Interview: Ceci Connolly

[What was the March 2009 White House forum on health care?]

... [White House Chief of Staff] Rahm [Emanuel] knew that they had to start so early because of the way that Washington and Congress works, and you had to seize that inaugural enthusiasm and momentum.

So almost all of the players in the drama assemble on the stage that day in early March at the White House summit. It was largely a photo op. It was largely a way for the new administration to say: "Yes, we really are serious. We're going to do this."

What was most interesting, though, about that particular gathering were the people that were in the room that day. They were largely the representatives of the major industries, or what we call stakeholder groups: trade associations; Big Pharma was there; the insurers; hospitals; physician groups, including the AMA, the American Medical Association -- many of these players who certainly for years, if not decades, had a record of opposing any sort of health care reform efforts. ...

Also very noteworthy: Sen. Edward Kennedy [D-Mass.], who by that point was quite ill with cancer, made a fairly rare appearance that day toward the end of the summit, kind of a closing ceremony. It was fairly dramatic, because Kennedy hadn't been seen much in public since Inauguration Day, when he of course passed out at that luncheon. So there was a good bit of high drama in terms of the Kennedy appearance there. ...

Why were they all there? ...

To understand the health care reform effort of 2009, you have to have an appreciation for what was happening in the marketplace. ... The economy for many of the players in the medical arena had changed and worsened. Several of these big industries were seeing a decline in customers, for instance, as people were either losing insurance altogether, especially if they were losing jobs in the terrible economy, or they were receiving less and less insurance coverage.

So just to take the example of the insurance industry, it was seeing a declining customer base, and it knew that health care reform offered the prospect of 46 million new customers. The same for the pharmaceutical industry. Even though pharma had done very well a few years back with the Medicare prescription drug benefit and picked up a lot of senior citizens in its customer base, it still knew that those 46 million uninsured and many other underinsured people didn't have much in the way of prescription drug coverage. So they, too, saw the prospect of new customers, and on down the line. ...

What brings Obama to that room at that moment, wanting to do this badly?

Obama's role in health care reform has been an interesting one. If you go back a year to the Democratic primaries in 2008, he was not the health care candidate -- far from it. Really, [former Sen.] John Edwards [D-N.C.] was the first Democrat to stake out the health care territory with a very ambitious universal coverage plan, followed quickly by [then-Sen.] Hillary Clinton [D-N.Y.]. ... Early in the primary season, Obama and all of the Democrats had a labor gathering in Nevada, and really everyone agreed, including his own people, that he didn't have that much to say on the subject. And he quickly realized that he was in a bit of a catch-up position during the campaigns.

Of course, once you got to the general election, it was a fairly easy contrast with Sen. John McCain [R-Ariz.]. Obama was able to use the issue rhetorically to sort of score points with a public that was already anxious about the economy, worried about their own health care coverage.

But even during the transition and sort of the early-going into the inauguration, it was not entirely clear, even to some of Obama's supporters and aides, whether or not health care was going to be the big domestic issue in his first year in office. In part, because they were so worried about the economy, they didn't think they were going to have much money to do some of the things that really cost a good bit of money. And then once [former Senate Majority Leader] Tom Daschle [D-S.D.] was forced to withdraw his nomination [for secretary of health and human services], they really lost kind of the lead cheerleader within the administration, as well as something of a key strategist for how they would go about this.

So for all of those reasons, no one was certain in early 2009 that it would become the year of health care reform, and that President Barack Obama would be so closely associated with, and potentially defined early in his presidency, by this issue. Why he became so committed to it, I think, is a story that we are still learning as we go along, but that, in some respects, it was he and his chief of staff, Rahm Emanuel, sitting down and looking at the reality of the country today, trying to determine what is it that we can do on the domestic front where we can score a legislative win our first year in office. And that's what they settled on. ...

[What was the administration's timetable?]

The Obama administration did not want to have health care reform an open-ended question at his State of the Union address in January of 2010, absolutely not. By then, they wanted to have had a marvelous signing ceremony and made what we love to call in Washington the pivot back onto the economy for that 2010 midterm election season. They also knew full well that by early 2010, Afghanistan would be a bigger problem on their plate. They also know that the second year in office, you begin to have turnover within your administration and that some people get worn out as well. That's another reality. ...

They really did want House and Senate votes, sort of the early preliminary votes, before the August recess, figuring that then members would go home to their districts in August and have something exciting and an accomplishment to trumpet. It wouldn't have been a final enactment, but it would have been a key important vote that they could tout during that long, hot recess, and that then they would have the fall to go about the behind-the-scenes negotiating of what we call the conference committee, bringing those two different bills together, and they could kind of hammer it out by, oh, maybe mid- to late fall. ...

And no doubt when the Obama team is deciding to create the playbook for how to make this thing happen, lessons from whatever happened to Hillary and Bill Clinton were foremost on the table?

Oh, absolutely. The Obama White House was determined not to make the same mistakes as the Clinton White House. And it's pretty clear that they didn't make the same mistakes. They did not write a bill. They made it very clear to Congress that that was the job of the lawmakers, and they were going to leave it up to them. They also moved very quickly, understanding that it was important to seize the energy from the inauguration excitement. They brought many of the players into the room, not only at that public summit but in all sorts of private conversations and negotiations as the year went on. But they made their own mistakes. ...

What happened to Tom Daschle?

Daschle had known for a period of months that there was a question and problem around not paying taxes on a car and driver that had been provided to him over a period of three years through this company that he had been working for in the private sector. He had made inquiries of his accountant many months beforehand but did not publicly disclose this. It became known to a very select few within the transition, but there was a thought that Daschle had such strong relationships on Capitol Hill, had an otherwise squeaky-clean reputation, that this was a mistake that he was correcting by paying about $125,000 in back taxes and that that would be a problem that could be overcome.

As it turned out, there were others who were nominated by Barack Obama for Cabinet positions, [Secretary of the Treasury Timothy] Geithner in particular and some others, who had tax problems as well, and this became a very uncomfortable storyline at the outset of the Obama administration. If Daschle's problems had arisen before Tim Geithner's, you might have seen the reverse occur. ...

But Daschle was also not helped by the fact that while he had many friends and former colleagues in the Senate, the Senate Finance Committee chairman, Max Baucus [D-Mont.], was not necessarily a close friend or ally. And Baucus really permitted the top Republican on the committee, Chuck Grassley [R-Iowa], and his investigative staff, to drag that out for a period of time. And like many things in Washington, the longer a problem hangs out there, the more damaging it becomes. And Daschle was forced to withdraw.

What was it between Daschle and Baucus that came to play finally in this moment?

The tensions between Daschle and Baucus go back to Daschle's leadership race. Also, Max Baucus is an interesting character within the Senate Democratic Caucus, because he is certainly right of center and has had a record of working with Chuck Grassley, his Republican counterpart, even sometimes supporting things like Bush tax cuts, which were very unpopular in the Democratic Party. So there has always been a little bit of a skepticism among Democrats toward Max Baucus. ...

So how emotional is it when Daschle says goodbye? Some people have [described] a kind of bloodless "See you later" from the president. Was it bloodless?

My understanding is that Obama quickly, calmly accepted the resignation offer. Did not pause, did not look back, and moved forward and onto the next thing. ...

But the loss of Daschle was harmful in many respects, first and foremost because they lost a very sharp strategist who was going to be devoted full time to health care reform; secondly, because the president lost someone who was closer to being a peer, which you need something of in the White House. Everyone else is staff. Daschle had been more on the same level. He had been a senator; he had helped show Barack Obama how to move through the Senate and through the Capitol and Washington. So they had a different relationship than many of those other advisers within the West Wing. ...

Purely logistically and on a policy front, it set them back a period of months, really, because they lost a team. ... There were others that thought they were in line for key positions and key roles on the health care front who were Daschle loyalists who were suddenly left hanging and didn't end up playing that role. ...

One of the things about [Sen. Baucus] is that he's received a tremendous amount of support, financial support, from PhRMA [Pharmaceutical Research and Manufacturers of America] and others, and that his staff has tended to migrate out to great jobs in the industry. Tell me the meaning of that. I understand that it's relatively easy to say lobbying equals influence, but is it more than that, especially vis-à-vis this particular go-round on health care?

When it comes to campaign contributions and the role that they might play or the influence that they have on lawmakers, I'm always a little bit reluctant to jump to conclusions, in part because there's so much money coursing through the system at this point and there are so many industries giving to so many lawmakers such enormous sums that I think it's become difficult to pinpoint, "Oh, that bundle of money really had an impact on this piece of legislation."

And especially when you get to the most powerful committees on Capitol Hill, the Senate Finance Committee, the House Energy and Commerce Committee, those committees have such enormous sway over so much of our economy, so many important sectors of the economy, that they're the money committees. ...

What the campaign contributions often do -- and it's something of a cliche, but it's true -- is that they open doors. They give industries entrée to important congressional staffers and lawmakers. ... What most of them want is the ability to get that meeting where they can sit down and market their case. And they'll come in with their reams of research and they might say, "This could cost jobs, or this will affect so many people in our district or your home state," or whatever it is. But what they want to know is they can get in the door, sit down and make their case. ...

Max Baucus forms the "Gang of Six," this sort of subgroup. Why?

Baucus formed this subgroup because he went into this process very committed for a number of reasons in attempting to forge some sort of bipartisan compromise. He had a history of doing this on the Senate Finance Committee, whether he was in the majority or the minority party. It certainly worked well for him politically back home in Montana, a more moderate to conservative state. So it fit his own politics and inclinations. ...

And he also felt that, and said publicly many times, that in something as ambitious as health care reform, where you are going to be impacting one-sixth of the U.S. economy, having a bipartisan flavor to the effort helps you sell it to the public. It becomes more palatable if it is not seen as simply a liberal Democrat initiative. ...

How powerful is he? How central is he to this moment? ...

Who do they get after losing Tom Daschle and largely Ted Kennedy? Max Baucus. Not the first choice of most of the people in the West Wing. Not the first choice because he doesn't have the background in health care policy. It had never been a burning passion for Sen. Baucus, and so many complained that he came late to the issue. He was viewed skeptically within his own caucus. Many say that he had very few friends within his own Democratic Party. And again, the Senate is a club. It is a cliche, but those 100 people feel something very special about their membership in that club, and sometimes it resembles junior high school. But for the variety of reasons, the White House was quite anxious about putting their signature domestic policy initiative in the hands of Max Baucus.

To his credit, he had been doing his own homework for a good year before things really heated up in Washington. In the spring of 2008, Baucus began convening town hall sessions in Washington and out in the country. He did a big daylong session at the Library of Congress with his entire Senate Finance Committee, sort of tutorials. In the fall of '08, he issued his white paper [PDF], which laid out not only the problems in the health care system, but sort of options for solving it.

And this was a very important step in the process for Baucus, because he became very educated and truly mastered the issue -- not an easy subject to learn. He had some very, very smart aides that helped bring him along. But he really got a command of the subject matter and understood the different trade-offs in policy decisions. He understood the financing of the system. He understood the problems of the uninsured, not just for them but the way in which that translated into cost shifting. He understood what was going on out in the delivery reform arena. So he was a person who, to his credit, did his homework and got a handle on the subject matter.

What was still not clear in the spring and summer of 2009 was whether or not he could pull off the politics of it. And there was great frustration about how long the Gang of Six spent meeting and talking and meeting and talking. And [it was] a real disappointment for Baucus that when they left for the August recess, he did not have an agreement from the Gang of Six. ...

[Did the president court Baucus, or vice versa?]

President Obama was very interested in courting not only Max Baucus but, for a period of time, Chuck Grassley and also [Sen.] Olympia Snowe [R-Maine] and any number of individual lawmakers that he felt he could use his own personal powers of persuasion to nudge along. He had been a colleague with all of these senators, albeit briefly, and some of them would sort of roll their eyes and think to themselves, well, he just kind of blew through here; he didn't really spend time lawmaking the way that I have. But he was able to speak their language. He was able to tap the relationships that he had developed during his years in the Senate.

And what we learned about President Obama during the spring and summer in particular, and even early fall -- I would talk to any number of people who had gone and had a meeting at the White House, often one on one or two people meeting with the president, and I would say, "Well, now, what did he say?" And the person would invariably tell me what they had said. "I told him this. I told him we need to do that. I have to have this." "And what did the president say?" "Well, he seemed receptive." "Well, he listened." And what we've come to learn about President Obama, at least early in his time in the White House, is that a, he's a pretty good listener; b, he doesn't reveal much of what he's thinking; c, he doesn't make a quick, on-the-spot decision or commitment to whomever he's sitting in the room with, but he certainly makes them feel good. He makes the lawmaker feel as if they're very important, that their ideas matter, that they are being heard and written down somewhere, taken into account. But you don't necessarily hear him making pledges.

Or deals?

No. The deal making is done by people below the president.

People like, I suppose, Jim Messina? Who is Messina?

Jim Messina is a former chief of staff to Max Baucus [and, as of January 2009, White House deputy chief of staff for operations]. They have, though, a relationship that is far deeper and more complex than a boss/employee relationship. It's often compared to, and in fact Sen. Baucus has referred to Messina as like another son. They spend birthdays together; they go on fishing trips out in Montana together. By all accounts, even when Messina left Baucus' employ to work for Obama and then into the White House, they speak on the phone constantly. So they remain very close, very loyal to each other.

Messina, as a result, in some quarters is viewed somewhat skeptically as being kind of the Baucus person. And from time to time he has had to demonstrate that he is much more than that and that, in fact, his boss now is President Obama, and he's committed to Obama. Sometimes Messina can play the important role of delivering a White House message to Baucus. He's also something of the interpreter or translator for others in the West Wing of what Sen. Baucus is thinking or doing at a given moment.

[How important was bipartisanship to the president?]

Obama is similar to George Bush [in that] when he arrived in office, [he] believed that, just as he had had relationships across the aisle in Illinois, as Bush did as governor in Texas, that he would be able to maintain that kind of bipartisan approach once he got into the White House.

Obama believes very strongly in his ability to rise above partisanship. He believes strongly in his ability to speak and convince others, the power of his rhetoric. We saw that, interestingly, when he went and thought he would secure the Olympic bid for Chicago: "I'll go, I'll give a wonderful talk, and they'll give my home city the Olympics." And it hasn't always turned out that way. ...

There were differences of opinion within the White House as to just how bipartisan the health care effort needed to be. I don't think that Rahm Emanuel ever worried much about bipartisanship. He was focused on winning; he was focused on delivering results. He knew that Democrats controlled the Congress, and it was going to be enough just to herd all those Democrats in line on this issue. ...

If, in fact, you were to think back over major legislative accomplishments over the past number of years, they were largely done on party lines. Rahm Emanuel in particular knew that.

The difference between the bipartisan relationships that, say, a Ted Kennedy had or even Baucus and Grassley, and Obama thinking about that, was that those other relationships had developed over years and years and even decades. They were true friendships. Obama was still relatively new. He hadn't had that much time in Washington to secure those kinds of bonds and relationships. And in fact, a good part of his time in the U.S. Senate, he was out on the campaign trail.

So as much as he sincerely, genuinely tried to reach out and continue to, through the fall, court and nurture some Republicans, ... realistically Obama did not have that simpatico Republican friend or ally that he was going to be able to turn to in the way that Kennedy had with [Sen. Orrin] Hatch [R-Utah] over the years, or McCain, [or] the relationship that Baucus thought that he had and was going to be able to tap with Grassley, because by 2009, politics in Washington had become so polarized that even the personal relationships were not carrying the day on most issues. ...

... Who is Karen Ignagni? What does she represent, and what kind of force is she in our story?

Karen Ignagni started as a labor activist for the AFL-CIO, but by '93, '94, was working for one of the insurance trade groups and by 2008 was running AHIP [America's Health Insurance Plans], the large insurance trade association. Very smart, very savvy, very personable, very grounded. Very difficult job, because those different insurance companies have different shares of the market and compete with each other in some respects and have different goals in terms of health insurance reform and where the system is heading. So keeping her entire board and membership happy was a real juggling act for her throughout this process.

But yet, she and many in the industry saw that the future was looking more and more difficult for the health insurance industry in this country. Many people were losing their health insurance coverage, or they were dropping it. The insurance industry was largely being portrayed as the big bad guy in the system. ...

So when she's standing there at that summit, what does she want, and what does she not want? What is she afraid of that might happen in health care reform?

Every single one of the people gathered at the March White House summit wanted one thing: a seat at the table. ...

So when she speaks and sort of seems to pledge [to participate] -- I mean, I've seen Obama. ... He actually seems surprised that she's speaking and that she's promising to cooperate?

Obama shouldn't have been surprised. Karen Ignagni and her insurance association had been participating in the regular sessions that Kennedy was convening. She had been saying publicly for a good long while that the insurance industry was committed to some amounts of reform. It was all going to be in the details, you know? And even, in fact, Obama had put in his first budget, he had proposed reducing the Medicare Advantage program by $180 billion over 10 years, an enormous hit. And the insurance industry and Karen Ignagni largely remained silent and did not protest that.

Now, I don't think that they ever wanted to take a $180 billion hit, but they knew that their silence was going to help buy them some credibility and some ability to chip away at that number through the process. ...

So, what's her power at the table?

The insurance industry has quite a bit of money; has many, many employees and workers all over the country; and has the ability to run advertisements -- as we saw in 1993-94 with "Harry and Louise" -- has the ability to run some very compelling, powerful commercials that could do serious damage to any sort of political effort.

Especially if Emanuel and Obama want to get it done in a hurry?

Sure, absolutely, because that can certainly slow down the process. The insurance industry has also long had plenty of allies on Capitol Hill who would assist in that sort of foot-dragging if need be.

So they're pleased when Max Baucus and the committee doesn't even deal with single-payer. ...

Right. But everyone knew that single-payer was not an option going into this. But yes, of course, that's always been a fear of the industry's. But realistically, in 2009, the industry wanted to guarantee that it was going to get a big increase in customers. It wanted to ensure that any of the government reimbursements that it was getting through Medicare and Medicaid and some other government programs were going to continue to be a good source of funding as well. So they were keeping an eye on what was happening with budget proposals, a little bit worried about that. And then there were some other industry-specific things that came into play as the negotiations unfolded.

Who is Billy Tauzin?

Billy Tauzin is a New Orleans politician. He has in his congressional career been a Democrat and a Republican. He was a very powerful chairman of the House Energy and Commerce Committee. Very colorful, lively figure who took over the pharmaceutical industry trade group, PhRMA. He himself has had some medical scares which has added to his ability to talk very personally and compellingly about the great lifesaving powers of medicines today. And he is first and foremost a deal maker. ... I am in admiration of his ability to cut deals in the tradition of a Lyndon Johnson or a [former Sen.] Bennett Johnston [D-La.]-type character.

... What does he want? And what does he fear?

Like Karen Ignagni, Billy Tauzin wants a whole lot more customers for his industry. There are also some things that PhRMA, though, going into this debate knew it did not want. PhRMA had some real concerns that there would be an effort by the Democrats to enable the government to negotiate for its prices on Medicare prescription drugs, and this could be potentially a very big hit to the industry.

The industry has long feared and opposed also allowing American customers to purchase drugs in other countries. It's called re-importation. It's become less of an issue since Medicare added a prescription drug benefit, but there certainly was a time when many senior citizens were hopping on buses and going up to Canada to buy their drugs much more inexpensively. ...

And the threat he comes to the table with? What gun does he lay on the table?

PhRMA is another one of those industries that has its allies on Capitol Hill, in part probably because of campaign contributions, but also largely because they're major employers in many important states in this country. PhRMA also is quite sophisticated about its marketing, whether it's the marketing of its products or the marketing of ideas and arguments in a political campaign. And PhRMA certainly had deep enough pockets to do some real damage advertising-wise if it wanted to in health care reform. So that was always a bit of a sword of Damocles hanging over the pro-reform effort.

... What was the deal that PhRMA got, and how did it happen?

In short, the PhRMA deal was to put $80 billion on the table to go toward health care reform. The industry was going to do that in a number of ways. It was going to, first and foremost, begin to close what's called the "doughnut hole" in Medicare for beneficiaries, senior citizens who hit a coverage gap in their Medicare and have to pay the full price of their prescription drugs. ... Democrats have long been upset about it. AARP, who also becomes involved in the negotiations as sort of the voice of retired America, has been very interested in closing that coverage gap. And so a good bit of the money that PhRMA says it will put on the table is by saying: "Look, we'll cut the price of those drugs in half. Seniors, instead of paying full price, can get a 50 percent discount." ... So that's a wonderful political tool for the Democrats.

And PhRMA also agrees to increase its government rebates and put some other sort of money on the table really in return for this individual mandate of having every American covered with health insurance. ... The long and the short of it is if all Americans have health insurance, you will begin to see more and more customers for those drug companies, whether it's in the first year or five or 10 years when they get a little older and start needing all of those wonderful medicines along the way.

[What happens when the deal is revealed publicly?]

There were two schools of thought on receiving these deals that were struck between the White House and Baucus and the different industries, PhRMA being the big one, the hospitals being another. They attempted with doctors and the AMA [American Medical Association]; that one didn't quite ever gel.

The one school of thought was, well, gee whiz, we thought Barack Obama was going to be a different kind of president and this was going to be a transparent, open White House that wasn't going to be in secret working with lobbyists, somebody who had campaigned against lobbyists. And here they were, having little private sessions hammering out $80 and $155 billion deals in secret.

On the other hand, there were many in Washington, especially those who had lived through previous unsuccessful health care reform efforts, who stopped and thought for a moment, well, maybe this isn't such a bad strategy, because in a sense, you appear to be neutralizing some of the historic opponents of health care reform -- at a minimum neutralizing them and potentially even bringing them on as supporters and proponents of this very difficult undertaking. And also, by the way, they've put some money toward the effort, and we know that there's going to be a lot of haggling over how health care reform is going to be paid for. So they've already voluntarily helped get us part of the way there. So there were real differences of opinion.

And then, beneath that there was a lot of dissection of the deals and whether or not the White House and Baucus had gotten the best possible deals, whether they could have gotten more money if they had held out longer. Were they getting enthusiastic, enough support from these industries? Or were they just kind of quiet? The hospitals, in particular, continued to be somewhat split within their own industry about this. You'd hear from the leaders of the hospital trade groups, "Yes, we've just had this wonderful agreement and we're supporting reform." But then you'd talk to individual hospital executives and they'd say, "No way, I'm not going to go along with that." ...

... What's the feeling [in August] as Congress flies out of Washington [for summer recess]?

By August, there's great frustration on the part of the White House because the president had so publicly set that August deadline, and it wasn't met. ... By setting that expectation, maybe an unrealistic expectation, while it did try to put some pressure on Congress, it also created an easy, quick storyline of a new White House not being able to deliver.

So that set the stage for a very difficult month back in the home states and districts. The opposition was ready. The opposition had prepared everything from the Tea Party gatherings to showing up at town hall meetings to even one lawmaker most famously being hung in effigy. So it was a very bad period for the Democrats and surprisingly caught them somewhat off guard. ...

If there was ever a chance of getting Chuck Grassley, I suppose the 100 town meetings he attended in Iowa that month secured or made that assumption unrealistic?

I'm sure there will forever be debate about whether or not Chuck Grassley was a possible yes vote in the Senate Finance Committee. The conventional wisdom, and a certain amount of reporting, I think shows that he did have a desire to; he did want to be a part of this. There was also some discussion that perhaps he would retire and that he had something of a legacy in mind.

But when he went home to Iowa in August and hit all of those town hall meetings, genuine skepticism on the part of many of the constituents and questions and uncertainty and unease, but also some of it ginned up by opponents, so a combination of the two, and also, increasingly a belief that he was going to run for re-election, his perspective on health care reform clearly changed. ...

... What inside the White House are they thinking about being able to do [at] the end of the August recess and Congress reconvening?

August begins as a difficult month for the White House. They're also exhausted. The whole group of them have gone through a grueling campaign, a frenetic transition and the start of a presidency with so much happening right out of the gate. So in some respects, they're just plain worn out themselves, including the president.

So part of what they do is they recover a little bit, and they regroup, and they begin to assess what are the different tools in their arsenal. ...

They know that their most powerful tool is Barack Obama. Always has been, probably always will be. So they think first and foremost about how to use him most effectively. And what they settle on, after some amount of discussion and debate and consulting with people who'd sort of been through these things before, was the joint address to Congress in early September.

What are the stakes for him at that moment?

... The stakes were high because he had largely set the stakes high. He was the one that said that he wanted this piece of health care legislation on his desk in 2009 and that he intended to sign it. He was the one that had set the goal of saving every average American family $2,500 on their health care cost. He had spoken about near universal coverage. So these were expectations that he had laid out, and now it was looking as if perhaps he and his Democratic Congress would not be able to deliver on those promises.

In that late-August period, Sen. Kennedy dies. It almost felt like a built-in pause. ...

Yes, it was certainly a pause. It also was a moment in which some of the central Republicans like an Orrin Hatch, like a John McCain, who had been very close to Sen. Kennedy for such a long period of time, stopped and thought, gee, isn't it too bad that he's not here to maybe help bring us together in some way? But it was not enough. Some people thought, well, gosh, maybe in memory of Sen. Kennedy, some of these old Republican friends of his would rejoin the effort. But at that point, it was too far along to help for that kind of a turnaround. ...

So the president speaks, and there's this moment where "You lie!" gets yelled out. What was the impact of that?

In some respects, [Rep.] Joe Wilson [R-S.C.] hollering out, "You lie!," was probably a good thing for President Obama, because, quite candidly, his speech to Congress was fine, but there was nothing terribly new in it. It was not the greatest oratory that we've seen on this subject, or certainly in history. And it provided a handy distraction from that. All of the commentary immediately that night of the speech and the subsequent days was about Joe Wilson, rather than attempting to score the new president on how he'd performed in this very difficult setting.

The other thing is that it probably rallied more of the Democrats together. They had been arguing throughout the summer, sort of among themselves, liberals and moderates in the party at different extremes. They'd gone through this terrible August. They'd come back; a lot of them returned kind of uncertain about how committed they were to this issue. But all of a sudden, they had a common enemy.

Joe Wilson?

Joe Wilson, at least for a moment.

In October, Karen Ignagni and the insurance guys decide to go into full battle rattle, and act like they're going to go to war with the White House. This report gets issued. What was the report?

... This was a report [PDF] that was commissioned by AHIP to assess the impact of some major elements of the Senate Finance Committee bill on the economy and average customers, etc. This was two days before the Senate Finance Committee was scheduled to vote. The report itself has been largely picked apart by a number of analysts who say it overlooked some important provisions in the legislation. It perhaps emphasized too much some other provisions.

But the importance of that report and its issuance was not really the substance of the report so much as the decision by the industry to put it out there. And it was the clearest signal in this long drama that the insurance industry was not going to be onboard with any sort of health care reform.

It was most upset because it didn't see enough new customers coming into play because there was not a strong enough individual mandate. And that was, interestingly, a point that was being made by many, not just the insurance industry but also the hospital industry. Also, a number of Democrats on Capitol Hill, a number of independent experts like [Director of the Health Care Program at the National Bureau of Economic Research] Jon Gruber, had been saying that as well. ...

And the White House response?

Oh, the White House was livid, and, in fact, doth protest too much, in my opinion, because Karen Ignagni had been at the White House the week prior and had an hour-long session with [Director of the White House Office of Health Reform] Nancy-Ann DeParle and [Director of the National Economic Council] Larry Summers laying out all of these exact concerns regarding the strength of the individual mandate and what was going to happen to the insurance marketplace under these reforms, etc. ...

She'd been warning and signaling in public and private and other conversations that I'm aware of as well that it was unhappy with the shape of the Senate Finance Committee bill and that this looked to be it, because recall that the Senate Finance Committee was where all of the action was taking place. It was the best hope for a bill. It was to be the framework of anything moving forward. So if you didn't like what you saw in that Senate Finance Committee bill, this was potentially getting near the end of your opportunity to change the shape of things. ...

What happens? The White House, as you say, probably knowing that some version of this was coming, may, if you go back and you look at it and you read what they said, it's almost like they don't mind having an enemy with the insurance companies right at that moment, right when everybody's about to vote.

No. And in fact, throughout the summer, Obama, Speaker [of the House Nancy] Pelosi [D-Calif.], others in the White House, had periodically had some fairly strong, tough things to say about the insurance industry. Obama tried to calibrate his criticism because he knew there was still the opportunity of working with that industry. And the industry knew that it was going to have to take a few rhetorical blows along the way and was pretty much willing to do so. So everyone was kind of playing to script throughout the summer and sometimes holding their tongues when they heard or saw things that they didn't much like and appreciate.

But the concern in the White House always was, from beginning to end, whether or not the insurance industry or one of those other important industries could pick off just a few Democrats, because in the Senate, it was all about the magic 60 votes. You didn't have to turn 10 or 15 votes in the Senate. You didn't even have to turn public sentiment in this battle. The only thing you had to do was pick off one or two Senate Democrats. ...

[How did Obama respond to the report?]

President Obama and the White House and Democrats on Capitol Hill reacted swiftly and furiously to that AHIP leak on the Sunday before the Senate Finance Committee. They had learned the lessons, really, of going back to [former Mass. Gov. and presidential candidate] Mike Dukakis, where you cannot let critics or attacks lie unanswered. And so although they claimed to be surprised and upset by this, they very rapidly swung into action. They denounced it as an 11th-hour attack. They said there was no merit to the report. It was really the most ferocious, furious single response that I had seen out of the Obama administration throughout this entire debate.

And it left her where?

Some would argue that it left Karen somewhat marginalized, certainly in Washington. But there were still some -- Sen. [Joe] Lieberman [ID-Conn.] was one; Sen. [Susan] Collins [R-Maine] was another; [Democratic] Sen. [Ben] Nelson of Nebraska a third -- who still said there's merit to what the insurance industry is saying. And those were all critical swing votes. So Karen continued to have her supporters, her allies, people that wanted to hear the industry perspective and were listening to it very carefully. So while she may not have gotten the party invitation to the White House Christmas party, she still was very much a force throughout the fall in this. ...

Overall, what does this drama that's been playing out before us say about Obama's style of leadership?

I think on Christmas morning, everyone was sitting around thinking that he was an LBJ-like genius, because it appeared that he was on the verge of accomplishing what no president had for 70 years, and that he had done it by just kind of nudging along the process and focusing on some of those outside deals with industries. By mid-January, he was looking ineffective. He was looking as if he had not used his bully pulpit strongly enough to communicate to the public and keep the public pressure on this issue. And he was looking as if he couldn't control his own troops in Congress. ...

[Where was the public anger coming from?]

My impression is that a great deal of the public anger, as is often the case, has to do with pocketbook issues. We sometimes forget here in Washington -- we're a little bit insulated -- but out in the country, the unemployment situation, the home foreclosures, the difficulties with the banks have really taken a toll on people now for a long, long time. And then they look at Washington, and they see that not much is happening. And so I think the biggest frustration on the part of the public when it came to health care was that it took so long and nothing was happening. And when they did hear about things happening, it was usually sweetheart deals for one particular state or one particular senator or industry.

Let's talk about one in particular, the Nelson story in Nebraska. Why was that ["Cornhusker Kickback"] deal necessary? Describe what exactly took place and the blowback.

By Dec. 15, [Senate Majority Leader] Harry Reid [D-Nev.] had 59 votes for health care, and he needed 60. And despite all of the attention that was being lavished on Olympia Snowe, the Republican from Maine, it appeared that she was not going to be willing to do anything until at least February. That was the signal that she had given to the president, Harry Reid and others. So that really put Ben Nelson on the spot and in the spotlight. And he appeared to be their last best hope in the waning days of December. And that meant sitting down and hammering out a deal, really giving him almost what he wanted, anything he wanted.

So what did he get? Who made the offer?

There were several people involved in these talks that went on for days and days. Near the end of the negotiations, he actually had two of his top advisers from Nebraska who flew in. Sen. Chuck Schumer was very involved in those final negotiations. You also had from the White House both Jim Messina and [Senior Adviser to the President] Pete Rouse brought in largely because they came from that part of the country, as people would say, that they had a better feel for Nebraska and the politics, and even had some personal relationships with some of these guys from [their] previous campaign time together so that there was at least a certain simpatico in the room and that there was a recognition of the very difficult politics that Ben Nelson faced at home.

Interestingly, earlier in the fall, Chuck Schumer, a very liberal Democrat from New York, known more as an advocate for gun control, actually made a weekend trip to Nebraska and went hunting with Ben Nelson, and went to a big football game and spoke to business groups, etc. And Schumer was very influenced on that trip by just how anti-health care reform people in Nebraska seemed. It was very different than what he would hear when he traveled on the East Coast. And that left a real impression on him and on others back in Washington that Nelson needed to be able to go back and say that he had cut the best possible deal.

So what was the deal? What did he get?

You can go through all of it. The most important things for Sen. Nelson were some protections for nonprofit insurance companies, because there are some in Nebraska that he was worried about. There were, of course, final negotiations on language around abortion coverage and that no government money [would] be directed in any way toward plans that covered abortion.

And then finally, the element that really sort of set off the fury was that in Nebraska, any extension of Medicaid, any expansion, the new people that would be brought in would be covered entirely by the federal government. And that was a big deal, because in most states around the country, the cost of Medicaid is split, not evenly, but the states contribute some part, and the federal government contributes some part. And Nelson was able to secure a promise, indefinitely, forever, for Nebraska, that any of those new patients in Medicaid would be entirely paid for by the federal government.

... Were they blind to the possible fury that the blowback [from] this would create?

No, I don't think that they were blind to it, although interestingly, Harry Reid made a comment publicly to the effect of, "Well, every senator ought to be able to point to something in this bill that they got." And it's something of an old-fashioned way of thinking about legislating and deal making, and I think he intended it to say, "Each senator ought to be in there fighting for their home-state interests," but it just added to this perception that it was really just a bunch of horse trading. And it was no longer about improving health care in America, but it was just the same old-fashioned way of dealing behind closed doors in Washington. And I think it was that general sentiment that angered voters in Massachusetts, that angers other voters across the country, and even upset a fair number of lawmakers who were either upset because they didn't get theirs, or they were upset because they realized what a terrible image this was. ...

Editors' Note: The following part of the interview was conducted on March 24, after the House passed the health care bill.

To start, let's talk about after the Scott Brown [senatorial] election in Massachusetts.

As 2010 opened, early January, the White House and everyone else thinks that they are just steamrolling toward completion of this historic piece of legislation. And the president is essentially doing what his Democratic colleagues have been clamoring for all year, which was in the room, negotiating the final deals between the House and the Senate. By the Martin Luther King holiday weekend, they are sending the legislative language off to get cost estimates on it. They are just about high-fiving, even snapping pictures of themselves at the White House as memory keepers.

But about one week before the Jan. 19 special election in Massachusetts, it started to become clear to the White House that there was a very good chance they would lose that Senate seat, and of course the irony of it being Ted Kennedy's seat. He'd been in it for nearly 47 years. He, of course, had the grand vision of universal health care and impressed that upon Obama. And now that seat was about to go into Republican hands, and they'd lose their filibuster-proof majority in the Senate.

So Jan. 19, 6:30 p.m., about an hour and a half before the polls close in Massachusetts, Obama calls for Pelosi, Reid, [Vice President Joe] Biden and Rahm Emanuel to come to the Oval Office. He's just had a brief meeting with David Plouffe, the architect of his 2008 political victory, and brought him back on to sort of fix the problems in his political operation. Now he looks at Reid and Pelosi, and it's a quite tense scene. They all realize they're looking at a horrible defeat, and he says, "What are we going to do now?" Reid, of course, says what he had been saying for some time: "The Senate can't do anything with 59 votes now. The House has to pass the bill that the Senate approved on Christmas Eve."

Pelosi is annoyed and quite adamant that there's no way that she can sell that to her House members. The liberals can't stand the Senate bill, and, frankly, institutional jealousies, which had always existed between the two groups, were at an absolute high point by this point. She says: "No way. I can't sell that to my members. That's not going to work." They go back and forth. Obama actually at one point kind of tries to jump in and say, "You know, I haven't finished my point."

They talk some more, Pelosi again almost kind of lecturing the four men in the room at this point, saying: "You don't understand the realities in the House. This won't work." And Obama finally snaps, uncharacteristically for him, and he says: "I understand that, Nancy. What's your suggestion?" And there is no suggestion except that Reid and Pelosi and everyone agree, "Well, we've got to take a little time and figure this out."

And the mood of Obama at that point?

Obama at that point is frustrated. He is still a determined person. He remarked more than once in this time period to a few of his aides that he himself can be quite stubborn. But more than anything, he is exasperated that it's dragged on for this long. He wants to move on to other subjects, and it's becoming very clear to him and his top advisers that they need to somehow regain control of a process that has slipped through their fingers.

Rahm suggests a scaled-down version. Tell us the story of that, and Obama's reaction.

Rahm Emanuel periodically throughout the entire year would bring up the idea of, "Maybe we should do something smaller than this enormous $1 trillion complete overhaul of the nation's health care system." Rahm, of course, had served in the Clinton White House and was, in fact, the architect of some of the small-bore initiatives that had come out of the Clinton administration. He saw them using the sort of sports metaphors that are very common in the Obama administration. He would talk about putting a few points on the scoreboard was better than none.

And so again, after the Massachusetts debacle, really, Rahm again asked a small group of advisers, including his brother, [Special Health Adviser to the Director of the Office of Management and Budget] Zeke Emanuel, to draw up some scenarios -- so, much more modest health care bills -- as a fallback. He still was not forcefully arguing they had to go that way, but he wanted to be ready with that as his plan B. And once again, they were discussing that about 10 days after the Massachusetts election, that option.

And Obama's reaction to the plan, to the potential plan?

As far back as April 2009, in a very big, important meeting, the president had said: "I don't want to do the small approach. I want to go comprehensive because I think that's the way that you achieve what I'm trying to achieve."

But in a meeting on Jan. 29 -- this was about 5:45 p.m. in the Roosevelt Room with about 15 of his advisers -- again, they're thrashing through: "Where do things stand? How does it look up on the Hill?" Still looking pretty bleak, actually. Pelosi is still very pessimistic. Rahm says, "What about a smaller bill?" And this time, Obama actually considers it. And the main reason that he pauses and thinks about this much more modest approach than he ever wanted is because he knows that Nancy Pelosi is an excellent vote counter, and she has been telling him that she doesn't think she can get the votes for the Senate bill. And if that's the case, they're either left with nothing, or perhaps the smaller thing.

So Obama says [something] to the effect of: "Well, we may not be able to pull this off, but I want to try. We are so close. We got the House to vote for this; we got the Senate to vote for it. If it's even in any way possible, I want to give it a try."

Is there a point when Obama realizes, or talks about it, that they had given Congress too much rope, too much control, which had led toward the process being the focus?

I think over the course of many months, there were people in the White House who got quite frustrated with how slowly Congress moved. We know that Rahm Emanuel periodically, Jim Messina and [White House Director of Communications] Dan Pfeiffer, some of the time, would get very frustrated. There was enormous frustration that Sen. Baucus had spent the entire summer with the "Gang of Six." That just dragged out for so long. There was some level of frustration that Harry Reid spent so much time, October, November, December, getting a bill through the Senate.

On the other hand, Obama had spent a little time in the Senate, not a long time, but enough to have a little bit more of a feel for the place and to understand that they kind of need to work through their processes. And Obama is patient; we saw that in his presidential campaign, and we saw it again, most of the time, through the health care debate that he is patient. And he was generally saying, "That's OK. Let the process unfold," also in part because he was hoping that would bring him some level of bipartisanship, which he really desperately wanted.

So for much of the time, the president might have shared a little bit of the frustration about Congress and the time, but not to the extent that he was really willing to step in and assert himself in some big, powerful way. It wasn't until Massachusetts and he saw that it was very possible he would get nothing out of this yearlong quest that he really made the decision to assert himself in a much more powerful way.

[What were the lessons of the Massachusetts Senate election?]

Obama became very stung by the criticism that he had not kept his campaign promise to air the health care debate on C-SPAN. He really thought of himself as different from so many other Washington polls, and that promise came to symbolize what was supposed to be his "differentness." And I remember one White House adviser saying that Obama came to conclude that so many of the deals that transpired on Capitol Hill in the closed-door meetings were "un-Obamaish," was the phrase that they sometimes used in the White House. And so part of the appeal of holding that bipartisan summit at Blair House for President Obama was a way to get back to what he thought was more of his image and reputation as "Let's all let it hang out in the public and let everybody see everything." He liked that idea very much.

He also saw in the summit in a way, in an almost academic kind of approach, because he is so professorial, to lay out in excruciating detail over seven-plus hours how the Republican proposals on health care stacked up against the Democratic proposals. He was probably more eager and more into those seven-plus hours than almost anybody else in the room or on any staff.

And you asked me about lessons learned and reinvention. I think in the White House, they would not say that Obama reinvented himself, but there was very much in mid-January a recalibration. It was re-centering their operation. They realized that their political operation and their message and communications operation had come way off the tracks, and they needed to quickly right that operation. And then they needed to figure out ways that they could put the president back in command, show to the public that he was in charge, that it was no longer sausage making, it was no longer wheeling and dealing; it was out in the open, and he was going to lead this final push.

So what did they do?

They began with the summit. That was their first effort to, as some in the White House would say, take the acid out of the air around health care, in particular the deals with Ben Nelson, the deals with [Sen.] Mary Landrieu [D-La.] that had gotten the nicknames like "Cornhusker Kickback."

The summit also bought them, and in particular Nancy Pelosi, time. After the Massachusetts election, there was this constant drumbeat in Washington of: "What are you going to do? How are you going to rescue health care?" And the White House in particular needed to get a little bit of breathing room from that terrible period of anxiety and panic that was occurring in the Democratic ranks and right the course of action.

And so the summit gave everyone -- it was almost a little bit of a sleight of hand. "Look over here at the summit. Here's the show that we're putting on at Blair House. Don't look over there, where we're quietly trying to get the votes in the House to pass something."

Explain what Dan Pfeiffer states and how it came to that.

The evening meeting on Jan. 29 in the Roosevelt Room -- this is two days after State of the Union -- the White House is feeling a little bit better, because at least with State of the Union they felt they were regaining the upper hand in terms of communicating with the public. In the session, Obama, sitting in his chair at the center of that table, first called for a briefing on what was happening on the Hill. Still pretty bleak.

Then Dan Pfeiffer, the communications director, talked about how were we speaking to the public about health care and what [are we] going to do. And Pfeiffer was very explicit. He said that fair or unfair, the perception had become that Obama was keeping his distance from the health care debate. They needed to change that perception -- or, the White House would say, misperception -- and show that Obama was back in charge, that he was leading the way; that it was going to be an open process and that they were going to get rid of a lot of the deals that were so unpopular.

So what is the president's response to this?

This did not come as a big surprise to the president, because every morning in the senior advisers' meeting with the president, they had been talking since Jan. 20 about the idea of a summit, about the idea of projecting that President Obama was, in fact, the person in charge.

But in the 29th meeting with 15 people there, the president in his seat in the Roosevelt Room, this was a chance for everyone on the larger team in the White House to understand now what the plan was going to be, what the talking points would be, how they were going to move forward.

Congress, you talk about, is pretty pissed that there's no plan. There's some back-and-forth on that. But privately it seems that there was a plan that was being worked on, that the House would pass the Senate bill and then do the reconciliation bill. What's the background to that? …

Rahm Emanuel and Jim Messina in particular understand the Hill. They quickly sized up that there were not very many procedural options before them. They knew that there was really only one legislative path to take, and that was for the House to pass the Senate bill and then for both chambers to approve this package of cuts. It was going to be difficult to sell to the House members politically because they were going to have to go first and vote for something that they didn't like. So even though inside the White House they settled on this strategy very quickly, it took them a long period of time to sell it to the members of Congress.

And they did it. Some of the time they did it gently, and other times they did it in very heated, tense exchanges of: "This is what you have to do." "No, I can't do it that way."

So there was sort of a joke in Washington during that period about so many people going through the Elisabeth Kübler-Ross stages of grief, and you'd bump into people who would say, "Well, I'm at denial now." And it really did sort of capture what was happening up on the Hill, and especially for Democrats in Congress. So it was not so much that it was a secret plan so much as it was the only logical way forward, but it took a long time for everyone to accept and to pursue it.

And when did they decide that this was the direction they would have to go? How early was that, does it seem?

Jan. 20 in the White House, they were already quickly reaching that conclusion, the few people: Rahm Emanuel, Jim Messina. But in Congress, Nancy Pelosi, her staff, many of her chairmen, her members, they didn't come around to that idea until well after the summit on Feb. 25.

It was the summit that reassured them that a, President Obama was indeed going to stick with them this time and really be out front and be prominent; and that b, they thought they saw some political openings against the Republicans sort of in making their case for health care.

So even though the summit accomplished nothing substantively, accomplished absolutely nothing from a legislative standpoint, it was a very important psychological boost for those Democrats in Congress.

… What are the changes that showed in this new presidency that they had decided they had to become?

The 61-day period from Jan. 19, the Massachusetts special election, to when the House passed the Senate bill and health care became a new law in this country, was really obviously the final, critical turning point. And over that 61-day period, you saw President Obama and his White House team transform themselves and, in a way, transform the process.

They went from a rather hands-off, leave-it-to-Congress approach to one in which, again, President Obama was front and center; he was the chief salesman out around the country, sleeves rolled up at rallies, revving up the troops. He was in the late-night meetings at the White House working out the deals. And then in the final stretch, he was courting those lawmakers one on one. He was cornering them at receptions at the White House where they were nibbling on hors d'oeuvres and sipping cocktails. He was telephoning them on his cell phone, on his office phone. He brought [Rep.] Dennis Kucinich [D-Ohio] up onto Air Force One for a ride to Ohio where they had a big, long heart-to-heart.

He used every traditional tool afforded a president to, in the end, achieve a very difficult piece of legislation that no other president in 60 years of trying had been able to accomplish.

What were the risks that they realized were out there, and why did they go forward?

There was danger all around at this point for Obama. I mean, they had just suffered the embarrassing defeat in Massachusetts on his watch. Now his signature domestic policy initiative, after a year, was in serious jeopardy. And really, almost everything else on his agenda had been put on hold in the hopes that health care would be first.

So he was looking at a big nothing after his first year, even possibly two years, in office. They were already bracing for losses in the November midterm elections.

But the real bind for this White House was they saw risks in moving forward and not moving forward. They thought to themselves: "Well, if we drop health care and go on to some other things, some people might be happy, because they'd like us to focus on jobs and the economy and other important issues, and maybe we could get some of those accomplished. But if we drop health care, a lot of people are going to say, 'You spent a whole year on something and you couldn't pull it off'; in essence, 'You can't govern.'" So that was an unattractive option for them.

But to go forward and pursue health care, which seemed to be getting less and less popular in the polls the longer that it dragged out, was certainly a risk as well. Massachusetts was interpreted, rightly or wrongly, as something of a referendum on the health care legislation and the health care debate. The White House, especially people like [senior adviser] David Axelrod, didn't really subscribe to that theory, but that notion was out there in the public arena. So they were sensitive to that, and they were sensitive that many lawmakers, especially in tough races, felt that perhaps another health care vote was going to cause them trouble in their races.

So it really was a difficult proposition moving in either direction. In the end, I think what they concluded was that President Clinton was not able to get his health care overhaul through, and there was a perception then that he was weakened, that he was not as capable. And they didn't think that they wanted to have Barack Obama cast in that same light.

The summit meeting: What were their expectations, and how did the president present himself?

… In some respects that Feb. 25 summit at Blair House was not completely well scripted. The White House threw it together pretty quickly. Even the few days beforehand, they hadn't figured out how they were going to handle invitations and what was going to be the shape of the table. There was actually quite a bit of anxiety and stress in the White House in those staff meetings, because they realized they were throwing this thing together on the fly, and it's not the way that the Obama team in particular likes to operate.

And what you saw in that summit was Obama being Obama. He knew more about the subject than probably anybody else in the room at that point, and he wanted to display that and show it. And you saw him unable, really, to not answer any Republican comment or charge or question that he felt he had an answer to. So he ended up dominating the session. Obama was the last person to leave that room, again in part because I think from the very beginning of this debate, he always felt that he had the power. If he just had the time, if he just had the opportunity, he could sell his ideas to just about anyone.

And so, even when the rest of them were exhausted and running for the doors, he was still grabbing lawmakers as they were putting on their coat: "One other little idea I wanted to mention to you," and, "What if we did this?," and, "Thanks for coming, and I'll call you tomorrow," because he was so convinced that he could still turn it around.

The dichotomy of this president, the pragmatic versus the idealistic organizer of the past -- or some would say an ideologue -- what does this whole process say about what Obama is or is not?

Throughout the health care debate, we saw Obama the pragmatist very early on. He dropped his opposition to an individual mandate, a requirement that every American get health insurance. Throughout the year, he wavered and sent mixed signals on a public option. So from the very beginning we saw a certain level of pragmatism. On the other hand, he had some idealism when it came to "I want the whole big, comprehensive approach."

When it finally got into the last two months of this campaign, Obama became increasingly pragmatic and practical. Some would even suggest he became much more of a traditional, old-fashioned Washington politician, almost in the same sense of a Lyndon Johnson. When you think about those final two weeks where he worked over something like 64 different members of Congress, usually one on one, sometimes in small groups, and he tried every argument available, and it was about one thing and one thing only -- and it was getting the votes. …

How big a turning point was getting Kucinich's vote?

Kucinich turning from no to yes was very important, not so much for the tally, because it's only one vote, but it came at just the right moment for the White House and for Nancy Pelosi to capitalize on that. It gave something of a liberal imprimatur to the bill for some others that were uncertain.

It also gave, in the words of Dan Pfeiffer, some momentum that they really needed. There is a certain rhythm of things on Capitol Hill and in Washington, and you can feel it. And you began to feel after that Kucinich announcement that things were breaking their way. And once that occurs, you see more people wanting to get onboard with what looks to be a winning operation. And then you saw boom, boom, boom, the announcements started coming in. Another yes vote here, another switch. [Democratic Rep. Suzanne] Kosmas from Florida: no to yes. [Rep.] Bart Gordon [D-Tenn.]: no to yes. Not every single one went their way, but it gave that energy to the final push.

The vote goes down; the president is surrounded by his chief aides, all watching it in the Roosevelt Room. Explain what that was like, what was going on.

In reality, by the time they got to Sunday evening, they were pretty confident that they had the votes. I was at the White House two days before the vote, and several of the president's top advisers were watching the NCAA basketball tournaments in their offices, and that was the first indication to me that they were starting to relax, at least just a little bit. There were still the last-minute hurdles around abortion and working out a solution that involved the president signing an executive order, so there were, of course, those last hiccups along the way. There was also the mysterious disappearance of Congresswoman [Loretta] Sánchez [D-Calif.], who was down in Florida fund-raising, and they had to quickly make sure she got back up in time for the vote.

But really, Sunday afternoon they had a pretty good sense that this was going to work. The president Sunday morning popped into a senior advisers' group meeting in Rahm Emanuel's office, and he came in and said to them, "Big day if we win." And Dan Pfeiffer kind of said, "Well, you know, big day either way, Mr. President." And Obama sort of said, "Yeah, but let's win." So they were all feeling fairly relaxed. There were people -- Nancy-Ann DeParle went for a run that day. You saw others just kind of catching their breath a little bit.

By nighttime, they were gathered in the Roosevelt Room. They, of course, were hoping that it would happen by, say, 8:00 or 9:00 at night because they knew they wanted the president to go out and make a statement for the cameras. But Congress being Congress, it of course dragged right on up to 11:00 at night, a little bit later than they'd hoped. The president was in shirtsleeves watching in the Roosevelt Room. All of his top advisers, Vice President Biden was there. There were some high fives, just, I think, almost more relief at that point after this whole saga. He went, did the statement for the cameras.

And then there was a little, smaller, private celebration on the Truman Balcony. There was some champagne and some toasting, and some of these top aides who had been with him since the early days of the campaign reflecting back on really three years earlier and how far Obama had come, because he was not a candidate who really was the health care candidate. And he was not an expert on this issue. And truly, he didn't have a particular passion about health care or a record on health care. And suddenly he had become the person who accomplished in health care what so many others couldn't.

It had taken a lot longer than expected. It had been deemed a failure many times over. The bipartisanship route had failed. But in the end, how did the administration view this victory?

In the White House they say a win is a win is a win, and there is certainly something to that. And this is, for them, a big win. On the other hand, it came at a high price. It came at the price of time, the entire first year basically dedicated to this; not being able to start anything else on his agenda until almost April, postponing overseas trips, being somewhat tarnished by the legislative process, having their hopes for bipartisanship dashed. So it was a difficult process that took a toll.

And the White House still is not certain how this will sell in the country. The president will be out there on the road campaigning for candidates, doing his best to spotlight what they see is the attractive pieces of this law. But it is going to change one-sixth of the U.S. economy. There's a lot of uncertainty, doubts, criticism about it. And really, you know, it's the cliche, but it will take a long time to assess if this win will really have paid off for them.

But it's a battle they've already jumped in full force on?

Yes, they definitely have. They made the decision and made the promise to a lot of lawmakers that he would visibly be out there selling this. Now, the White House is eager to talk about some other subjects, so this will not be the only topic that we hear from Barack Obama in the coming months and leading into the election. They'll be eagerly looking for something else to talk about.

What does it say about what it takes to be a successful president watching these many months of this whole thing?

I suppose after this, to be a successful president requires some magical blend of patience, toughness, savvy, inside operating skills, but also great communication to the public. It really did require every set of skills.

And he became that?

He largely became that in the closing months.