Promised Land (9781524763183)

by Obama Barack

  “Unless I’m missing something,” I said, “we’re doing everything we can do on the economy.”

  “I know that, Mr. President. But the American people don’t know that.”

  “So what are we saying here?” I asked. “That despite having the biggest Democratic majorities in decades, despite the promises we made during the campaign, we shouldn’t try to get healthcare done?”

  Rahm looked to Axe for help.

  “We all think we should try,” Axe said. “You just need to know that if we lose, your presidency will be badly weakened. And nobody understands that better than McConnell and Boehner.”

  I stood up, signaling that the meeting was over.

  “We better not lose, then,” I said.

  * * *

  —

  WHEN I THINK back to those early conversations, it’s hard to deny my overconfidence. I was convinced that the logic of healthcare reform was so obvious that even in the face of well-organized opposition I could rally the American people’s support. Other big initiatives—like immigration reform and climate change legislation—would probably be even harder to get through Congress; I figured that scoring a victory on the item that most affected people’s day-to-day lives was our best shot at building momentum for the rest of my legislative agenda. As for the political hazards Axe and Rahm worried about, the recession virtually ensured that my poll numbers were going to take a hit anyway. Being timid wouldn’t change that reality. Even if it did, passing up a chance to help millions of people just because it might hurt my reelection prospects…well, that was exactly the kind of myopic, self-preserving behavior I’d vowed to reject.

  My interest in healthcare went beyond policy or politics; it was personal, just as it was for Teddy. Each time I met a parent struggling to come up with the money to get treatment for a sick child, I thought back to the night Michelle and I had to take a three-month-old Sasha to the emergency room for what turned out to be viral meningitis—the terror and helplessness we felt as the nurses whisked her away for a spinal tap, and the realization that we might never have caught the infection in time had the girls not had a regular pediatrician we felt comfortable calling in the middle of the night. When, on the campaign trail, I met farmworkers or supermarket cashiers suffering from a bum knee or bad back because they couldn’t afford a doctor’s visit, I thought about one of my best friends, Bobby Titcomb, a commercial fisherman in Hawaii who resorted to professional medical help only for life-threatening injuries (like the time a diving accident resulted in a spear puncturing his lung) because the monthly cost of insurance would have wiped out what he earned from an entire week’s catch.

  Most of all, I thought about my mom. In mid-June, I headed to Green Bay, Wisconsin, for the first of a series of healthcare town hall meetings we would hold around the country, hoping to solicit citizen input and educate people on the possibilities for reform. Introducing me that day was Laura Klitzka, who was thirty-five years old and had been diagnosed with aggressive breast cancer that had spread to her bones. Even though she was on her husband’s insurance plan, repeated rounds of surgery, radiation, and chemo had bumped her up against the policy’s lifetime limits, leaving them with $12,000 in unpaid medical bills. Over her husband Peter’s objections, she was now pondering whether more treatment was worth it. Sitting in their living room before we headed for the event, she smiled wanly as we watched Peter doing his best to keep track of the two young kids playing on the floor.

  “I want as much time with them as I can get,” Laura said to me, “but I don’t want to leave them with a mountain of debt. It feels selfish.” Her eyes started misting, and I held her hand, remembering my mom wasting away in those final months: the times she’d put off checkups that might have caught her disease because she was in between consulting contracts and didn’t have coverage; the stress she carried to her hospital bed when her insurer refused to pay her disability claim, arguing that she had failed to disclose a preexisting condition despite the fact that she hadn’t even been diagnosed when her policy started. The unspoken regrets.

  Passing a healthcare bill wouldn’t bring my mom back. It wouldn’t douse the guilt I still felt for not having been at her side when she took her last breath. It would probably come too late to help Laura Klitzka and her family.

  But it would save somebody’s mom out there, somewhere down the line. And that was worth fighting for.

  * * *

  —

  THE QUESTION WAS whether we could get it done. As tough as it had been to pass the Recovery Act, the concept behind the stimulus legislation was pretty simple: enable the government to pump out money as fast as it could in order to keep the economy afloat and people employed. The law didn’t take cash out of anyone’s pockets, or force a change in how businesses operated, or discontinue old programs in order to pay for new ones. In the immediate term, there were no losers in the deal.

  By contrast, any major healthcare bill meant rejiggering one-sixth of the American economy. Legislation of this scope was guaranteed to involve hundreds of pages of endlessly fussed-over amendments and regulations, some of them new, some of them rewrites to previous law, all of them with their own high stakes. A single provision tucked inside the bill could translate to billions of dollars in gains or losses for some sector of the healthcare industry. A shift in one number, a zero here or a decimal point there, could mean a million more families getting coverage—or not. Across the country, insurance companies like Aetna and UnitedHealthcare were major employers, and local hospitals served as the economic anchor for many small towns and counties. People had good reasons—life-and-death reasons—to worry about how any change would affect them.

  There was also the question of how to pay for the law. To cover more people, I had argued, America didn’t need to spend more money on healthcare; we just needed to use that money more wisely. In theory, that was true. But one person’s waste and inefficiency was another person’s profit or convenience; spending on coverage would show up on the federal books much sooner than the savings from reform; and unlike the insurance companies or Big Pharma, whose shareholders expected them to be on guard against any change that might cost them a dime, most of the potential beneficiaries of reform—the waitress, the family farmer, the independent contractor, the cancer survivor—didn’t have gaggles of well-paid and experienced lobbyists roaming the halls of Congress on their behalf.

  In other words, both the politics and the substance of healthcare were mind-numbingly complicated. I was going to have to explain to the American people, including those with quality health insurance, why and how reform could work. For this reason, I thought we’d use as open and transparent a process as possible when it came to developing the necessary legislation. “Everyone will have a seat at the table,” I’d told voters during the campaign. “Not negotiating behind closed doors, but bringing all parties together, and broadcasting those negotiations on C-SPAN, so that the American people can see what the choices are.” When I later brought this idea up with Rahm, he looked like he wished I weren’t the president, just so he could more vividly explain the stupidity of my plan. If we were going to get a bill passed, he told me, the process would involve dozens of deals and compromises along the way—and it wasn’t going to be conducted like a civics seminar.

  “Making sausage isn’t pretty, Mr. President,” he said. “And you’re asking for a really big piece of sausage.”

  * * *

  —

  ONE THING RAHM and I did agree on was that we had months of work ahead of us, parsing the cost and outcome of each piece of possible legislation, coordinating every effort across different federal agencies and both houses of Congress, and all the while looking for leverage with major players in the healthcare world, from medical providers and hospital administrators to insurers and pharmaceutical companies. To do all this, we needed a top-notch healthcare team to keep us on track.

  Luckil
y we were able to recruit a remarkable trio of women to help run the show. Kathleen Sebelius, the two-term Democratic governor from Republican-leaning Kansas, came on as secretary of health and human services (HHS). A former state insurance commissioner, she knew both the politics and the economics of healthcare and was a gifted enough politician—smart, funny, outgoing, tough, and media savvy—to serve as the public face of health reform, someone we could put on TV or send to town halls around the country to explain what we were doing. Jeanne Lambrew, a professor at the University of Texas and an expert on Medicare and Medicaid, became the director of the HHS Office of Health Reform, basically our chief policy advisor. Tall, earnest, and often oblivious to political constraints, she had every fact and nuance of every healthcare proposal at her fingertips—and could be counted on to keep the room honest if we veered too far in the direction of political expediency.

  But it was Nancy-Ann DeParle whom I would come to rely on most as our campaign took shape. A Tennessee lawyer who’d run that state’s health programs before serving as the Medicare administrator in the Clinton administration, Nancy-Ann carried herself with the crisp professionalism of someone accustomed to seeing hard work translate into success. How much of that drive could be traced to her experiences growing up Chinese American in a tiny Tennessee town, I couldn’t say. Nancy-Ann didn’t talk much about herself—at least not with me. I do know that when she was seventeen, her mom died of lung cancer, which might have had something to do with her willingness to give up a lucrative position at a private equity firm to work in a job that required even more time away from a loving husband and two young sons.

  It seems I wasn’t the only one for whom getting healthcare passed was personal.

  Along with Rahm, Phil Schiliro, and deputy chief of staff Jim Messina, who had served as Plouffe’s right hand in the campaign and was one of our shrewdest political operators, our healthcare team began to map out what a legislative strategy might look like. Based on our experiences with the Recovery Act, we had no doubt that Mitch McConnell would do everything he could to torpedo our efforts, and that the chances of getting Republican votes in the Senate for something as big and as controversial as a healthcare bill were slim. We could take heart from the fact that instead of the fifty-eight senators who were caucusing with the Democrats when we passed the stimulus bill, we were likely to have sixty by the time any healthcare bill actually came to a vote. Al Franken had finally taken his seat after a contentious election recount in Minnesota, and Arlen Specter had decided to switch parties after being effectively driven out of the GOP—just like Charlie Crist—for supporting the Recovery Act.

  Still, our filibuster-proof head count was tenuous, for it included a terminally ill Ted Kennedy and the frail and ailing Robert Byrd of West Virginia, not to mention conservative Dems like Nebraska’s Ben Nelson (a former insurance company executive) who could go sideways on us at any minute. Beyond wanting some margin for error, I also knew that passing something as monumental as healthcare reform on a purely party-line vote would make the law politically more vulnerable down the road. Consequently we thought it made sense to shape our legislative proposal in such a way that it at least had a chance of winning over a handful of Republicans.

  Fortunately we had a model to work with, one that, ironically, had grown out of a partnership between Ted Kennedy and former Massachusetts governor Mitt Romney, one of John McCain’s opponents in the Republican primary for president. Confronting budget shortfalls and the prospect of losing Medicaid funding a few years earlier, Romney had become fixated on finding a way to get more Massachusetts residents properly insured, which would then reduce state spending on emergency care for the uninsured and, ideally, lead to a healthier population in general.

  He and his staff came up with a multipronged approach in which every person would be required to purchase health insurance (an “individual mandate”), the same way every car owner was required to carry auto insurance. Middle-income people who couldn’t access insurance through their job, didn’t qualify for Medicare or Medicaid, and were unable to afford insurance on their own would get a government subsidy to buy coverage. Subsidies would be determined on a sliding scale according to each person’s income, and a central online marketplace—an “exchange”—would be set up so that consumers could shop for the best insurance deal. Insurers, meanwhile, would no longer be able to deny people coverage based on preexisting conditions.

  These two ideas—the individual mandate and protecting people with preexisting conditions—went hand in hand. With a huge new pool of government-subsidized customers, insurers no longer had an excuse for trying to cherry-pick only the young and healthy for coverage to protect their profits. Meanwhile, the mandate ensured that people couldn’t game the system by waiting until they got sick to purchase insurance. Touting the plan to reporters, Romney called the individual mandate “the ultimate conservative idea” because it promoted personal responsibility.

  Not surprisingly, Massachusetts’s Democratic-controlled state legislature had initially been suspicious of the Romney plan, and not just because a Republican had proposed it; among many progressives, the need to replace private insurance and for-profit healthcare with a single-payer system like Canada’s was an article of faith. Had we been starting from scratch, I would have agreed with them; the evidence from other countries showed that a single, national system—basically Medicare for All—was a cost-effective way to deliver quality healthcare. But neither Massachusetts nor the United States was starting from scratch. Teddy, who despite his reputation as a wide-eyed liberal was ever practical, understood that trying to dismantle the existing system and replace it with an entirely new one would be not only a political nonstarter but hugely disruptive economically. Instead, he’d embraced the Romney proposal with enthusiasm and helped the governor line up the Democratic votes in the state legislature required to get it passed into law.

  “Romneycare,” as it eventually became known, was now two years old and had been a clear success, driving the uninsured rate in Massachusetts down to just under 4 percent, the lowest in the country. Teddy had used it as the basis for draft legislation he’d started preparing many months ahead of the election in his role as chair of the Senate Health and Education Committee. And though Plouffe and Axe had persuaded me to hold off on endorsing the Massachusetts approach during the campaign—the idea of requiring people to buy insurance was extremely unpopular with voters, and I’d instead focused my plan on lowering costs—I was now convinced, as were most healthcare advocates, that Romney’s model offered us the best chance of achieving our goal of universal coverage.

  People still differed on the details of what a national version of the Massachusetts plan might look like, and as my team and I mapped out our strategy, a number of advocates urged us to settle these issues early by putting out a specific White House proposal for Congress to follow. We decided against that. One of the lessons from the Clintons’ failed effort was the need to involve key Democrats in the process, so they’d feel a sense of ownership of the bill. Insufficient coordination, we knew, could result in legislative death by a thousand cuts.

  On the House side, this meant working with old-school liberals like Henry Waxman, the wily, pugnacious congressman from California. In the Senate, the landscape was different: With Teddy convalescing, the main player was Max Baucus, a conservative Democrat from Montana who chaired the powerful Finance Committee. When it came to the tax issues that occupied most of the committee’s time, Baucus often aligned himself with business lobbies, which I found worrying, and in three decades as a senator he had yet to spearhead the passage of any major legislation. Still, he appeared to be genuinely invested in the issue, having organized a congressional healthcare summit the previous June and having spent months working with Ted Kennedy and his staff on early drafts of a reform bill. Baucus also had a close friendship with Iowa senator Chuck Grassley, the Finance Committee’s ranking Republican, and was op
timistic that he could win Grassley’s support for a bill.

  Rahm and Phil Schiliro were skeptical that Grassley was gettable—after all, we’d been down that rabbit hole during the Recovery Act debate. But we decided it was best to let Baucus’s process play itself out. He’d already outlined some of his ideas in the press and would soon pull together a healthcare-reform working group that included Grassley and two other Republicans. During an Oval Office meeting, though, I made a point of warning him not to let Grassley string him along.

  “Trust me, Mr. President,” Baucus said. “Chuck and I have already discussed it. We’re going to have this thing done by July.”

  * * *

  —

  EVERY JOB HAS its share of surprises. A key piece of equipment breaks down. A traffic accident forces a change in delivery routes. A client calls to say you’ve won the contract—but they need the order filled three months earlier than planned. If it’s the kind of thing that’s happened before, the place where you work may have systems and procedures to handle the situation. But even the best organizations can’t anticipate everything, in which case you learn to improvise to meet your objectives—or at least to cut your losses.

  The presidency was no different. Except that the surprises came daily, often in waves. And over the course of the spring and summer of that first year, as we wrestled with the financial crisis, two wars, and the push for healthcare reform, several unexpected items got added to our already overloaded plate.

  The first carried the possibility of a genuine catastrophe. In April, reports surfaced of a worrying flu outbreak in Mexico. The flu virus usually hits vulnerable populations like the elderly, infants, and asthma sufferers hardest, but this strain appeared to strike young, healthy people—and was killing them at a higher-than-usual rate. Within weeks, people in the United States were falling ill with the virus: one in Ohio, two in Kansas, eight in a single high school in New York City. By the end of the month, both our own Centers for Disease Control (CDC) and the World Health Organization (WHO) had confirmed that we were dealing with a variation of the H1N1 virus. In June, the WHO officially declared the first global pandemic in forty years.