Industries and advocacy groups with a stake in health care reform legislation are increasingly assuming that Congress will approve an overhaul and are shifting their focus to ensure that their top priorities are protected in the final bill.

Doctors, hospitals, drug companies, businesses and labor unions as well as liberal and conservative groups have spent the past year waging an all-out effort to either shape or kill the legislation. Those campaigns, replete with expensive ad wars and organized citizen rallies, were aimed at moving public opinion and key lawmakers.

But now that the legislation has passed both the House and Senate — and Democratic leaders are huddling to hammer out a final version — lobbyists are scurrying to figure out what will be in the fine print of the ultimate product and how they can make implementation of the bill more palatable for their clients.

“The tea party days are way behind us,— said one longtime health care lobbyist, referring to the anti-health care rallies of the summer. “We are now in the end game.—

Democratic leaders still face challenges in the weeks ahead trying to bridge differences within the party on hot-button issues such as abortion, taxes and whether there should be a public insurance option.

But even some of the most vocal opponents of the Democrats’ health care efforts appear resigned to a bill being signed into law.

“The bow is almost wrapped around the Christmas gift,— said Amanda Austin, a lobbyist for the National Federation of Independent Business, which has criticized the legislation as not doing enough to curb costs for its small business members. Austin said the goal for her organization during the final negotiations is to “try and keep in some of things we want to remain in there and not make it any worse.—

Some organizations are so convinced that health care legislation is a foregone conclusion that they have started working on a post-reform landscape.

Mark Merritt, president of the Pharmaceutical Care Management Association, for example, is already trying to figure out how best to make the health care changes work once the measure becomes law.

“Our advice is being sought out by policymakers to make sure the rollout of the reform goes well,— Merritt said.

Playing Favorites

Most business groups favor a final version that is closer to the Senate bill, which places fewer mandates on employers than its House counterpart and does not include the public insurance option.

But Austin said her organization’s top priority is now to press lawmakers to strike one provision slipped into the Senate version that would slap financial penalties on construction firms that employ five workers or more but do not provide health insurance. In other sectors, businesses with 50 or more employees would face the penalties. The measure was pushed by labor unions, which argued that without it most small construction firms would not offer health insurance.

However, business groups and homebuilders say it would place an onerous financial burden on construction firms.

The health insurance industry, led by America’s Health Insurance Plans, has also been critical of the Democratic reforms, claiming they would increase insurance costs for customers.

But AHIP spokesman Robert Zirkelbach said the industry is now seeking changes in the legislation that would make it less disruptive to consumers — such as changing implementation dates so that financial penalties don’t kick in before new benefits do.

Others in the health industry who have been more supportive of the health care efforts are banking on getting a more receptive hearing from staffers and lawmakers on the Hill.

Chip Kahn, president of the Federation of American Hospitals, said he hoped his organization “would have some influence because we were at the table early.—

“I’m hoping our concerns will be their concerns because we were able to invest ourselves early,— he said.

Hospitals reached an agreement last July with Senate leaders and President Barack Obama to contribute $155 billion over 10 years in savings as part of the health care overhaul effort.

Kahn, however, cautioned that outside groups must be judicious in what they ask for given the competing demands being placed on harried Congressional staffers.

“You’ve got to focus,— he said. “You can’t be wasting their time.—

Supporters’ Reward?

Other groups that have been largely supportive of health care reform also have wish lists.

The American Medical Association, which endorsed legislation approved in both chambers, does not want the final version to include an Independent Payment Advisory Board for Medicare that was added in the Senate version but not the House legislation.

The brand-name drug industry, led by the Pharmaceutical Research and Manufacturers of America, will be fighting off efforts by a key House Member to make the industry substantially increase its contributions beyond the $80 billion over a decade the sector has already agreed to.

The drug companies have pledged to help defray costs of drugs for senior citizens in Medicare. But Rep. Henry Waxman (D-Calif.), chairman of the House Energy and Commerce Committee, has pressed drug companies to contribute more, citing the windfall he has said they will get under the health care bill because of more customers.

On the other side, the generic drug lobby is fighting provisions contained in both House and Senate versions that would give brand-name drugmakers 12 years exclusivity to market biologic drugs.

The senior citizens group AARP has made it a top priority to push for the elimination of the gap in Medicare drug coverage, known as the “doughnut hole.— The House bill closes the doughnut hole, but the Senate version does not. Senate Majority Leader Harry Reid (D-Nev.) has pledged that the gap would be eliminated during the final negotiations.

AARP will not only be working behind the scenes on Capitol Hill but also on the grass-roots level to keep up support for the overall legislation, said lobbyist Nora Super. She said the grass-roots activity is necessary to provide encouragement to vulnerable lawmakers who are under attack for their backing of the legislation.

Keeping Up the Fight

While much of the activity at this point is going on behind closed doors among a small group of leaders, some lobbyists said they believed grass-roots and media campaigns were still beneficial at this late stage to put the pressure on Members whose votes leaders will need for final passage.

Laurie Rubiner, vice president for public policy and advocacy at Planned Parenthood of America, said that abortion-rights activists would mobilize their grass-roots network if negotiators opted for restrictive abortion provisions from the House bill. She said the passage of the House measure, sponsored by Rep. Bart Stupak (D-Mich.), galvanized her side’s opposition.

Rubiner added that her group has to remain vigilant.

“I think this has been a very unpredictable process all along,— she said.

Anti-abortion groups are equally energized in their opposition to the Senate version, arguing that only the Stupak provision meets their criteria.

Meanwhile, the union-backed coalition Health Care for America Now recently launched a new national cable television ad campaign to buoy the House plan because it includes a public option and does not include a tax on “Cadillac,— or high-cost, insurance plans that is opposed by organized labor.

HCAN spokeswoman Jacki Schechner conceded that she wasn’t sure what the affect of the ads would be but said, “you have to keep up the fight.—

A business coalition led by the U.S. Chamber of Commerce is also running ads, but it wants to derail the measure because it is too costly.

“I think advertising helps educate people,— said Randy Johnson, vice president of the chamber. Johnson conceded that despite polls showing the unpopularity of the health care plan, Congress will likely pass a bill.

But he warned that the “intensity of the opposition is underestimated by the supporters and could come back to haunt them in the November elections.—