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The Democratic coalition's ability to bridge its economic, regional, and class differences is endangered by values conflicts threatening to emerge over a wide range of domestic issues, including health care, global warming, labor rights, and consumer protection.

President Obama's desire to slow the growth of medical spending, for example, has the potential to force to the surface differences within his party over whether it is appropriate or morally justifiable to impose new limits on treatment of the elderly, the terminally ill, premature babies with severe birth defects, and people in need of organ transplants. Such values disputes may well complicate regional and class tensions, pitting the party's "empathy" wing against its less liberal, more tightfisted "discipline" wing.

In a remarkably frank interview with The New York Times last spring, Obama said that one of the toughest cost-cutting issues involving health care "is what you do around things like end-of-life care.... Whether, sort of in the aggregate, society making those decisions to give my grandmother, or everybody else's aging grandparents or parents, a hip replacement when they're terminally ill is a sustainable model, is a very difficult question.... So that's where I think you just get into some very difficult moral issues. But that's also a huge driver of cost, right? I mean, the chronically ill and those toward the end of their lives are accounting for potentially 80 percent of the total health care bill."

The president has said he wants to cut as much as $600 billion from Medicare and Medicaid spending over 10 years. More than a quarter of all Medicare money is spent on patients in what turns out to be their last year of life. Much of that cost is for treatments that almost by definition fail any effectiveness test. The Medicare Payment Advisory Commission found that just 1 percent of the program's beneficiaries, many of them terminally ill, accounted for 19 percent of the $272 billion in outlays in 2003.

In the case of Medicare, the question of when to deny treatment has already produced a head-on, intraparty collision between the Senate Finance Committee, backed by Obama, and a powerful minority of House Democrats. The Senate faction is committed to "bending the cost curve" for Medicare and sees the billions to be saved by arming MedPAC to set binding limits as taking precedence over potential complaints from beneficiaries when cuts materialize after 2012. Senate Finance Committee Chairman Max Baucus of Montana, perhaps the quintessential utilitarian Democrat, has dubbed the empowered board the "Medicare Preservation Commission."

The Finance Committee's action has produced a groundswell of House opposition. In a letter to House Speaker Nancy Pelosi, 75 members -- including 45 Democrats -- warned that if MedPAC is strengthened, "Medicare beneficiaries and the range of providers who care for them would be greatly limited in their ability to help develop and implement new policies that improve the health care of our nation's seniors."

Empathy Democrats argue that medical science should do its utmost to prolong life; utilitarian Democrats are more inclined to weigh costs against probable benefits. Reining in costs -- critical to freeing up money needed to get more Americans insured -- might jeopardize the cohesion of a center-left coalition as much as more-straightforward issues of wealth redistribution.

Take the debate over whether the money spent on infants born very prematurely -- an amount that can reach $1 million or more for a single infant -- has become excessive. In April 2008, the New England Journal of Medicine reported that "rates of survival without profound impairment were as low as 2 percent and 5 percent, respectively, for boys who weighed 401 to 500 grams at 22 weeks' gestation." Still, substantial numbers of Americans believe that to withhold or withdraw intensive neonatal care from very low birthweight infants is wrong. Adding to the ethical and public policy quandary, the official journal of the American Academy of Pediatrics reports that "birthweight-based rationing schemes also are shown to increase further the racial disparity of (neonatal intensive care unit) deaths.... To attain significant reduction in neonatal intensive care unit charges, policies offering care to the larger or more mature very low birthweight infants only will result in denying care to many infants who would otherwise survive."

A politician looking at health care costs faces a grueling policy dilemma: Should Medicaid pay for 100 days on a ventilator for a tiny premature baby very likely to have severe disabilities if the infant survives at all? The potential political ramifications of such questions were demonstrated dramatically in comments sent to the National Public Radio program On Point With Tom Ashbrook during an April 20 discussion with a neonatologist. "Ann-Marie" asked: "One NICU baby's care = 20 yrs of care for 20 regular children. Is it ethical to save ONE life at the cost of poor health to 20 others?" "Cindy" replied, "If that one baby was yours, Ann-Marie ... would you want it to be saved?" Such debates in the academy and in the news media will inevitably spill over into politics.

No less contentious is the issue of costly organ transplantation, a subject that key federal health agencies are scrutinizing. The first-year costs of the 28,110 organ transplants performed in the United States in 2005 (excluding bone-marrow and tissue transplants) were about $18.3 billion. The average first-year billed charges for individual procedures ranged from $1.1 million for an intestine transplant to $259,000 for a kidney transplant. One high-level federal health official says on background, "Kidney transplants save costs, since the U.S. is expansive in paying for dialysis. Heart transplants are probably contraindicated overall."

A Democrat seeking to cut health care costs could well support creation of federal bureaucracies empowered to place new restrictions on transplants. But the question remains: Can party unity survive clashes over expenses such as these?

Many of the Democrats' current intraparty conflicts do not follow clear ideological or interest-group lines. The more-open-handed Democrats tend to be old-line liberals, including many congressional committee chairs, and representatives of urban and minority districts. Penny-pinchers find their strength in the New Democrat Coalition, those with ties to the Democratic Leadership Council and the "Blue Dogs." Empathy-oriented Democrats are tilted toward their party's downscale wing, and hard-nosed Democrats can tilt upscale. Some religiously observant voters believe that the huge sums spent on the terminally ill elderly would be better spent on children. Other religiously motivated voters believe strongly in trying to prolong the most-fragile lives.

Within the Democratic Party, new health care benefits would flow almost entirely to the party's downscale members. Moderate-to-upper-income Democrats would bear the brunt of the costs and the cutbacks to existing benefits. At the same time, neonatal care for Medicaid patients goes disproportionately to black and Hispanic infants.

The Heaviest Burden

Although health care is becoming ground zero in the economic and values conflicts that loom within the Democratic majority, a host of other issues also have the potential to undermine party solidarity.

Liberal Democrats, for example, argue that companies should not be allowed to delay paying taxes on overseas income until it is repatriated. More-market-oriented Democrats counter that ending the deferral would put U.S. corporations' foreign subsidiaries at a decisive disadvantage in competing with subsidiaries not taxed by their home countries.

On the global-warming front, fresh class-tinged tensions within the Democratic coalition surfaced over cap-and-trade legislation intended to curb greenhouse-gas emissions. The climate measure is a top priority of the Democratic Party's upscale, coastal, environmental faction. Those bearing the brunt of the cap-and-trade initiative include tens of millions of employees (many of them middle-income whites whose partisan loyalties are up for grabs) in carbon-producing industries, including steel and iron workers, machine operators, and metal fabricators concentrated most heavily in the coal-dependent Central time zone, along with their supervisors and managers.

In its June 19 report on the House legislation, the Congressional Budget Office played down any potential regressive impact of cap-and-trade. It noted that with all of the bill's amendments, the average family would pay $175 a year more for the added energy costs in the production of consumer goods but that special tax provisions would insulate low-income families from any net increase. Buried in the report, however, are oblique references to provisions that, if enacted, would adversely affect some workers.

Democrats are, in effect, prepared to place the heaviest burden of greenhouse-gas restrictions on a slice of the middle-income electorate whose support for the party has been eroding. The workers identified by CBO are heavily concentrated in the Midwest Rust Belt, many of them in such swing states as Indiana, Ohio, and Pennsylvania where Democrats made substantial gains in 2008. Communities suffering layoffs as a result of cap-and-trade are very likely to become increasingly disenchanted with the Democratic Party.

These costs will be imposed even though the legislation was amended to dilute or eliminate most of the consumer incentives to conserve energy and shift to less polluting power sources. The Democrats' environmental wing, although a powerful agenda-setter, remains a minority faction. And concessions to other party factions -- rural, agricultural, coal-state -- resulted in House legislation that some environmentalists contend would do more harm than good.

The compromises made to win House approval of cap-and-trade point to the kinds of problems that are plaguing Obama and his fellow Democrats: Without an economic center of gravity or a real consensus on values, the party is so sharply divided that gaining majorities for substantial legislation requires deals that severely constrict the scope of a reform agenda.

Privileged Status

The emergence of the super-rich wing of the Democratic Party has resulted in another faction with veto power, as was demonstrated by the administration's handling of financial reform legislation. The near-unanimous view of critics of existing regulatory practices, including many in the administration, is that controls must be more stringent and centralized.

In the aftermath of last year's financial meltdown, such reforms should be a chip shot. Yet if there is one segment of the economic elite that now enjoys an especially privileged status among Democrats, it is the financial services industry: banking, securities, investment, and hedge-fund firms. Over two decades that included 12 years of Republican congressional majorities, this industry gave a total of $656.8 million in campaign contributions, 51 percent of which went to Democrats. And since Democrats took over Congress, their party has gone from receiving 57 percent of these contributions to 70 percent. At $15.9 million, Obama was the biggest recipient of donations from securities-industry employees. Even though his administration initially signaled that it was prepared to get tough with the financial industry, its resolve quickly faded.

Discounting Loyalty

If there is one Democratic constituency that has taken a beating with the rising influence of Democrats from the high-tech sector and the ranks of the nation's professionals, it is organized labor. As labor leaders attempt to capitalize on Democratic control of the White House to win approval of key legislation, they face opposition from Democratic representatives and senators from places with declining or nonexistent union membership and indifference from the party's upscale Starbucks faction, which seemingly could not care less about the future of the labor movement.

As a result, union leaders have been unable to push through a central goal: the "card-check" provisions of the Employee Free Choice Act. The Senate is on the verge of killing card check, which would replace union representation elections using secret ballots with a system guaranteeing union recognition once a majority of employees sign cards affirming their support. For years, card check has been the be-all and end-all for Big Labor, which sees it as crucial to its survival.

Few interest groups have been a better friend to the party than labor. Not only do unions donate millions to Democrats -- $617.6 million since 1990, 12 times the amount they gave to Republicans -- but for the past decade, they have also been able to persuade their members, including whites, to vote decisively for Democrats.

Past loyalty, however, counts for little in today's Democratic Party. The harsh reality facing unions is that they are fading as a force in America politics, and fellow Democrats know it. Since the 2002 enactment of McCain-Feingold legislation barring soft-money contributions, labor donations in federal campaigns have fallen from $96.8 million in 2001-02 to $74.6 million in 2007-08. More important, the number of unionized workers, and their share of the national workforce, has been on a steady downward path since 1955, when 35 percent of U.S. workers were represented by a union. By 2008, that percentage had dropped to 13.7.

Chipping Away

Schisms -- those already visible and those likely to soon appear -- within the Democratic Party may limit what the Obama administration is able to achieve. As legislation on health care, global warming, the financial sector, and union organizing moves through Congress, its ambitious agenda is slowly being diminished.

If much of the electorate is disappointed by the Democrats' inability to swiftly implement universal, high-quality, affordable health care, to noticeably slow global warming, to address the injustices afflicting American workers, and to manage the cataclysms of free markets, that dissatisfaction may well provide an opening for the GOP. Keeping Democratic infighting from paralyzing the legislative process and eviscerating promised reforms requires truly inspired leadership. That will be Obama's test.

The author is a journalism professor at Columbia University and political editor of The Huffington Post.