate the status quo. And unlike the Clinton effort, where the White House essentially handed down language for the reform package, Obama and lawmakers have been seeking stakeholder input from the very start of the process and continue to do so.

As a result, while many business groups had opposed this earlier effort, the industry is now largely on board. There has been a “philosophical truce between the sides,— Sen. Ron Wyden (D-Ore.) told CongressNow.

Obama has capitalized on the current economic circumstances by constantly reinforcing the link between health care reform and the economy. Doing so, through a variety of public and private meetings on health care, has been a “real trump card for the president,— Hickey said. These meetings have also served to highlight the unity between the stakeholders on the need for reform, establishing the basic framework for the effort.

As opposed to Clinton’s effort, industry groups are harder pressed to turn away from reform because they cannot argue that they have been excluded from the process, Arensmeyer said.

Judy Feder, a professor at Georgetown University’s Public Policy Institute, said that essentially these meetings served as a warning to potential opponents that health care reform will get done one way or another, “so you’d best get on board.—

Correction: April 10, 2009

The article misstated David Introcaso’s position. He is vice president of health care research for Marwood Group.