Health care reform may not be finished after all. Despite the political reverberations of last week’s special election in Massachusetts, Democratic leaders on Capitol Hill are still discussing ways of passing a comprehensive reform bill.

But it’s going to take heroic political efforts, given the number of Democrats suddenly skittish about supporting such a bill. And it’s not clear whether the Hill’s strongest reform advocates are getting the kind of political help they say they need from the White House.

According to multiple sources, the preferred option for congressional leadership remains what it was last week: Having the House pass the Senate bill, as it is currently written, and then working with the Senate to fix the bill through the budget reconciliation process.

You know the story: With reconciliation, filibusters can’t block a majority from passing legislation, so the Senate could move a bill even with “only” 59 members in the Democratic caucus. And you know the catch: Rank-in-file Democrats in the House are either spooked by the Massachusetts results, strongly opposed to elements of the Senate bill, or both. Their counterparts in the Senate, meanwhile, don't seem in any great rush to make it easier--by, say, signing a letter promising they'll support in reconciliation the same changes they had been negotiating over the last few weeks.

The White House seems to agree that passing the Senate bill and fixing it with reconciliation would be the best way to proceed. But that doesn’t mean they’re pushing hard for that option. According to the same sources, the Obama administration sent vague, sometimes conflicting signals about its intentions for much of last week--making the task for reform advocates even harder.

Even as administration staffers were indicating their support for the leadership's strategy individually, these sources noted, Chief of Staff Rahm Emanuel was calling members and soliciting their opinions on more scaled-down versions of reform. President Obama, meanwhile, said relatively little on health care reform during the first few days after the election--except to give ABC News an interview in which he talked up the less controversial areas of reform. Congressional staff and outside observers both interpreted these moves as implicit support for scaling back reform.

As one senior congressional staffer wrote in an email, expressing a common sentiment, "It is VERY frustrating not to hear from them and/or not to hear a single plan or strategy.” This staffer went on to speculate that “maybe there’s a split among advisors on what to do.”

Ohio Senator Sherrod Brown, among the Senate's most reliable and strongest progressives, expressed similar frustration last week in an interview with TPM's Brian Beutler.

It's impossible to know--or, at least, impossible for me to know--whether the mixed messages were the product of ambivalence or deliberate ambiguity. (The White House wouldn't offer official comment when contacted by TNR, except to note that Obama spoke with House and Senate leaders over the weekend.) It's also not clear the extent to which the administration was merely trying to let the "dust settle," as spokesman Robert Gibbs put it, rather than lower its ambitions.

Among other things, the president himself offered stronger rhetoric during Friday's town hall in Ohio. Towards the end of the event, Obama himself brought up health care, pointing out that severing the bill into pieces--a strategy many critics have urged and that some House Democrats have said they’d prefer--wouldn’t necessarily work:

Now, some people ask, well, why don't you just pass that and forget everything else?  Here's the problem.  Let's just take the example of preexisting conditions.  We can't prohibit insurance companies from preventing people with preexisting conditions getting insurance unless everybody essentially has insurance.  And the reason for that is otherwise what would happen is people would just -- just wouldn't get insurance until they were sick and then they'd go and buy insurance and they couldn't be prohibited.  And that would drive everybody else's premiums up.

So a lot of these insurance reforms are connected to some other things we have to do to make sure that everybody has some access to coverage.  All right?

Obama followed that with a stronger defense of the plan than he’d issued in several days:

This is our best chance to do it.  We can't keep on putting this off.  Even if you've got health insurance right now, look at what's happening with your premiums and look at the trend.  It is going to gobble up more and more of your paycheck. Ask a chunk of you folks in here who have seen your employers say you've got to pick up more of your payments in terms of higher deductibles or higher copayments.  (Applause.)  Some of you, your employers just said, we can't afford health insurance at all.  That's going to happen to more and more people. ...

Let me talk about Medicare.  Medicare will be broke in eight years if we do nothing.  Right now we give--we give about $17 billion in subsidies to insurance companies through the Medicare system--your tax dollars.  But when we tried to eliminate them, suddenly there were ads on TV--"Oh, Obama is trying to cut Medicare."  I get all these seniors writing letters:  "Why are you trying to cut my Medicare benefits?"  I'm not trying to cut your Medicare benefits.  I'm trying to stop paying these insurance companies all this money so I can give you a more stable program. ...

We can't shy away from it, though.  We can't sort of start suddenly saying to ourselves, America or Congress can't do big things; that we should only do the things that are noncontroversial; we should only do the stuff that's safe.  Because if that's what happens, then we're not going to meet the challenges of the 21st century.  And that's not who we are.  That's not how we used to operate, and that's not how I intend us to operate going forward.

Of course, whatever clarity Obama offered on Friday faded by Sunday, when administration officials appeared on the Sunday shows and, as Joe Klein notes, offered no clear party line.

Obama will have one big chance to clarify his message this week--on Wednesday night, when he gives the State of the Union. As another senior congressional staffer puts it

State of the Union will be incredibly important for the message. It's ok to leave things vague until then. It's not ok to leave things vague at that point.

Update: Slate's Tim Noah has a terrific rundown of the various political obstacles to passage. And he's even made a reader game out of it. I also added a reference to the Sunday shows, along with Joe Klein's commentary on it. Klein seems to think the president needs to scale back or drop health care reform, given the political consequences. I think it's still better, by far, to move forward--although I agree it must be quick, leaving room for the president and the whole Democratic Party to talk about the economy. More on all of that soon...