So far, a dominant theme of the health care rationing debate seems to consist in Democrats achieving major ‘breakthroughs,’ only to find those breakthroughs fall through. There were the encouraging negotiations with Snowe, the multiple approaches to the ‘public option,’ and the compromises on abortion funding. But each time Democrats have touted a turning point, it s turned out to be less than meets the eye. That’s worth keeping in mind as you read the stories about Democrats touting a breakthrough that will set up a final vote.

Because despite the glib talk from Democrats about coming together to pass a bill, it seems their agreement may be coming apart at the seams. First, the drug makers – whom Obama bought off at the start of the process – are now angry at seeing their deal threatened:

The drug industry is threatening to end its support for President Barack Obama’s health overhaul effort because of a rift with the administration over protecting brand-name biotech drugs from low-cost generic competitors.

In an e-mail obtained Friday by The Associated Press, the president of the Pharmaceutical Research and Manufacturers of America told the trade group’s board members that “we could not support the bill” if the industry is given less than 12 years of competitive protection for the expensive products.

Obama and House Energy and Commerce Committee Chairman Henry Waxman, D-Calif., are leading the drive to shorten that period, which proponents argue would be a boon to consumers.

“Please activate immediately all of your contacts,” said the e-mail from Billy Tauzin, the group’s president.

And it’s not just the drug makers getting set to fight the deals made in the last few days. It’s also the states saddled with high Medicaid bills:

How much of a burden states would have to shoulder for a proposed Medicaid expansion is the latest friction point between the House and the Senate, and is threatening to blow a hole in the measure’s price tag.

“There’s a lot of angst right now from members from states like New York and California over this,” a senior Democratic aide said. “And there’s a growing concern that these states are getting the short end of the stick. And that’s particularly frustrating because it was members from these states that carried this bill to the point we’re at now.”

Lawmakers from these states and others are disgruntled because states that already offer more generous Medicaid coverage would be offered less additional assistance than states with relatively smaller programs…

Rep. Anthony Weiner (D-N.Y.) called it the last potential deal breaker from the perspective of House Democrats.

“It’s not so much a problem that Nebraska got [100 percent Medicare reimbursement],” he said. “We in the House thought everyone should get something like that, that we shouldn’t just expand Medicaid and then just cost shift it to the states. It would obviate everything we’re doing on stimulus and everything else by trying to relieve the burden on the states.”

Nelson on Friday sent Reid a letter asking that the “specific exemption for the State of Nebraska be removed, and that it instead be replaced with a provision giving all state governments the same treatment regarding the state match for the new Medicaid expansion.”

As Phil Klein points out, extending the Nebraska deal to all 50 states will be awfully expensive. Nelson and others are asking for this. Are they willing to block a deal that doesn’t provide it? After all that Nelson has been through, it will be hard for him to vote for a bill that doesn’t answer this concern, right?