By the time his ambitious health care legislation was introduced and carved up and cursed and left for dead and revived and compromised and passed and finally signed into law, the whole process had taken a toll on President Barack Obama.
The passage of the Affordable Care Act would be his signature legislative achievement, but it propelled Republicans to a sweeping midterm election victory and control of the House. And Mr. Obama thought he might be the next to pay the price at the ballot box. “This is shaping up to be a one-term presidency,” he told an aide in late 2010.
He turned out to be wrong, but the fatalism Mr. Obama expressed privately that day captured the weighty consequences of one of Washington’s most high-wire legislative battles in modern times. A new set of oral histories released on Friday, on the eve of its 14th anniversary on Saturday, documents the behind-the-scenes struggle to transform the nation’s health care system to cover tens of millions of Americans without insurance.
The interviews of key players in the drama were conducted by Incite, a social science research institute at Columbia University, and were made public as the second tranche of a yearslong effort to document the eventful times under the nation’s 44th president. The transcripts posted online on Friday included recollections from 26 members of the White House staff, his cabinet and Congress as well as activists, interest group figures and a handful of Americans who made their voices heard, but not from the former president himself or, for that matter, his Republican opponents.
The oral histories chronicle Mr. Obama’s journey from an uninformed candidate embarrassed by the banalities he found himself spouting on the campaign trail to a besieged president gambling his political future on all-or-nothing legislative brinkmanship. They also flesh out a portrait of Mr. Obama as a steady-as-she-goes, hyper-disciplined but not especially warm, policy wonk who scrolled the Brookings Institution website for ideas and had to overcome his own political mistakes.
The story of the Affordable Care Act in some ways started at a candidate forum on health care in 2007 when Mr. Obama was running against Senators Hillary Clinton, John Edwards and Joseph R. Biden Jr., among others, for the Democratic presidential nomination. “Senator Obama was terrible,” remembered Neera Tanden, who worked for Mrs. Clinton at the time. “He was vapid. He had no facility with the issue, so he kept talking about, ‘This is why we need to come together.’”
Mr. Obama knew he had done badly, and it drove him to take the issue more seriously, she said. “I honestly think if he did not have his butt kicked that he would not have put out such a detailed plan,” Ms. Tanden said.
After Mrs. Clinton lost and Ms. Tanden joined the Obama campaign in 2008, she said, “a lot of his advisers were like ‘We should just drop this health care thing.’ He said very clearly, ‘I am doing health care when I’m president. You guys have to figure out how we succeed in the campaign to build a mandate, but I’m doing it.’”
Upon taking office in January 2009, Mr. Obama tackled a challenge that had vexed presidents of both parties, most recently Bill Clinton, whose first term nearly collapsed after his own failure to pass sweeping health care legislation. Mr. Obama’s advisers were determined to learn from the mistakes of the past.
By developing their own plan in public and involving major players with stakes in the issue like insurance companies and congressional chairmen, the Obama administration hoped to build support rather than simply springing a plan crafted in secrecy on Congress as the Clintons had done in the 1990s.
“The Clinton administration was focused inward on the perfect policy — and I was part of that, so I don’t want to sound ‘otherworldly’ about it,” said Nancy-Ann DeParle, a Clinton administration veteran who became director of Mr. Obama’s White House Office for Health Reform. “The Obama administration was the opposite. It focused much more on stakeholders and people and getting Congress to do the work of debating the policy and passing a bill.”
But Mr. Obama made his own misjudgments. Ms. Tanden, who became a senior adviser at the Department of Health and Human Services and admired Mr. Obama’s determination to pass sweeping reform, said his team nonetheless spent “an inordinate amount of time” on smaller issues rather than systemic questions and did not initially anticipate the “big problem” abortion would become.
Ezekiel J. Emanuel, a special adviser on health care, who likewise appreciated that Mr. Obama “never wavered,” said the White House should have sent members of Congress home for their summer recess in 2009 with a slide deck to describe the plan to constituents. “We did not do our work, and I think that was a big mistake,” Dr. Emanuel recalled. “They needed better tools to explain it to people.”
Peter R. Orszag, the director of the Office of Management and Budget, got a taste of the misunderstandings and distortions of the plan while vacationing that summer in Maine, where he saw signs in front of shops falsely warning about “death panels” that supposedly would be created by the legislation.
“That was probably the first time it really hit me,” he said, “just seeing sign after sign after sign about things that — you can see why people might think that that’s where it would go.”
Hopes of gaining Republican support all but evaporated after that, leaving Mr. Obama to work only with Democrats. He was deeply involved in the haggling. Kathleen Sebelius, then secretary of health and human services, recalled a key meeting in January 2010 to reconcile different versions of the plan. “The president led those negotiations from start to finish,” she said. “He was negotiator in chief.”
Eventually it would pass, but not without painful concessions and legislative machinations. Ms. Sebelius recounted the champagne celebration on the Truman Balcony at the White House the night that it passed. Mr. Biden, then the vice president, told her, “This is the most important thing that the president will do for the international community.”
She asked what he meant. “The world will now know when this young president says, ‘I will do something,’ that he will do it,” Mr. Biden answered.
Still, Mr. Obama was not sure how much time he would have to do something more. Ms. DeParle was the aide who remembered Mr. Obama musing about having only a single term while trying to persuade her to stay at the White House after health care.
“That’s OK with me,” he said of a possible four-year presidency, “as long as we’re able to get the things that I think are important to get done.” But Ms. DeParle found his comment “very surprising” and thought to herself, “Gee, this is my fault.”
Ms. DeParle offered some of the most personal observations of the ascetic president. Among other things, she said, he refused to eat in public and only ate at his set times each day. When he did eat with his staff, “you ate with him silently” while he sat reading or preparing for his next event. And his meal was almost always the same — either salmon or dry chicken breast, brown rice and broccoli.
“Trust me,” she said. “That was it.” His only nod to taste? “Lemon juice on the side, or something lemon.” And never dessert. “Food to him, it’s like putting a coin in the meter,” she said. He would not even eat pie, even though he said he liked pie. “He has no weaknesses that I can tell,” she said.
Ms. DeParle found him a mystery and only came to understand Mr. Obama when she accompanied him to his home state of Hawaii. “The waves come in, and they go out,” she said. “He has a calm demeanor that’s like that to me. He doesn’t get too upset about anything. And the fact that he was located in a place that was as close to Tokyo as it was to New York — he’s got an international vantage point,” she added. “He sees the world differently than many American presidents have.”
As it turned out, of course, he had two terms to do so after all. And the Affordable Care Act, for all of its birth pangs and flaws and the Republican efforts to repeal it, remains the law of the land.
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