Joe Luchok, a communications consultant who has worked on health care issues for organizations including the March of Dimes and the now defunct Health Insurance Association of America, argues that the timing is drawing near for President Obama to use his bully pulpit to offer his leadership on key health reform issues.

"As Marilyn points out, President Clinton sent Congress a detailed proposal, and we all know how that turned out. Most members of Congress have large egos; it is difficult to get elected without one. They like to feel they are in control. If the President engages too early or too directly, Congress has a tendency to try to show they will not get pushed around by the administrative branch.

"President Obama has been trying to walk a fine line, keeping the administration engaged with Congress without making them feel they are being dictated to. While this strategy has its dangers, the important thing for a President is to get a bill to place where he can step in to try to shape some of the final points. The debate seems near or at the point where President Obama should start leading. What will he accept as a public option? What cost is acceptable and how will it be covered? Where is the line to be drawn between controlling health care costs and covering the uninsured?

"As Mr. Altman points out, the President is the only person who can build and maintain public support for policy decisions. No one else has the “bully pulpit” at their disposal."

He should return to last year’s campaign promises:

1. Instead of the one-party approach that is currently underway, endorse a bipartisan approach to reform.

2. Instead of an approach based on backroom deals made with special interests, keep the promise of an open, principled approach to reform.

3. Instead of the smoke and mirrors in the current bill, endorse a plan that pays for itself.

4. Keep the promise that if “people like the plan they are in, they can keep it” – unlike the current legislation that will cause up to 8.5 million seniors to lose their Medicare Advantage coverage and 19 million workers to lose their employer coverage.

Marilyn asked me to kick off a discussion of presidential leadership strategy in health reform. She asked because I addressed this issue in one of my recent web columns. I wrote that the conventional wisdom often heard inside the Beltway that the President should have taken positions on key issues in the legislation much earlier on in the debate is wrong. You can check out the column here.

In that column I concluded:

"it is not self-evident, as the conventional wisdom seems to hold, that it would have been the best strategy for the President to have taken clear positions on all the big health reform issues early on. It would certainly have satisfied the media to have the President's position, issue-by-issue, to dissect every day. It may have made the leadership's job on Capitol Hill easier for the President to declare himself earlier on key details of the legislation so they weren't faced with so many of the tough decisions on their own. But it might also have slowed legislative progress and eroded influence and maneuvering room the President will need when the health reform process reaches its critical final rounds very soon."

I continue to believe that taking specific positions on every issue would have made others’ jobs easier at the risk of making the President and his policies a target and bogging down progress on the legislation. I do not intend this particularly as a defense of President Obama's strategy in this health reform debate. I have often observed in other debates that there are dangers for candidates and presidents who take overly detailed policy positions despite the constant pressure for them to do so (while at the same time noting that there are differences between working with the Congress — which I believe this Administration has been doing — and punting to the Congress instead).

Now, however, we are entering a new phase — the end game in the health reform debate. The President will certainly need to remain health reform advocate-in-chief to maintain public support across the country as the debate gets down to crunch time and opposition efforts intensify. He will no doubt need to be directly involved in winning key votes in the Congress to assure passage. And, while he may well want to leave many details to the Congress, he will almost certainly want to preside over fundamental policy choices in legislation that will bear his stamp in the history books and determine its ultimate success or failure. What big cost containment ideas are in or out of the final legislation? What should the final cost of the legislation be and what, among the list of politically painful choices, should the final savings and revenue measures be that will pay for the legislation? And what should the tradeoff be between keeping the overall cost of the legislation down and providing adequate coverage and subsidies to people who now will be required to buy health insurance as a matter of law?