For all the ideological talk about divisions among Democrats on health care reform, there are some institutional issues that are equally important. Ezra Klein did a good job of analyzing the House-Senate dynamics over the weekend:
Some sources are speculating that the Blue Dogs are getting cold feet as they watch Max Baucus dither. Many of them felt burned by the hard and damaging vote on the cap-and-trade bill, as it looks like nothing will come of it in the Senate. Committing themselves to a health-care bill before the Senate shows its hand carries similar risks, and they're no longer in a risk-taking mood. The worst outcome for conservative Democrats in the House is that they're on record voting for a health-care reform bill that dies in the Senate and is judged a catastrophic example of liberal overreach.
The problem, of course, is that the more dissension there is among Democrats in the House, the less pressure there'll be on the Senate Democrats to make a hard vote on health-care reform. This makes health-care reform something of a prisoner's dilemma for conservative Democrats. If Blue Dogs in the House and centrists in the Senate both put it on the line to pass the bill, they're both better off. But if one puts it on the line and the other whiffs, then the other pays the price.
Matt Yglesias notes the obvious way out of this "prisoner's dilemma:"
[T]hey call it a “prisoner’s dilemma” because the idea is that the players are held incommunicado in separate cells. House and Senate Democrats can all get together in a room and talk this stuff out.
That's all true, but from my own experience as a public-sector lobbyist and as a Senate staffer, I'm reasonably sure that getting House and Senate Members "together in a room" to "talk this stuff out" is really difficult, regardless of partisan or ideological issues. The institutional divisions between the two Houses are ridiculously, but obstinately, real. It goes beyond the problem of House members walking the plank on legislation that Senators may reject or significantly modify. Senators and House Members belong to very different clubs, with very different electoral cycles, committee systems, floor voting mechanisms, and constituencies. These institutional differences aren't as large, at least lately, as partisan and ideological differences, but they can't be discounted. And it's yet another reason that the president must play a crucial role in leading, not following, congressional action on health care reform. The White House--the institutition, if not the actual physical location--is the only place you can get bicameral members from one party, much less from both, "together in a room" to "talk this stuff out."