Washington - After decades of failed efforts to reshape the nation's healthcare system, a consensus appears to be emerging in Washington about how to achieve the elusive goal of providing medical insurance to all Americans.

    The answer, say leading groups of businesses, hospitals, doctors, labor unions and insurance companies - as well as senior lawmakers on Capitol Hill and members of the new Obama administration - is unprecedented government intervention to create a system of universal protection.

    At the same time, those groups, which span the ideological and political spectrum, largely have agreed to preserve the employer-based system through which most Americans get their health insurance.

    The idea of a federal, single-payer system patterned on those in Europe and Canada, long a dream of the political left, is now virtually off the table.

    Rejected as well is the traditionally conservative concept, championed by Sen. John McCain (R-Ariz.) during the presidential campaign, of reforming healthcare mainly by giving incentives for more Americans to buy insurance on their own.

    There also is a widespread understanding that any expansion of coverage must be accompanied by aggressive efforts to bring down costs and reward quality care. And key players in the healthcare debate increasingly back a massive investment of taxpayer money for healthcare reform despite the burgeoning budget deficits.

    Beyond those areas of basic agreement, the details of what would be one of the most momentous changes in domestic policy since World War II remain vague.

    As a presidential candidate, Barack Obama embraced both expanded insurance coverage and preservation of the job-centered system, but since he won the White House he has provided few specifics about his plans once he takes office.

    Disagreements over specifics could again lead to a stalemate. Even the most sanguine advocates of sweeping reform concede that difficult negotiations lie ahead.

    But what is taking shape is a debate very different from previous discussions about what America's healthcare system should look like.

    "A lot has changed," said Karen Ignagni, president of America's Health Insurance Plans, or AHIP, a leading trade group whose members helped kill the Clinton administration's healthcare campaign in the early 1990s.

    AHIP is participating in talks with other interest groups to build consensus before Obama takes office in January and Congress begins debating any healthcare legislation.

    Unresolved Issues

    Among the issues to be decided as more concrete proposals emerge in the months ahead is whether the roughly 46 million uninsured people in the U.S. will be pushed to buy private coverage or will be enrolled in a government insurance program, as some consumer groups want.

    Hospitals and doctors fear another public program would reduce what they are paid, as Medicare and Medicaid have done. Insurers worry they could lose customers to the government.

    Also unresolved is what mechanisms might be created to force individuals or businesses to get insurance, both potentially contentious subjects.

    And few have tackled how the government will control costs and set standards of care, proposals that raise the unpopular prospect of federal regulators dictating which doctors Americans can see and what drugs they can take.

    "There are some very big questions and some very big stumbling blocks," said Stuart Butler, vice president for domestic policy at the conservative Heritage Foundation, who has been watching the healthcare debate for three decades.

    "Once you get into the details, the consensus is going to vanish pretty quickly, I suspect," he said.

    At the same time, advocates for a single-payer system, including the California Nurses Assn., have vowed to continue pushing the idea next year along with many Democrats on Capitol Hill.

    Republican lawmakers, still reeling from their election day losses, have signaled discomfort with a major expansion of government spending, a position many in the GOP hope will help return the party to power.

    "Increasing access for the uninsured is not going to come cheap," Sen. Charles E. Grassley (R-Iowa) said at a recent hearing on healthcare reform. "And it's clear to me that our economy cannot stand much further deficit spending."

    Nonetheless, the current agreement on principles contrasts markedly with previous reform efforts. Today, many of the key players in the debate see the importance of preserving elements of the current healthcare system that many Americans say they like.

    "There is a growing understanding that you have to give people choice and you can't take away what they have," said Ron Pollack, head of Families USA, an influential advocacy group for healthcare consumers that is working with a diverse collection of interest groups to build consensus. "One of the big no-nos is that you must not ever threaten the coverage that people have."

    The Clinton Effort

    Fifteen years ago, there was much less agreement about preserving an employment-based system that now insures about 177 million people.

    Opponents of President Clinton's plan were able to sink it by raising the specter that government would take away consumers' choices in a new system that would force them into inferior health insurance.

    But now the prospect of bold government action to address the healthcare crisis appears to have been accepted far more broadly by many of those involved in the debate.

    Even business leaders traditionally wary of government intervention now are pushing for the federal government to act decisively to reshape the healthcare marketplace - in large part because of the increasing burden imposed on them by rising costs.

    "Doing this piecemeal is not going to work," said Todd Stottlemyer, president of the National Federation of Independent Business, which was also instrumental in defeating the Clinton plan.

    Many involved in the healthcare debate, including Democratic lawmakers and members of Obama's team, also see healthcare reform as part of a broader economic picture.

    Democratic leaders on Capitol Hill have begun sketching out plans for healthcare reform that, like Obama's plan, preserve the employer-based system and create a new system for those without insurance.

    Last month, Senate Finance Committee Chairman Max Baucus (D-Mont.) outlined such a plan in an 87-page white paper titled "Call to Action." Similar approaches have been endorsed by House Democrats.

    In contrast, the Clinton administration drew up its healthcare reform plan with little involvement from congressional Democrats. In the Senate, then-New York Democrat Daniel Patrick Moynihan, who was chairman of the finance committee at the time, actively resisted the idea of sweeping change in healthcare.

    There are no signs of a similar rift today, said Jacob Hacker, a political scientist at UC Berkeley who has written a book about the failed Clinton effort.

    "Possibly more important than policy agreements," Hacker said, "is the fact that the political forces now are in alignment."

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    Levey is a writer in our Washington bureau.