Believer: My Forty Years in Politics (49 page)

The Dodd-Frank Wall Street Reform and Consumer Protection Act finally passed in the summer of 2010 after a long, bruising fight. While these historic reforms wound up pleasing neither Wall Street nor its critics, they did deliver that much-needed “improvement on the status quo” that Obama had sought, with a sweeping law that would make the markets more transparent and the banks more accountable.

The Republican-leaning business lobby would seize upon his tart lines to paint Obama as antibusiness, which struck a nerve with a president who felt he had taken great risks to right their ship in the midst of the raging storm.

On one occasion, while I was still working at the White House, a top aide told Obama that he had just returned from a meeting in New York with financiers and corporate chiefs where he had his head handed to him. “They say they have a fifty-page list of concerns,” he said. “They asked me, ‘Where’s your list of accomplishments?’”

The president shrugged. “How about saving the economy? That’s my list. One page. How about that?”

W
HEN
THE
GREAT
DEBATE
over
A
merica’s health care system began,
I
didn’t need a primer on its problems.
I
had lived them.

In my early days as a reporter at the
Tribune
, I had signed up for an insurance plan that seemed perfectly adequate. Susan and I were young, healthy, and fit, and we believed the health maintenance organization we had selected provided all the coverage we would need. Then, in 1982, when Lauren’s seizures began, we learned very quickly how wrong we were. We had no prescription policy, so our insurance didn’t cover all the expensive medications Lauren required. Even as the plan’s designated specialist spoke of surgically removing a part of our child’s brain, the HMO refused to pay for a second opinion. Finding better coverage was out of the question. Now that Lauren had a preexisting condition, no other insurer would take us.

Susan had quit her job to stay home with the baby, whose constant seizures and frequent hospitalizations made a steady work schedule impossible. I was making a decent salary at the newspaper, about forty thousand dollars a year, but with annual out-of-pocket medical expenses of ten thousand or more, we were routinely shuffling bills and taking on debt. Even as we dealt with the heartache of Lauren’s struggles, we grappled with the huge financial burden that came along with them—and we
had
insurance. I often wondered, as I sat in emergency rooms, how folks who
didn’t
have coverage dealt with these pressures.

What wouldn’t I have given then for minimum coverage standards that included prescription drugs? Or for a law that would have prevented insurers from turning us down because of Lauren’s preexisting condition? Back in the 1980s, though, a health care law like that seemed a pipe dream.

Obama had his own searing story. When his mother was diagnosed with ovarian cancer at age fifty-three, she was denied the disability pay she needed for her medical and living expenses. “She spent the last months of her life worrying as much about the medical bills as she did about trying to get well,” he recalled with sadness and anger.

As a state senator from liberal Hyde Park, Obama had sponsored an amendment to the Illinois Constitution guaranteeing every resident the right to health care, but it went nowhere. During his Senate race, Obama stopped short of universal coverage, sticking instead to a plan that insured children, the poor, the temporarily unemployed, and the elderly. He did not advance a plan in the U.S. Senate because, coming from a junior senator who didn’t even sit on the committees that had jurisdiction over health care, it would have been viewed as grandstanding.

We presented a comprehensive plan in the 2008 campaign, but we pummeled Hillary for including in hers a mandate requiring every American to obtain coverage. Then, in the general election, our research suggested that even our more moderate plan could be turned against us. So we ran a series of ads that infuriated some of our strongest supporters, denouncing both “government-run health care” and the excesses of the insurance industry. Finally, we beat up John McCain for proposing to tax health care benefits Americans got through their employers.

Yet the public policy case for action was hard to ignore.

By the time Obama took office, the number of people without coverage was nearing fifty million. Health care costs claimed a much higher share of our economy than in the other industrialized nations, almost all of which have some form of universal coverage. Also, despite the belief most Americans held about the superior quality of care in the United States, we lagged far behind most of those other countries in health outcomes. The cost of health care to consumers had been rising sharply for years, placing huge and growing pressures on families and businesses. As our budget director, Peter Orszag, drilled home in our internal deliberations, health care was the fastest-growing item in the budget and the greatest driver of long-term debt. The status quo would not hold.

In my role as the new president’s political adviser, however, I knew what a perilous mission health reform would be.

Americans, in principle, were concerned about the growing number of uninsured and abuses by the industry, and they were reeling from the rapidly rising costs. Still, 85 percent had coverage, and they were leery of government plunging more deeply into health care, fearful that this would further raise their costs and limit their choices in order to cover the uninsured.

That resistance wasn’t new.

For generations, health care reform had been the siren song of American politics, attracting presidents who wanted to solve the problem only to smash them against the rocks of furious industry lobbying and fickle public opinion. With Hillary as the skipper, Bill Clinton was the last to run up against these rocky shoals when he pushed a plan for universal coverage during his first years as president, in the early ’90s. It was widely seen as one of the factors leading to Clinton’s disastrous 1994 midterm elections, in which Republicans seized control of the Senate and, for the first time in forty years, the House of Representatives.

Given my own family’s experience, I desperately wanted to see the system reformed. Yet, at least until the president made his decision, my job was to advise him candidly of the high political cost of taking it on and the long odds of success.

Adding to my anxiety were the details of the comprehensive plan he would advance if he decided to move forward. A team of health care experts had been hammering out a proposal since the election. It included both the mandate, which they said was essential to guarantee that healthy people join the insurance risk pool, and a new tax on high-cost health care plans offered by employers. Both, they argued, were indispensable elements of reform.

The tension over what to do about health care came to a boil at a meeting we held in the Roosevelt Room in early March 2009. The debate was centered on two huge questions: First, should we tackle health care in the first year of the administration? Second, if we tackle it, should we shoot for the whole package of comprehensive reform or settle for a more modest improvement?

“You’re going to have to do something because Nancy and the House Democrats will insist on it,” said Rahm, who spoke with the authority of a man who, just months earlier, was on Speaker Pelosi’s leadership team. He argued for a more modest approach, the better not to expend our political capital on one vexing issue. The vice president, who knew more than a little about the workings of Congress, agreed that large-scale reform was too ambitious given everything else on our plate. He felt we needed to be squarely focused on the economy.

Fearful of how a contentious health reform battle would play out in the middle of an economic crisis, I suggested that the president defer it and place the focus on another of his causes: education reform. Ensuring every American got the education and training they needed was a sacred value and essential to long-term economic growth and competitiveness, I argued, and was the best answer to the burgeoning gulf between the wealthy and everyone else. Of all the major issues, it also had the best chance to attract some bipartisan support.

Then a woman I didn’t recognize spoke up. “Mr. President you’ve made a commitment and you have to keep it,” she said with a sharpness and finality that I didn’t appreciate.

The speaker was Jeanne Lambrew, who had coauthored a book on health reform with Tom Daschle, Obama’s first choice to lead the Department of Health and Human Services. When Daschle withdrew from the nominating process because of a personal tax controversy, Jeanne stayed on, working for his replacement, Kathleen Sebelius. I would later learn just how smart and committed Jeanne was, but at that moment, I viewed her as a meddlesome and presumptuous interloper.

“Look, I don’t know who you are because, so far as I know, you weren’t involved in our campaign,” I said. “So let me tell you exactly what commitments the president made. He promised not to have a health care mandate. He promised not to tax health benefits. That’s what he promised, and now you folks want him to break those promises.”

The president, sitting in the slightly taller chair reserved for him at the center of a long, wooden conference table, took it all in. I could tell by the questions he asked and the comments he made, however, that Jeanne’s bold thrust had been unnecessary. He was already on her side. He felt a commitment to move forward, boldly and swiftly. After spending two years telling the country that we needed leaders who would make decisions for the next generation and not just the next election, he was going to embrace that principle.

“I understand the risks,” he told me later. “But what are we going to do? Are we going to put our approval ratings on the shelf and admire them for eight years? Or are we going to spend down on them and try to get some important things done for the future? If we don’t take this up in the first two years, there’s a good chance we won’t get it done at all. We’ll end up kicking the can down the road, and millions more people will go without insurance and the whole thing will implode.”

Half of me wanted to stand up and cheer. This was exactly why I loved Obama, who saw the winning of elections as the gateway to do meaningful things, not as a final destination.

To pass through that gateway, Obama had proven himself to be a shrewd politician, willing to make the necessary compromises. Without that quality, he would have been just another smart guy teaching law back at the University of Chicago. It was he who insisted during the primary that we omit the mandate from our campaign plan, arguing that it was unfair to force people to buy insurance unless and until we could make it affordable. It was a respectable policy argument, but I knew the politics were not lost on him. He had not been shy about flaying Hillary for her mandate, just as he’d green-lighted our health care ads against McCain. However, now he
was
the president, and he wasn’t going to duck what might be his best opportunity to tackle what no other president had done. He was determined to help the desperate folks he had met along the way and all those whose anxious letters he was now reading each night. Their stories truly haunted him. The crisis of the uninsured and underinsured was an affront to American values and a threat to our country’s solvency.

Obama’s sense of urgency also reflected his understanding that there was zero chance he would be greeted by a
more
hospitable Congress after 2010, and he knew that presidents rarely became more powerful and influential over time. He was likely at the zenith of his power and popularity and was intent on fighting to accomplish as much as possible before the midterm elections. Health reform; tough, new financial regulations; a cap-and-trade bill to combat climate change; immigration reform—everything was on the table.

“Whenever I leave here, in four years or eight, I just want to leave knowing I did everything I could,” he said. “We may not solve all these problems, but I want to know that we tried.”

The half of me that wasn’t poised to cheer was just worried. As much as I admired Obama’s resolve, I knew that we really hadn’t run on any of those issues except in the most general of ways, and if we had, we may not have won. Now, in the midst of an economic calamity, we were going to take a sharp turn and focus on some of the most divisive questions in Washington. Yes, they were issues that screamed out for solutions, but they hadn’t been solved yet for a reason.

A rationalist in an often irrational business, Obama believed that if we just did a good job of explaining the health care plan to the American people, they would respond. I wasn’t so sure. He also underestimated the reluctance of many politicians in Washington to stick their necks out on an issue that had traditionally been a killing field. For these reasons, to pass the bill, we would have to employ some of the time-honored techniques of legislative commerce in Washington that he had attacked as a candidate.

If I was concerned, Rahm was despondent.

More than most, he understood the limits of Congress. Moreover, the Clinton years had schooled him on the peril of big endeavors, particularly ones that put the White House at odds with both powerful Washington forces and widespread public sentiment. “David, I don’t know how we’re going to land all these planes,” he said, sitting at his desk, staring at a pile of papers in front of him. Nonetheless, the president had made his decision, and Rahm went to work.

It was better to partner with Congress from the beginning, he concluded, and let them draft the plan with our input. Also, he was determined not to let “Harry and Louise” ride again—that fictional couple whose skeptical ads for the insurance industry had helped kill the Clinton plan. “We need to keep the insurance industry people off the battlefield for as long as possible,” Rahm said at one of our early morning meetings. “We can’t let them strangle this in the crib.” This would set up another juncture where the idealistic promises of the campaign collided with the real politics necessary to get things done.

As a candidate, Obama had promised to give all the heath care stakeholders a “seat at the table,” suggesting fancifully that the negotiations could be aired on C-SPAN so all of America could witness the process. As it turned out, the insurance industry and drug companies did have a seat at the table, but the discussions were discreet and out of public view, to facilitate the frank, bottom-line bargaining that characterizes any big piece of legislation. If the insurance industry considered the proposed regulations too burdensome, even the promise of millions of new customers wouldn’t keep them in the fold. For PhRMA (Pharmaceutical Research and Manufacturers of America), the calculus was even simpler: it wouldn’t accept any plan that allowed American consumers to import prescription drugs from overseas, where they are often sold at a fraction of their U.S. price.

Although Rahm deliberately kept the president at arm’s length from some of the details, to give him the latitude to disown them, Obama understood that getting the job done would require difficult and unpopular trade-offs. If passage of comprehensive health reform required some bitter pills along the way, he had resolved to swallow them, as long as the larger goals (extending coverage to tens of millions of Americans and broadly reducing overall costs) were not compromised away.