WASHINGTON - The long national health care debate reaches its final round this week with congressional Democrats on the cusp of a historic breakthrough that could bring medical coverage to millions of uninsured Americans -- including some 500,000 in Minnesota.

But for some of President Obama's faithful on the left -- unabashed progressives such as Minnesota Democrat Keith Ellison -- the final vote could bring something of a day of reckoning.

The public option is dead. There likely will be new restrictions on abortion funding.

Forget about last summer's right-wing Town Hall anger. The pivotal drama of the closing days of the health care overhaul could be left-wing angst.

"It's going to be a tough vote for me," Ellison said after a Democratic caucus meeting last week. "At some point I'm going to have to decide red or green, and if the public option isn't in there, it's going to be an incredibly hard lift to push green."

Democratic pragmatists in the Senate caution that even if this is not the bill many wanted, the 60-vote threshold to overcome a Republican filibuster dictates that this is the bill they're going to get.

"It's a meaningful beginning," said Sen. Amy Klobuchar, D-Minn., noting that the thrust of the cost reforms in Medicare -- a central part of how the bill will be paid for -- are based on the state's model of high-efficiency, low-cost health care.

"The concerns about Medicare were the concerns of Minnesota," she said.

But for those who still remember the heady days of Obama's inauguration a year ago, the health care legislation the president could sign in the coming weeks clearly will fall short of the goals of universal health care or a single-payer national health care system that many of them wanted.

"I have a lot of single-payer people in my district," said U.S. Rep. Betty McCollum, a St. Paul Democrat. "They wanted single-payer. I would have to explain to them, 'Here's the math.'"

For McCollum and many other Democrats, the bill's guarantees of expanded medical coverage and insurance industry regulation come close enough to their idea of reform to virtually assure passage.

"We're close to coming together to cover between 30 million and 35 million more Americans," McCollum said. "Do people always want more? Yes. But this is significant. It is historic."

Heading into the home stretch of negotiations on the House and Senate versions of the bill, the main sticking point has been an intramural squabble among Democrats over high-cost "Cadillac" health plans -- which under the Senate bill would be subject to a new 40 percent excise tax.

The Obama administration agreed to soften the levy for union members, but according to some reports, that has left Democrats looking for ways to make up the lost revenue, including possibly levying an additional $10 billion in fees on medical devicemakers, an important industry in Minnesota.

Even without the creation of a government-sponsored insurance program, or public option, critics such as Minnesota Republican Rep. Michele Bachmann see enough governmental intrusion into health care to brand it socialism that carries a trillion-dollar price tag.

Congressional Republicans, who uniformly oppose the bill, have largely sidelined themselves on negotiations that they complain have taken place largely behind closed doors.

That did not stop Bachmann, along with Minnesota Republicans Erik Paulsen and John Kline, from writing a letter to House leadership last week citing estimates by Minnesota social services officials that the proposed expansion of Medicaid could cost the state $2.1 billion over six years.

'Screwing up the cosmos'

But for partisans on the left, the legislation represents a missed opportunity.

"At one point, we had more than 50 votes in the Senate for a public option," said Democracy for America Chairman Jim Dean, brother of former Vermont Gov. Howard Dean. "To have that derailed by a few senators who just happened to take millions of dollars from insurance companies in campaign contributions is very, very frustrating -- particularly for those who voted for Obama and really wanted to clean that kind of culture up."

For die-hard advocates of a public option, this was supposed to be their big chance. They had the Congress and the president they needed. The stars might not be aligned like this for another generation.

"The stars are aligned right now," Ellison said. "Except for we have stars called Lieberman and Nelson that are kind of screwing up the cosmos."

Connecticut independent Sen. Joe Lieberman and Nebraska Democratic Sen. Ben Nelson, centrists who held out against the public option, have been widely reviled on the left for blocking or weakening their agenda in the Senate.

Some on the left also blame Obama for an early deal that gave up on negotiated drug prices for Medicare, and for not pushing for the re-importation of cheaper prescription drugs from Canada and elsewhere.

Those who sought more sweeping change instead will have to gird themselves for the incremental battles that will stretch out for years to come -- much like the struggle for civil rights and gradual expansion of Social Security.

"We passed civil rights in 1964, and we've spent 45 years trying to perfect that, too," said Steve Francisco of the Minnesota Council of Nonprofits. "I understand a lot of people are upset. But as the saying goes, you live to fight another day."

Feeling flat

In what's already shaping up as a tough election year for Democrats, party leaders worry that the biggest legislative achievement of their generation could leave part of their liberal base feeling flat.

Republicans have seized on national polls suggesting the health care agenda in Congress has grown increasingly unpopular, and could be used to target vulnerable Democrats. But a new poll by Twin Cities pollster Bill Morris -- a former state Republican party chairman -- shows that 57 percent of Minnesotans favor the health care plan proposed by Obama and congressional Democrats, while 37 percent are opposed.

"Tacking to the right is not going to save a single Democrat," Ellison said. "We have to do more for people, not less."

But for outspoken liberals like Ellison, who has sworn not to vote for a bill without a public option, the suspense of the final hours will not be whether one or two House Republicans can be coaxed to support the bill, but whether he can bring himself to compromise and join a unified front.

"The Republicans have stepped out of the room and are just letting us swing at each other," Ellison said.

Kevin Diaz • 202-408-2753