Every Christmas, our Uncle Billy makes Italian sausage. In addition to various ground meats, he uses a rotating cast of cheeses and spices, along with the some well-guarded Testa family secrets (our guess: orange zest added to the fennel seeds). It's a big undertaking, full of cranks and casings. But it's nothing compared to the sausage making ahead for Congress on health reform.

The New York Times sets the stage in the House and Senate, laying out the challenges faced by Speaker Nancy Pelosi and Senate Majority Leader Harry Reid as they try to craft legislation that can pass their respective chambers of Congress and be merged into a final bill that President Obama can sign into law.

The challenge for Ms. Pelosi is to write a measure with sufficient coverage and benefits to appease the left wing of her caucus without alienating too many of the moderate and conservative Democrats whose votes she needs. [...]

Mr. Reid may have the more difficult job since Ms. Pelosi, of California, has a larger majority as well as stricter House rules that limit opportunities for Republicans to slow the process.

Mr. Reid has to come up with a bill that can win at least procedural backing from virtually all 58 Democratic senators and two independents aligned with his party, which will necessitate navigating divisions between the majority of his members who are pushing for a public option and centrist Democrats opposed to the idea. All while holding Republicans at bay.

Here's a rundown of the big issues being hashed out -- Congress's equivalent of Uncle Billy's ingredients.

The public health insurance option remains a focal point as liberal lawmakers hope to preserve its place in the final bill. Sen. Tom Harkin, chairman of the Senate HELP committee, told reporters he believed the final bill "will have a public option." Meanwhile, the Associated Press says the junior Senator from Illinois, Roland Burris, "can no longer be ignored," because of his strong stance on the public option. (Were you ignoring him? How soon we forget.)  The White House continues to express support for a public health insurance option without drawing any lines in the sand.

"For all the focus on the public option," Al Hunt argues in the Times, "ultimately the issue of affordability and how to pay for the overhaul will be more important." Affordability, he notes, is key to holding the vote of Olympia Snowe (R-ME). Her support, in turn could bring a few more Republicans on board, (Republican Sens. Susan Collins (R-ME) and George Voinovich (R-OH) are two names mentioned). Centrist Republican support from Snowe and potentially others provides political cover for moderate Democrats like Sens. Blanche Lincoln (D-AR) and Ben Nelson (D-NE).

Affordability is kind of like the Chinese finger trap of health reform. On one hand you have subsidies which are necessary to make insurance and health care affordable for all Americans. On the other, you have the challenge of financing a plan that is fully paid for and ensuring that reform will not add one dime to the deficit. Pull too much in one direction, say subsidies, and you risk jeopardizing fiscal sustainability.  Writing at Politics Daily, Walter Shapiro fears, however, that we've pulled to hard in the opposite direction:

The underlying problem is that there is the lack of the political will in the Senate and the White House to spend enough money on subsidies to come close to achieving universal coverage. With Barack Obama publicly embracing a 10-year cost figure of $900 billion, and the White House worried about the political repercussions from a trillion-dollar price tag, the possibilities for maneuvering are limited. The central issue is not the deficit, since both pieces of legislation pay for themselves with new taxes and reductions in other types of federal health care spending. Rather, the difficulty is rooted in the politics of assembling a 60-vote filibuster-proof Senate majority and the atmospherics of appearing to contain health care spending in the midst of record red ink budgets.

Ouch.

The fiscal side of the equation may have gotten a little bit easier last week. The Washington Post reported that early estimates from the CBO of the revised House bills put the cost of legislation at $905 billion or less. (Of course all these estimates are exactly that -- estimates. Our colleague Allison Levy posted on a must-read Washington Post profile of Phil Ellis, the man behind the CBO's health care numbers.)

It's a long road ahead. There are many deals to be brokered, compromises to be made, obstacles to overcome, sausage meat to be ground. And that's just to get a health reform bill to conference between the House and Senate -- where differences in financing reform (e.g. the high value health insurance tax in the Senate Finance plan vs. the House bills high-income tax surcharge) are quite pronounced. While Democrats continue to stick to a Thanksgiving target for their legislation, we have full confidence that come Christmas we'll be eating sausage. With zest.