Going into the fall, Obama has a plateful

Heading into the fall, President Obama has his work cut out for him.

Healthcare reform, his top domestic priority, is hardly the only issue on his plate. Obama is fighting wars in Iraq and Afghanistan. Iran and North Korea's nuclear ambitions demand attention. The Jan. 22 deadline for closing the Guantánamo Bay prison camp looms large. And the appointment of a federal prosecutor to review treatment of Bush-era detainees has reignited debate over past conduct in the war on terror.

Back on domestic affairs, major climate-change legislation and reform of financial regulations also loom.

But it's the drive for sweeping changes in the healthcare system that may well define Obama's first year in office. And after a rough August, with its rowdy town halls and claims that "death panels" would "pull the plug on grandma" under Obamacare, the president enters the home stretch politically weakened.

"August did damage," says Cal Jillson, a political scientist at Southern Methodist University in Dallas. "Essentially, the big package that envisioned a ‘public option' as well as health insurance reform and cost reductions, the whole nine yards, is probably off the table."

Still, Mr. Jillson believes there's "a good prospect for a significant health reform bill." It is likely not to include the so-called public option, a government-run health-insurance plan designed to compete with private insurers, but he predicts it will include elements of health-insurance reform, such as preventing insurers from denying insurance to people with preexisting conditions or dropping coverage when they get sick. It would also likely ban lifetime caps for coverage as well as caps on out-of-pocket expenses.

Forces beyond Obama's immediate control made success on big, sweeping reform a long shot from the start.

He took office in January with an economy in free-fall, and took bold steps to keep a deep recession from turning into a depression - winning passage of a $787 billion stimulus bill, bailing out banks and insurers like AIG, and propping up the domestic auto industry. By the time Obama got to his own signature priority, healthcare reform, the public's appetite for big government action had waned.

His diminished mandate has been reflected in sliding public opinion. At the beginning of July, Obama's weekly average job approval rating in the Gallup poll was 60 percent. By the end of August, he was approaching 50 percent. On the handling of healthcare policy, Obama has polled at 44 percent and 43 percent approval both times Gallup asked the question this summer.

The good news for Obama is that the public trusts him more than other players – congressional Democrats, congressional Republicans, the healthcare industry – to improve the system.

But the loss of two key allies – Sen. Edward Kennedy of Massachusetts, who died Aug. 25, and former Sen. Tom Daschle of South Dakota, who was to be Obama's health secretary and reform "czar" until he withdrew over tax issues – cannot be overestimated.

Senator Kennedy's illness took him away from the day-to-day workings of the Senate, but he had remained a force in the healthcare debate and the drive for universal coverage until the end. In particular, advocates of reform will miss Kennedy's ability to work with Republicans and craft bipartisan legislation. Even from a distance, Kennedy played a role in shaping the bill that came out in July from the panel he chaired, the Senate Health, Education, Labor, and Pensions Committee.

Mr. Daschle hasn't left the scene entirely; he speaks frequently with Obama and his top advisers. But the former Senate Democratic leader, who has expertise on the inner workings of Capitol Hill and relationships with the members most involved in reform, would have been more valuable to Obama as a top aide. Now that Daschle is a paid adviser to clients in the pharmaceutical, hospital, and insurance industry, some liberals are wary of him.

Despite all the setbacks, Obama has options, even as the Senate Finance Committee races to meet a Sept. 15 deadline to produce legislation. Most critically, advocates say, he needs to reach out to senior citizens, the age bracket most concerned about reform. Because they are covered by Medicare, they feel they have the most to lose.

John Rother, top lobbyist for the seniors' advocacy organization AARP, says Obama needs to stress that proposed savings in the Medicare system will not come from the beneficiaries, access to care, or quality of care.

"It would be helpful if it wasn't just Obama saying this," says Mr. Rother. Obama needs "leaders in medicine, hospitals, people directly involved in the system saying [the proposed reforms] are not going to hurt Medicare."

Obama also needs to again stress to the Medicare population that the status quo is unsustainable as costs skyrocket and that reforms will benefit seniors in concrete ways, says Rother. These changes include fixing the "doughnut hole," the gap in prescription-drug coverage that leaves seniors paying out of pocket until expenses have reached a certain level.

Jennifer Duffy, a political analyst at the nonpartisan Cook Political Report, says Obama's ability to move the ball forward on reform is limited, unless Democrats reach agreement on a strategy.

"He could devote every radio address from now until the end of the year on debunking myths, and it won't change anything," she says.

To Donald Taylor, a professor of public policy at Duke University in Durham, N.C., the most surprising aspect of Obama's healthcare initiative is how long he has held to general principles for reform, while letting Congress take the lead in crafting details.

"It makes it tricky for his supporters, because it's not clear what his final bill will be," Professor Taylor says. "I don't see how [reform] goes forward without the president coming back after Labor Day and saying, ‘Here's what I really want.' "

In the wake of Kennedy's death, liberal advocates of reform mourned the loss of the senator's legislative skill. But as the fall push begins, his memory will be present.

Healthcare reform "was the cause of his life, and he fought it all the way to the end of his life," former aide Bob Shrum told ABC-TV the morning after Kennedy's passing. "Maybe his absence now will cast a long shadow and actually make it happen."