Such changes could be combined with federal funding for high-risk insurance pools to provide affordable coverage for people in poor health shut out of the private market. Obama supports risk pools, as does Sen. John McCain, the 2008 Republican presidential candidate.
Notably, individual components of the Democratic megabills are far more popular than the whole, according to a poll released Friday by the nonpartisan Kaiser Family Foundation. Seventy-three percent of Americans support small business tax credits, and 62 percent back a Medicaid expansion. Allowing dependent children to stay on their parents' coverage until age 25 got 60 percent support.
Such steps could help many who now lack coverage, but that would leave holes in the safety net.
On cost-control, incremental improvements also are possible.
There is broad agreement that the way government's elderly health care plan currently pays hospitals and doctors rewards high-volume, low-quality care. Shifting these payments to make providers more accountable for whether the patient ultimately gets better could have a positive impact throughout the health care system. The Democratic bills would launch a series of experiments aimed at getting good quality care at lower cost, and those could be incorporated into a scaled-back bill.
Alternatives to medical malpractice litigation also could yield savings. The Congressional Budget Office, reversing a previous analysis, says curbs on jury awards in malpractice cases could save the government $54 billion over 10 years by reducing defensive medicine.
It is too early to tell whether Democrats will embrace the smaller-is-better route, much less get it through Congress in the current political climate.
"The well has been poisoned," said Robert Laszewski, a health industry consultant. "The Republican base is not going to let any Republican senator take Democrats off the meat hook they are on now."
Still, for Democrats, there is a hopeful precedent. After the Clinton-era health overhaul imploded in 1994, Democratic and Republican lawmakers coalesced around the idea of a new health insurance program for the children of low-income working parents. That program, still thriving, now covers about 6 million kids.