Speaker Nancy Pelosi (D-Calif.) was wrapping up a leadership meeting last week when she turned the conversation to a politically vulnerable Democratic freshman.

Pelosi noted that the lawmaker had recently received a big legislative assist from leaders but then declined to show up for a press conference promoting their health care reform push, sources in attendance said.

Some people in the room said Pelosi’s implication was clear: Marginal Democrats need to be team players in the party’s make-or-break drive to restructure the health care system — or stop expecting the legislative favors that they covet to establish track records for re-election.

Others said the Speaker was simply airing her frustration with the turn of events. “Of course we are always looking for opportunities to highlight new Members who have good ideas to strengthen the health legislation or promote other bills that are important,— Pelosi spokesman Nadeam Elshami said. “Suggesting that there is a link or quid pro quo between supporting health care and championing other critical initiatives is simply false and uninformed.—

Either way, the episode highlights a delicate balance that leaders are seeking to strike as they make final decisions about the shape of the House package and prepare to pivot to a whipping effort to secure support for it. Pelosi privately is talking up her desire to gather 230 votes for the measure to strengthen House Democrats’ negotiating position in talks with the Senate, top Democratic aides said. But moderates worry that even a bare majority will come at the expense of Democratic majority-makers, lawmakers elected from Republican-leaning districts.

Democratic leaders expect to receive cost projections from the Congressional Budget Office today, setting up determinations this week on outstanding issues — including the shape of a public insurance option.

Closing in on the final design of the package in recent days, Pelosi has begun taking a more direct approach with skeptical lawmakers, making it clear that she is unlikely to make tweaks for people inclined to vote against the package anyway, top aides said.

“She has to think about how it impacts those who support the bill and would remove their support if that were to be added,— one Democratic leadership aide said. “That’s how you get to consensus.—

While House leaders haven’t made hard and fast decisions, Pelosi made it clear that she’s intent on pushing the strongest bill that she can through the House — in her words, to bring as much “muscle— for the middle class to conference with the Senate.

Pelosi hasn’t, however, drawn lines in the sand on what she will be willing to accept in those House-Senate negotiations, potentially setting up a scenario where her moderates are steamrolled on the initial bill and her liberals are rolled in the endgame.

Pelosi seems to have minimized the concern expressed by many fiscally conservative Blue Dog Democrats that they will be asked to vote for a liberal bill that has no chance of emerging from the Senate.

Several factors seem to have moved in Pelosi’s favor — and that of a Medicare-based public insurance option in the House — in recent weeks. Backers of the public option had a rough August during which opponents ginned up town hall protests, but they regrouped in September. A bloc of liberals has continued to insist on a Medicare-based public option to provide a low-cost alternative to private insurance companies, which they often view as malicious leeches who gorge on profits by denying care to the sick. And they have been bolstered of late by polls showing nearly 2-to-1 support for a public option, as well as a Congressional Budget Office score showing that a Medicare-based public option saves $110 billion over the next decade, while providing more affordable insurance for the middle class.

Blue Dogs emerged from August divided and without a unified proposal of their own. Rep. Mike Ross (D-Ark.), who had emerged as a key deal-maker for the group in the spring, talked himself out of the room when he quickly declared he would not vote for any kind of public insurance option.

And the Blue Dogs’ demand for cost cutting ran directly contrary to the demands of many in their group as well as largely rural Members that the public plan be divorced from Medicare reimbursement rates, which they argue are unfairly low in their areas and would bankrupt their hospitals.

Using negotiated rates would leave an $85 billion hole in the bill, and Blue Dogs didn’t come up with a unified way to make up that difference.

They didn’t seem willing to push aggressively as a group for the two items most likely to achieve long-term savings: a Medicare commission with the power to significantly cut costs or a tax on high-cost insurance plans.

House Majority Leader Steny Hoyer (D-Md.), the one member of leadership most attuned to the moderate wing of the party, has not been pushing to weaken the public option.

Leadership aides complained that moderate and vulnerable Members are quick to point out the host of issues that they don’t like in the health care bill but do a much poorer job of saying what they would support instead.

“I think there are people at the table … who could advocate for the marginal Members, but they’ve not been as organized, cohesive and clear about what it is they want,— the aide said. “It’s hard to advocate when you don’t know what they want.—

Rep. Jim Matheson (D-Utah), a Blue Dog leader, blamed the broader debate for focusing too heavily on the shape of the public insurance option. “There are a lot of moving parts to this,— he said. “So is it always as clear-cut a message as everybody wants? Probably by definition it can’t be.—

He said that while Blue Dogs have various concerns with the measure, they have consistently advocated for cost containment and deficit neutrality — issues that he said could come into sharper resolution when the CBO delivers its assessment.

Rep. Patrick Kennedy (D-R.I.), a liberal who, like his late father, Sen. Edward Kennedy (D-Mass.), has championed health care reform, said it really doesn’t matter much what the House can pass — it’s about the endgame with the Senate.

The conventional wisdom at this point is that “the Baucus plan is the only one that has 60 votes over there,— he said, referring to the proposal that passed out of Finance Chairman Max Baucus’ (D-Mont.) committee last week.

Kennedy said the choice that leadership has to make is to pass a strong bill that makes liberals feel good but causes trouble back home for moderate Members and likely won’t survive a conference committee, or pass a more moderate bill that advances the ball a bit and try again next year, and the year after.

He pointed to his father’s legacy, cited by President Barack Obama in his joint address to Congress on health care, of achieving what can be achieved.

“You can’t be ideological; you’ve got to be practical,— he said. “This place isn’t about getting everything you want.—