Interview: Dan Pfeiffer

He is the White House communications director. This edited transcript is drawn from two interviews, conducted on March 11 and March 24, 2010.

We start the film with the March 5 summit meeting [at the White House]. What's the reason for it? Was the administration a bit over-optimistic about the possibilities? ...

I think there are several things. The first is this was a campaign promise. The president, all throughout the primaries and general election, talked about getting everyone around the table and having a discussion and having it be open to the press. He often said C-SPAN would be in the room filming. This was the first iteration of that. He wanted not just supporters of health reform but traditional opponents as well -- the pharmaceutical industry, the insurance industry, doctors, nurses, Republican members of Congress, Democrats, labor unions. Everyone who's been a participant in the effort to either pass or derail health reform over the decades, he wanted at the table. That was one.

Two, I think it's very important to understand the president's approach to bipartisanship, which is he is less concerned about the number of votes for something as opposed to a process to get the best ideas for both parties into the legislation. And this was the first step in that.

[President and CEO of America's Health Insurance Plans (AHIP)] Karen Ignagni stands up and throws her support. Was that surprising?

I think yes, it was surprising, and hopeful. We were skeptical. We had people in the White House like [Chief of Staff] Rahm Emanuel who were very involved in the first effort to pass health reform who remembered the sort of deceptive campaign the insurers ran to sink the Clinton plan. And so this was a trust-but-verify moment for us.

Sen. [Ted] Kennedy [D-Mass.] is there, of course. Talk to me a little bit about the importance of Sen. Kennedy to health care reform and the role he played in influencing Obama.

Sen. Kennedy has been the primary person driving health reform over decades. There's been a period between the Clinton plan and the Obama plan where people decided that health reform was too hard, they weren't going to take it up. The one voice who was out there every day saying, "We have to do this. It's the right thing to do [for] the country; it's the right thing to do for the Democratic Party," was Sen. Kennedy.

And from the moment Sen. Kennedy endorsed the president during the primaries, he was always in his ear telling him that this is what you've got to do. And one of the reasons why he endorsed the president was he thought that he was the only one who could actually bring health reform into law, because traditional politics weren't going to get it done. You're going to have to do it in a different way. You're going to need a transformative figure, and he thought that Sen. Obama, then-Sen. Obama, was that figure.

... What were some of the thoughts behind the idea of Rahm as chief of staff?

I think it's important to understand that the president and Rahm have a relationship that goes back to Chicago. They've known each other. Rahm is one of the smartest guys in this town. He understands both ends of Pennsylvania Ave., which as we knew would be critically important to getting the president's agenda done. Those of us who were on the campaign with him from the very beginning have little to no White House experience. Rahm spent about seven years in the White House and then a number of years in Congress, so he understood the process. He is a force of nature, and he could help drive the agenda and help get things done in a way that no one else could. I think there's no question the president viewed, and everyone in the president's staff agreed, that Rahm was the perfect person for this role.

Early on in the administration, there was widely reported debate over, do we push health care forward first? The economic team, the vice president and others ... are pushing for the fact that the economy has to be dealt with first. Some wins have to be put into the win column before we go after the big health care. Certainly, [former] Sen. [Tom] Daschle [D-S.D.], certainly Sen. Kennedy are on the other side saying it's important. Give us a little bit of the back-and-forth on how that debate came forward, how it was resolved and how the president made the final decisions to go forward.

The debate's been a little mischaracterized in the press. It wasn't economy versus health care. The thing we all agreed upon when we first came in were the first two things we had to do was one, deal with the financial crisis that had put the economy on the precipice of the next Great Depression. That was dealing with solving the problems on Wall Street and the auto companies. The second thing was stemming job loss, which was the Recovery Act. ...

The next step in the economic plan was to build the foundation for the future. In order to build a strong foundation for the future, you had several things you had to do. You had to deal with health care. You had to create a clean energy economy with jobs in the future. We had to reform our education system so we were no longer lagging in the world and could compete with India and China. And we needed to deal with reforming our institutions -- financial regulatory reform, political reforms, the special interests weren't blocking progress, finding a way to make sure that there were rules of the road on Wall Street, those sorts of things.

So the question really was, was health care going to be next? And so that was the debate. Was it going to be health care? Was it going to be energy? And Rahm was for doing health care; "Ax" [Senior Adviser to the President David Axelrod] was for doing health care; the president was for doing health care. It was a question of when. ...

And the president was very clear that our first year was our best chance to get it done, because you're not going to get it done in an election year. As soon as the election year is over, we're heading into a Republican presidential primary and a presidential campaign. And then you're a second-term president. In the history of doing huge legislation, the second term is pretty skimpy. So that was how the decision was made.

The president felt that this was, to him -- we were sitting in the Oval Office, and we were sort of having a debate around health care at one point, and the president said: "This isn't about my presidency. It's not about how we're going to do in 2010. It's about health care, but it's not really about health care. It's also about proving whether we can still solve big problems in this country." And this was going to be the test case for that. ...

... There's a debate again after the [senatorial] election in Massachusetts where Rahm is sort of saying, "Hey, maybe we go smaller." ... How was it resolved, and what was the debate? ...

The debate was not about what the best thing to do was. Everyone agreed -- the president, Rahm, the Cabinet -- that the best thing we could do would be to pass a bill like the House bill or the Senate bill. There was a comprehensive piece of health care legislation, because health care is a Rubik's cube. You have to do all the pieces to really solve the problem. If we were to pass a smaller bill, that would be good. It would improve some people's lives, but it wouldn't solve the problem. It wouldn't take us off the path we're on, which is basically essentially headed for a fiscal cliff because of health reform.

And so it was entirely a conversation of feasibility. Are there the 218 votes in the House? Can you get enough votes in the Senate to get it through? And so that was the debate.

And there was an ongoing debate within the White House and with the House and Senate about what could be done. Option A: Pass the comprehensive bill. Option B: Smaller bill. And option C, which no one would entertain, would be to do nothing. We thought that would be a tragedy for the country and a political disaster for the Democrats.

And Rahm's advice?

Rahm worked very hard ... to preserve option A, [and] if option A wasn't there, that we'd be ready to do option B. This is one of these great myths of Washington, that he was pushing for something other than what his job was to do -- give the president the best advice he could, and then help him to implement the choice he made.

What was the damage done by the loss of Sen. Daschle [as nominee for secretary of health and human services]? ...

It was a challenge. There's a lot of work you have to do before you ever fire the starting gun on a health reform bill -- doing the scut work with members of Congress, talking to your allies -- to figure out the best plan. We thought we'd have Tom Daschle at HHS and then running the health reform project from the White House on day one, and we didn't have that, and so it took a little time.

Now, we were very fortunate that one of the heroes of this whole process and one of the most talented people I've ever worked with, [Director of the White House Office of Health Reform] Nancy-Ann DeParle, agreed to come in from the private sector and work for us. But Tom Daschle is one of the smartest guys in Washington. He understands the politics of this; he has deep relationships in the Senate that would have worked for us. He understands the policy. There was no other Tom Daschle for this job, which is why instead of having one person as the HHS secretary and health reform director, we now have two. …

Another big point that everybody talks about is the president made the decision to pursue this through Congress, to learn the lessons of the Clinton administration, allowed Congress basically to take the reins. Once you had lost Daschle and Kennedy, really, were there second thoughts about maybe that might not be the best way to go?

The great lesson that everyone shared, both folks like Rahm who were there, and historians who have looked at the '93-94 health care fight, is that handing over to the Congress a telephone book-sized piece of legislation wouldn't work. You need congressional buy-in on the front end. And in every scenario that we ever discussed, we would lay out a general set of principles and work with Congress to implement those principles.

The "Gang of Six," of course, becomes very involved in debating the issues and trying to push forward the direction it was going. ... Just give me some of the thinking about those negotiations. ...

At the beginning of the Gang of Six process, there was hope for a bipartisan process, that Sen. [Chuck] Grassley [R-Iowa] or Sen. [Mike] Enzi [R-Wyo.] would become involved and work with Sen. [Max] Baucus [D-Mont.] to pass the bill. But every day, that hope diminished, and it became clear that there was no bill which Sen. Grassley would support. Basically, the sort of demands that were coming out of that was we need an ironclad guarantee that what we mark up out of the [Senate] Finance Committee is the final bill, and that's the one the president signs on his desk. That's not realistic. He says he can only go forward if he can get 10 other Republicans. No one with any great imagination could come up with a list of 10 other Republicans who would come onboard with him. You had the Senate leadership in Mitch McConnell [R-Ky.] and Jon Kyl [R-Ariz.] saying, "Don't get involved." You have Jim DeMint [R-S.C.] at the time saying: "This is going to be the president's Waterloo. It's our way to win back the Congress." It was very clear.

Now, another thing driving the process of concern for us is that with every passing day, health reform gets harder. You have to build an intricate coalition of groups, regional interests, policies, everything that all comes together, and it's a very hard coalition to maintain because there's tremendous overlapping interests and equities. And every day the Gang of Six process went on, the process got longer. And so there was frustration in the White House and hope that it would come to a conclusion soon.

Why was Grassley lost?

I can't speak for Sen. Grassley. This was at the same time the Tea Party is emerging as a force in Republican politics. He's staring down the barrel of a primary in his election and real fear that he could lose the nomination fight if he is seen helping a Democratic president work on health reform.

... When does it become apparent in the Oval Office that the GOP is just not going to allow this victory to take place?

Over the course of the summer, sort of last summer, [we're] pushing and pushing and pushing to get at least the Finance Committee to mark up by the beginning of August. The president had a meeting with Sen. Grassley, and he basically says to him, "Chuck, is there any bill you'll support?" And the answer is basically, "Yes, if I get 10 Republicans," which he's not going to get. And at that point, it became very clear that a, this wasn't going to get done by August, and b, it was going to move primarily on a partisan basis, the one hope being Sen. [Olympia] Snowe [R-Maine].

Let's talk about the PhRMA [Pharmaceutical Research and Manufacturers of America] deal a little bit. Lots written about it, lot of different points of view. Some people say it's a sweetheart deal that was necessary. Was it necessary, and how was it viewed by Obama and folks close to him as something that needed to be done?

I think it's important to put it in the context of the overall process in health reform. We did the summit in March with all the interest groups and members of Congress. A few weeks later the president had a meeting with providers, pharmaceutical industry, doctors, hospitals, medical device manufacturers, to talk about health reform and the need for it. And there was a general consensus that at some point we're going to need to fix this, because everyone knows where it's going. And he got a commitment from all these industries. ...

And everyone -- the insurers, the pharmaceutical industry -- everyone said that they agreed we need health reform, and they agreed that they'd take a haircut. And you realize that if they were more efficient, they could find trillions of dollars of savings within the system to help pay for health reform.

And so coming out of that meeting, we began meeting with all these groups -- AMA [American Medical Association], pharmaceutical industry, insurers, hospitals -- to see if they would come to the table and be part of it. It's not a sweetheart deal; it's to get everyone in the tent working together to pass health reform. So that's what that was. That's how we came to that case.

It's the exact promise the president made during the campaign. He said every single time: "We're going to get a big table. Around that table is going to be Republicans, Democrats, doctors, labor unions, the pharmaceutical industry." And he said: "I'll even invite the drug companies and the insurers. They can have a seat at the table; they just can't buy all the seats." ...

Was there a sensitivity, though, as far as the president was concerned? He even had an advertisement sort of denigrating dealing with special interests. This was something that was very close to a lot of the folks in the base. How did the president feel about the deal?

I think there was an understanding of the importance of working with all of the groups. Obviously we had some very big disagreements with the drug companies on a lot of things. We have disagreements with then-Congressman [and now president and CEO of PhRMA Billy] Tauzin [R-La.] over the Medicare bill and other things he had done. However, if they agreed with us that reform needed to be done and they were willing to help contribute to make that happen in terms of finding savings, to help fill in the "doughnut hole" for seniors, which is something Democrats have been trying to do ever since the Medicare bill passed seven years ago, and so they brought stuff to the table and were willing to work with us. And the president said that having people at the table is better than having them throw stuff at the table.

But not an easy thing to do?

No, certainly not. Certainly not. And went in with full eyes open that there are going to be people in our party who would be critical of that. ...

And as far as AHIP and Ignagni, the report [PDF], when they released the report, how did the White House view that? Did that just feel like a double cross or what?

Absolute dishonest double cross. They had never been at the table, but they'd been hovering around the table. They were in this place of not supporting health reform but not opposing it, either. But they did say if they were going to change their position that they would let us know.

And then I'm sitting at home on a Sunday evening, and I get a phone call from Ceci Connolly, the Washington Post health care reporter, saying that they've released this report that completely attacks our health reform efforts. And our policy experts at HHS and the White House looked at it and realized in six seconds that it was completely bogus. And so it wasn't just they didn't give us a heads-up, which was traumatic, but also it was a completely shoddy piece of work. It was sort of dirty. ...

The summer town hall meetings, surprise in the Oval Office, West Wing -- why'd you miss it?

I think we were surprised by the media obsession with it. I think we were surprised at the tactical success of some of the organizers at generating press coverage for their town halls. There was very real anger that's fueled by economic insecurity; it's fueled by frustration with the situation in the country, fear of the unknown with health reform that fueled those protests. Now, there were thousands of town halls held that summer that did not include raucous demonstrations, which suggest that the anger was real; it just wasn't as widespread as the media would lead you to suggest.

But it most definitely spooked Congress very quickly, and there was real discussion about whether we could move forward after the August recess. And the president was very clear that he was not going to let this derail health reform.

We interviewed Grassley yesterday, and he said the following: "It was the first time that I had what I would say is very violent feelings against health care reform we were working on. ... I had people come up to me at town meetings with sheaves of paper off the Internet quoting from the bill. I've never had that happen. People were up on it and didn't like what they were reading." ... What's your take on that?

I think the experience he had is one that a number of members of Congress had. There are two things related to Sen. Grassley. I think one, his reaction to the town halls, where he is someone who has been a supporter of the idea of health reform and argued for a lot of the things that the folks at the town hall were criticizing, the mandate and things like that, instead of standing up and speaking out for what he had done in the past, Sen. Grassley decided simply to ride the wave, where he accused the White House of being willing to "pull the plug on Granny," which was a quote he used, which, if there was a moment when any last hope of the "Gang of Six" producing a bipartisan process, it was that moment, when he echoed [Republican vice presidential candidate and former governor of Alaska] Sarah Palin on something everyone knew to be false.

There are some really good senators in the Republican Party who have been part of bipartisan efforts to deal with health care issues in the past -- Sen. Grassley, Sen. [Orrin] Hatch [R-Utah], Sen. Snowe, and a number of others. And with the exception of Sen. Snowe, instead of standing up to do what was right here, standing up to the anger and helping correct the lies and misperceptions, they decided to jump in the pool with everyone else. And that was a disappointing moment for those of us who had hoped to have bipartisan support for health reform.

... The moment of the speech before Congress, the "You lie" moment, what did that say about the state of the bipartisan possibilities at that point?

By the time that the president was standing before the Congress giving that speech, the target list of possible Republicans supporting us was one: Sen. Snowe. She was the only one who had expressed a willingness to be a constructive part of the process.

And so, what Rep. Joe Wilson [R-S.C.] did spoke more to the absolute breakdown in decorum in the Congress, in cooperation. It also, I think, was a manifestation of the challenges we face in trying to do something serious with an opposition party that decided to be incredibly unserious in their approach to governing the country.

The Scott Brown election seemed to come out of left field. When did the White House start to worry about it? Why was the president sent? What was the message being sent?

About two weeks before the election, in our morning senior staff meeting, our political staff reported to Rahm and gave Axelrod and others [information] that the polls were tightening very quickly in Massachusetts. That was the first warning flare that had gone up. We had been talking to the [state Attorney General Martha] Coakley campaign, the DSCC [Democratic Senatorial Campaign Committee], others, and hadn't heard any alarm. It was Ted Kennedy's seat; how could we possibly not win it? And that was the first moment when we had great concern.

And every day going forward, it became more and more clear that Martha Coakley was in serious trouble in that race. Scott Brown was the better candidate; he had more enthusiasm. Some serious tactical errors had been made by the Coakley campaign that compounded the challenge. And we began to think in our head what the possible scenario would be if we lost that seat.

One of the things that Brown focused on a lot was the "Cornhusker [Kickback]" deal with [Sen. Ben] Nelson [D-Neb.]. Did the White House understand the strength of that argument, and how was the deal itself viewed?

We certainly understand the strength of the argument now. There was such intense pressure to get this bill done and then move it as quickly as we possibly could that we ended up having a process that represented a lot of what the American people hated about Washington. It ended up being behind closed doors. It was filled with a lot of partisan wrangling, people yelling at each other across the table, and the sort of special deals like the Nebraska deal that really sullied -- the process we went through sullied the substance.

And that one had a viral effect. It's not often that a huge majority of the country would hear about a special Medicaid provision in a 2,000-page health care bill, but this one had great impact. It had impact not just in Massachusetts and around the country but in Nebraska as well. Even that deal for Nebraska, it generated great problems.

So the deal itself, how did the president view the necessity for a deal like that to be done by Congress? ...

... There was this tension between the need to get something done and through the system and a desire to change the system. And that tension ran right into each other at the very end, where you had one singular senator who had the potential to stop health reform, who made demands that were acquiesced to, that ended up coloring the whole process.

The president is a reformer by nature. He feels very strongly about how our politics is broken and we have to change Washington. He also understands the need to pass this bill, what it would do in terms of lowering premiums for families, giving health care coverage to 30 million Americans who will not otherwise get it. And this is the only shot. He believes very strongly that if he fails here, the next time we take on health reform will be when the system just breaks and we have no choice. If Bill Clinton can't do it and Barack Obama can't do it, no one's going to go down this path again.

But the way it was done, this is so much the question that seems to be out there. President Obama was seen as Mr. Outsider. ... Critics on both sides are now saying that ... what he's had to do has been swallowed up by the Washington establishment that he was supposed to change. How does one define why that happened?

I think there are several issues here. First, the urgency to get this done and working through the current legislative process was challenging. The process is messy. The metaphor of sausage making is very appropriate, and it took a long time, and so it turned people off.

If there were lessons to be learned in how 2009 went in passing health reform, the White House learned them in 2010. You saw the first thing he did when he took control of the process after Massachusetts was get rid of the Nebraska deal, get rid of the deal that advantaged some states like New York and Florida on Medicare advantage, to do the entire summit with the Republicans on C-SPAN so everyone can see it. ...

[Some say] that what this whole process has shown -- and the partisan nature of it -- is that the bottom line is not only on health care, but in general, Washington is broken. What's the truth here?

Health reform is, in some ways, a microcosm to everything that's right about Washington and everything that's wrong about it. The part that's right is we are taking on a very big issue. We have reached across the aisle; we have extended our hand. We have brought everyone to the table. We have done it in an open and transparent fashion.

What's wrong about Washington is that millions of dollars are being spent on lobbyists to try to eat away at the effectiveness of the bill, to put in loopholes and special deals, to defeat the legislation; the fact that our politics are so broken that there is not a single member of the other party who is willing to help the president achieve this goal, and that's not because they disagree with it.

The bill the president has put forward is incredibly similar to the one the Republicans put forward as the alternative to Bill Clinton in 1993-94. It is based on the bill that [former] Sens. Daschle, [Howard] Baker [R-Tenn.] and [Bob] Dole [R-Kan.] put together at the beginning of the process from the bipartisan policy center.

What this is about is partisanship and special interests who have held even the most responsible Republican senators and members of Congress hostage to working in a bipartisan fashion. They know if they help Obama, they're going to get a primary challenge from the Tea Party candidate. They know they're not going to get donations from the insurance industry and other special interests.

And so that is the challenge. We've been dealt an incredibly difficult hand, the willingness to take on a big problem with no partner on the other side. ...

Christmas last year, so close. Explain what was felt at that point, how it seemed that it was so close that this thing would be done.

We thought it was basically done. We thought that getting the 60 votes in the Senate for the Senate bill was the hardest part of the process, and then we would just have a conference, work through it, and pass the bill before the president gave the State of the Union at the end of January.

We had basically begun to move on to other issues. There were still people working on health reform, but it was time to move on to jobs and the other parts of the president's agenda. And that's why the loss in Massachusetts was like a thunderclap. We went from basically beginning to plan how and when the president would sign the bill to if we could even resuscitate the bill in seven days.

Mid-September, there seems to be the new strategy, which is walking away from bipartisanship. Why was this, and was this a strategy, or was this necessity?

This was not a strategy; it was a reflection of reality in that the key -- and the president said this at the beginning of the process before he even took on health reform, and this was a lesson he learned from the stimulus, which is he cannot control whether Mitch McConnell and [Rep.] John Boehner [R-Ohio] are going to let their members vote for his legislation. That should not be the test of bipartisanship.

The test of bipartisanship should be whether we get the best ideas from both parties, and we give the Republicans a seat at the table. How they choose to use that seat is up to them. Whether they get the seat or not, that's up to us. And we think that's what the American people think of as bipartisanship. They don't think about whether it's 58 votes, 55 Democrats, three Republicans, that that's bipartisanship. It's the process, and it's the final product.

But it became clear that the Gang of Six process was not going to produce anything. There was not going to be very many Republicans in the House who were going to step forward. We were going to plow ahead; we were going to make it clear to the American people we had accepted their ideas and let them defend their motivation for opposing health reform, despite us embracing some of their ideas.

Editors' Note: The so-called "Gang of Six" were: Democratic Sens. Max Baucus (Mont.), Jeff Bingaman (N.M.) and Kent Conrad (N.D.); and GOP Sens. Charles Grassley (Iowa), Mike Enzi (Wyo.) and Olympia Snowe (Maine)

Grassley told us yesterday: "So Sept. 15 comes, and I think they just decide, 'We're going to go the partisan direction.' I think they thought they needed to get it done before there was too much change in public opinion."

We came to the conclusion that Sen. Grassley and the Republicans were going to kick the can down the road forever. There was always, "Give us another week, give us another two weeks, give us another three weeks." There was never a point at which they were going to be willing to act. And the insurance companies aren't waiting when they're raising premiums on people. The insurance companies aren't waiting to deny people coverage for pre-existing conditions, and we felt we could no longer afford to wait. ...

The insurance companies becoming sort of the enemy -- there's something written about the fact that this was Axelrod sort of bringing up a thing that we need an enemy. We had no enemy during the campaign; we need an enemy. Was that partly motivating the decisions on how the administration went up against the insurance industry?

No. It's always great to have an enemy in politics; there's no question about that. However, we didn't pick the insurance companies as the enemy. They decided to play that role when they decided to spend tens of millions of dollars to defeat health reform. Up until that point, we were critical of insurance company practices that were predatory on consumers and how we wanted to reform those in the process. But they decided with the AHIP report and Karen Ignagni, they made a political decision that it was going to be in their fiduciary interests to defeat health reform. And at that point, they became the enemies of health reform. And that was their choice, not ours.

What ever happened to single-payer?

The president has always believed that the most realistic and best health reform that we could enact would be based on the employer-based system. If you were creating a country from scratch, maybe you would start with a system like they have in Canada and in other countries. But that wasn't realistic here, wasn't the right thing to do. It was never on the table. Not only is it not politically feasible, it's not substantively feasible to do. ...

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

Take me to Sunday night. Take me into the room and what was the feeling. What took place?

Sunday night was a very special night. Even though we knew from the Speaker [of the House Nancy Pelosi, D-Calif.], from everyone else that we had the votes, sitting in the Roosevelt Room, the president, the vice president, a couple of dozen staff, many of whom had been with him since the very beginning, all of whom had labored for over a year, night and day, to get this done, we still sat there. There was a small bit of anxiety as we watched the votes tick up. We've had victory snatched from us before, so we were very nervous. But to see it happen -- the president stood up, and we all applauded. And we knew that he had done something that he had pledged to do.

I don't know that the history of it sat in front of any of us until that moment.

And the more private event afterward?

After all the votes were done and he had made a couple of calls, he invited all the staff who had worked on this up from the Truman Balcony for a toast, the toast that we had been able to accomplish [this] together.

And the president stood before us and said: "Relish this moment. It's not that often you get to do something that helps so many people at once. We can talk about the history, and we can talk about the full significance. What really matters is we all worked very hard, and we were all able to accomplish something that was going to help a whole bunch of people make their lives just a little bit better." And it was very heartwarming.

It was very surreal for some of us who had been with the president for a very long time, thinking about how three years prior we'd been in a small auditorium [where] he would announce his health care plan. And now here we were standing on the Truman Balcony of the White House celebrating, signing into law one of the most important pieces of social policy in 50 years. It was very powerful, but very surreal. ...

... [On the day of the Massachusetts election] when the understanding was that Ted Kennedy's seat was going to be lost, [there was a meeting] with Pelosi and [Senate Majority Leader Harry] Reid [D-Nev.] and everybody in the room. Tell us a little bit about that meeting and how the conversation went. …

I wasn't in the room for that meeting. But where we were -- about a week before Massachusetts, we knew the odds were pretty good we were going to lose that seat. We were going to do everything we could to avoid that fate, but the train was [coming] down the tracks, and it was going to be hard to stop.

So we immediately began, under the leadership of the president, trying to figure out what the political ramifications of that were going to be. We're now down to 59 seats in the Senate. What was the appetite going to be? What was the level of panic going to be among Democrats within Congress and around the country?

And so at the very beginning, the president did not want to lose sight of what was important here, which was regardless of the political consequences, the political atmosphere at the time, [what was important] was achieving this very important goal for so many American families. And so from the very moment that it was clear that Scott Brown was going to win that seat, he began thinking through what the next steps would be to be able to right the ship and get health care done. ...

Rahm suggested going small, scaling down. What was the reaction?

To be clear, Rahm's mission throughout the entire process was to implement the president's mission. And what Rahm and others were trying to do was simply just suss out -- if you could not do option A, a comprehensive bill, was there an option B, a smaller bill? And it was all about legislative math. We all wanted the same thing. We all wanted comprehensive health reform that would achieve the goals that were laid out at the beginning of the process. It was just a question of possibility.

And there were a lot of people on the Hill who were saying at the time, and in the coming weeks, that doing a comprehensive bill was impossible. So folks were looking for what plan B would be.

And how did the president come to agree with plan B, which eventually was not scaling down? How did he decide, "Wait a minute, we're not scaling down"?

Right after the Massachusetts election, we were sitting in the Oval Office of the president talking about the State of the Union, and ... we came to the question of how do you want to address health care in the State of the Union. The State of the Union was one week after Massachusetts. It was way too early to be able to pick a course.

And the president said: "Well, here's how I think we should approach health care. We should show that we're still committed to do it, and we explain why it's the right thing. We should take a pause to do the jobs bill and let the dust settle so we can make an educated calculation on how to proceed. We should come up with our own proposal, put it online and then hold a summit."

And the summit was the event that helped build momentum so that we could do the comprehensive bill.

But right from the beginning, he was going to go for it.

He was going to create a situation where he would potentially have the opportunity to do it. But it was all going to be a question of what the political environment would be a month after Massachusetts. A week after Massachusetts? Impossible. Two weeks after Massachusetts? Probably still impossible. That's why he held this summit that was five weeks after Massachusetts to begin a process to go forward.

... After Massachusetts, what were the lessons learned, and how did that redefine the role of the president?

After Massachusetts, it became clear that the president was going to have to drive the process forward to get it done. He was going to have to be the primary spokesperson for health reform. He was going to have to force action, and he did that in concert with the House and Senate leadership. But he became a driving force. ...

There had been this myth that the president wasn't very involved in health reform prior to Massachusetts. He was incredibly involved. He had given the legislative leaders the room to operate and work their caucuses and produce bills, which they did do and achieve. And had someone other than Scott Brown been running as a Republican nominee in Massachusetts, we would have won that seat, and the president would have signed health reform probably prior to the State of the Union. We got thrown a curve ball by the Massachusetts election, and we had to react to it. And that required a different strategy from the president to get it done.

But where did the idea that ... we're going back and we're relooking at this [come from]?

As we looked at what had happened in health reform over the course of the last several months, it was clear that the process had come to define the product, and there was concern about some of the special deals that had been in the bill. The one that got the most attention was the one about Nebraska. There had been a lot of criticism for the president not abiding by the pledge he made about C-SPAN, even though it had been a very transparent process to that point, that sort of came to define the whole thing. And it came to seem like something that was very reminiscent of the Washington the president pushed to change.

And the summit was an opportunity to hit the restart button on how people viewed the process in two ways: one, bring the Republicans to the table and show that we have reached out to them, we have incorporated their ideas and make them actually articulate a vision for what they want to do going forward; and second, to do it all on live TV, open for the American people to see and make them feel more comfortable with the process. It was a reset button of sorts.

When you look at that summit, the president is the one that's talking more than anybody else. He's the last one in the room. What does that say about him and what he's learned as a leader? ...

I think that event shows that the president has a fundamental understanding of how much the American people want to be engaged in the process. It used to be things that happened in Washington basically kind of stayed in Washington, and the American people just sort of read the headlines afterward. In a world of tremendous amounts of information through the Internet, through blogs, through YouTube, people have the opportunity to be engaged in their government, and they want to be engaged.

And when they're shut out of their government, as they feel they were in the health debate prior to that, they get upset and angry about it. And this was a chance to open up the doors. ...

This big question that keeps on coming out, the practical versus the idealist -- where is this president, and has he changed over time? Has he learned something that now his leadership has practiced in a different way?

I actually think that his leadership has been caricatured in a lot of ways over the last year. The Barack Obama who sat in that room at the Blair House and who I saw in the Roosevelt Room the day this passed, the same Barack Obama I sat across a conference table with in Chicago in 2007 when we were putting the finishing touches on his first health care plan, he's not an ideologue. He wants the best ideas from both parties and cares passionately about helping people. It would have been so easy to give up at any step in the process. ...

Let me put it this way. What the president said to us the day after Massachusetts was: "I don't know what the odds are, but if there's still a chance that we can do something very important here for the American people and solve this problem with health care by passing a bill at the Senate floor or the House bill, I want to keep that option open. If we can do it, we should try to do it."

He wasn't worried about the odds or the political costs. There would have been a great cost politically to losing, but in his mind the cost would have been the American people, because what he knew is that if he failed at health care here, the next president who took on health care would do so when the system was broken. ...

Take us through that 61 days from Baltimore on. ...

You have to take this in two phases, two months and two phases. The first phase was the effort to create an opportunity to possibly take health care on again in some capacity, and that's the meeting with the Republican caucus. That's the president [posting] his bill online. That's the summit.

After the summit, we had a decision to make. The president said at the end of that summit, "I'm going to announce what I think is the right way forward after this." And we had a choice [about what] the right way forward could be. The one we took: Go for the big bill with some improvements. ...

And from that day, that Wednesday right after the summit until last Sunday night, every day we woke up and then went to bed, and health care hadn't died, was a victory. And the key was to keep it alive; keep momentum going forward; don't let the opponents derail it; don't let it fall off a legislative cliff somewhere. Just keep pushing, keep pushing, keep pushing. That's all the president did 24 hours a day; that's all the White House did; that's all the Democrats in Congress [did]. For 24 hours they just keep pushing this thing forward.

And the president said to us that he would do anything; he will call anyone, meet with anyone; he will speak anywhere. He will do whatever it takes to make the case for health reform. And he did it publicly; he did it privately. He did it in TV interviews. He did it traveling around the country. He did it directly to insurance executives themselves. And every day we got a little bit closer, got a little bit closer. But we didn't really know we had it until on Sunday night when that 216th vote was cast. ...