obama's deal
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Lobbying & Deal Making

Excerpts from FRONTLINE's interviews for this report

The Health Care Lobby

Dan Balz The Washington Post

Dan Balz

The health care lobby is one of the most powerful lobbies in Washington. But the notion that there is, if not a revolving door, a transmission belt from ... some of the committees that deal with health and tax issues, into the industry once they leave the Hill, [that] is naïve. That's the way Washington has worked for as long as Washington has been modern Washington -- half a century or more. …

Washington offices are peopled by folks who have come out of that legislative environment. They're some of the smartest people that work on the Hill, and when they leave the Hill, they, in a sense, cash in. But they cash in because they have an expertise that is valuable and relationships they've built up over years that create bonds of trust.

Some people see it legitimately as sort of a venal set of relationships because it can be corrupting to the process. I don't mean it's corrupting to these individuals, but it does create a kind of an insider's game. But it has been the way of the world through Republican administrations and Democratic administrations, and Republican majorities and Democratic majorities on Capitol Hill.

It is part of the foundation of any big piece of legislation that is this complex, that is this central to the economic well-being not only of individuals, but of corporations.

Dan Pfeiffer White House Communications Director

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. [Tom] Daschle [D-S.D.], [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.

Matt Bai The New York Times Magazine

Matt Bai

At the end of the day, on an issue like health care, industry and all its money can only be important enough to a point. Because if you sell the public on this plan, whenever it's finalized, and the public believes that it is fundamental reform and believes that it is necessary, there's a tipping point I think where all the industry money and all the industry muscle in the world doesn't matter anymore. …

Because politics is, at the end of the day, about getting elected. And it's about doing what the public wants you to do. ...

People say: "You're an insider. You've been in Washington too long. You think industry's benign." I mean, of course everybody's fighting for their interest. That's part of the process, too. And there's too much money in politics and way too much corporate money in politics. But when you see politicians every day and talk to them, people who take vast sums of money for their campaigns, it's much harder to just caricature them as people who do industry's bidding because it makes them safe and wealthy. You see them as three-dimensional individuals who have principles and have beliefs, and those beliefs tend to coincide with industry's. They have a very complicated relationship with a lot of those funders in industries. And it may be too cozy, but also based on sort of common convictions in many cases, right? They don't see themselves fundamentally as people who aren't doing the right thing. They see themselves as doing the right thing. ...

It's very hard to imagine a president getting this kind of bill done without at least attempting to build some consensus with the industries who will be seriously affected by it, industries who employ a lot of people, industries who are powerful businesses in their states and in the country.

So the notion that there's something inherently corrupt in a president sitting down with industry groups and attempting to craft an agreement in which a major piece of reform legislation is going to affect them less adversely than it might otherwise, the notion that he can't offer them something in exchange for the sacrifices they'll make, I think that's unduly pure and sort of much too remote expectation when looking at politics.

Stan Jones Aide to Sen. Ted Kennedy, 1970-76

Stan Jones

When I was on the Hill ... we had a controversial measure in our committee that affected the AMA [American Medical Association]. It was demolished in the committee. The vote was unbelievable against it, and I was stunned. … Afterward, the lobbyists for the AMA assigned [to] me and us, came in and … says, "Stan, you're new to this. I just want to show you," and he pulls out of his briefcase a printout. … "Here are all the physicians in each of the states who gave money to each of the guys on your committee last year. And here's how much all the medical societies gave them. And here's the total for each one. And yesterday, we made the rounds and went to each of them and just showed them this list." [laughter]

So, what does AARP [American Association of Retired Persons] have to show in that regard? And what do the churches have to show? ... They saw Senator So-and-So and he was so nice, and they got their picture taken with him. And I used to say, "When they take their picture with you, you're in trouble because that's all they can think of to give you." … Money talks.

David Nexon Senior adviser to Sen. Kennedy, 1983-05

David Nexon

The [Sen. Max] Baucus [D-Mont.] and the Kennedy staff have a different approach to it, but both involve the interest groups in a way that made them feel they were part of the process and therefore helped keep them from going into opposition. Baucus was in a more of a hardnosed bargaining mode, particularly with PhRMA [Pharmaceutical Research and Manufacturers of America], AHIP [America's Health Insurance Plans] and the hospitals, which is "OK, we want your support. We need some money from you to help pay for this thing. Let's see how we can get together on a deal." And they were successful in making a deal with PhRMA and the hospitals. And I'm not sure how far along they got with AHIP. I think they were probably disposed to make a deal with them, but they had an awful lot of pressures around this public plan. ...

Kennedy staff had a process ... called stakeholder meetings, where we were meeting with them twice a week for like three hours a day. It was a grueling process which kept people engaged and feeling that they were a part of the process and having an impact, because I think they were. I think it helped the Kennedy staff in design, because they got a lot of insight as to where the groups were coming from. ... But it also helped keep the groups from going into opposition because they thought their voices were being heard and they were being part of the process. I'm sure the Kennedy staff had a lot of separate meetings as well.

Wendell Potter Vice president, CIGNA Insurance, 2003-08

Wendell Potter


The [health insurance industry's] tactics are to provide a lot of data and information to members of Congress, particularly to the Finance Committee members. Keep in mind that there is a great shortage of information in the Congress about how the commercial insurance industry works. There are a lot of people in Congress who know quite a bit about the public programs like Medicare and Medicaid, the veterans programs. But as I certainly found out over the time that I was being invited to talk to members of Congress and their staffs, there's a very superficial understanding of how the health insurance industry really works. And the industry knows that and is able to kind of fill this void of information with their own propaganda, their own data that they use very selectively to build a certain point of view. And that can be quite persuasive, and that's what they've been doing over many months leading up to this. …

I was asked by a congressman to speak at one of his town halls in New Jersey in the summer. … I was talking a little bit about how the industry goes about trying to manipulate public opinion and the practices it engages in. A woman came up to me at the end, very indignant and said, "No one paid me to be here." And I said: "No ma'am, no one paid you to be here. That's not how it works. You didn't get a dime out of this, but a lot of money went into the effort to get you here.

"If you're privately insured, some of your premium dollars went to this trade association that hired a big PR firm in Washington … to develop relationships with people that you listen to and find credible and who were talking about reform in such a way that you got very angry and very upset, so much so that you came out here today."

The Deal with Billy Tauzin's PhRMA

Sen. Tom Daschle (D-S.D.) Majority Leader, 2001-03

Sen. Tom Daschle (D-S.D.)

The deal the White House cut with Billy Tauzin, president and CEO of PhRMA in June, ... very controversial thing for the White House to do?

Very. In part because it was the one time when they probably weren't as inclusive as many members of Congress would have liked. They would have liked to have been in on the deal and negotiated. I would defend the White House to a certain extent in that the bigger the room, the harder the agreement is to reach and I think they felt we just needed to make this deal and it doesn't have to be the last word. But we've got to move on and start with something.

But it was controversial in part because it was a decision made between the White House and the stakeholders. It was controversial in part because many people felt that the stakeholders were all getting off fairly easily. It was controversial in part because it was not viewed necessarily as moving us that much closer to keeping the stakeholders in the room, once these concessions were made. ...

Why did the president do it?

I think because he saw it as an opportunity to seize the moment, to get signatures on the line, to say: "This looks like an opportunity we haven't had before. Having stakeholders and people at the table that have opposed us on every one of the occasions up until now is a big deal. So let's lock them in to the extent we can. We can argue about how much and other issues, but the fact that they're committed is a big deal and I'm going to seize the moment."

I think it was the right thing to do.

Ryan Lizza The New Yorker

Ryan Lizza

I guarantee you if Republicans take over Congress, [the PhRMA deal] will be investigated. Not to say that they did anything wrong, but it's one of those things that they will have their eye on.

Now, what might mitigate that is that … the Republicans are more in the pocket of the pharmaceutical industry than the Democrats. So if you're a Republican committee chairman, you'd be investigating one of your party's benefactors. But I know a lot of Democrats who are nervous about that [PhRMA] deal, and frankly, in the White House it was a very closely held negotiation. … When Billy Tauzin went public with the deal, the speculation is he went public with it maybe to protect the deal. But I know the White House was not, as far as I know, expecting him to go public. …

Talk a little bit about the liberal outrage.

… They're angry about the way the Senate has treated them and about the way that the White House has taken them for granted. And the roots of that anger are in some of these deals -- the deal with PhRMA, the fact that Obama didn't fight aggressively for the public option. And to some, probably that single payer was never even considered in the process.

David Nexon Senior adviser to Sen. Kennedy, 1983-05

David Nexon

Drug companies are very concerned about their public image. Their public opinion is very low. ... There are many Democrats who have a residual bitterness against them because they saw them as really being in the pocket of the Republicans for many years. So they want to be on the side of the Democrats if they can. They have a tremendous amount to lose, because they're big, fat targets for financing the thing. And if you compare what happened in the House to what happened in the Senate, where they made the deal, you can see how much they potentially can lose if they're not part of the process and support.

From the point of Obama and the Finance Committee, it's a huge advantage to have this interest group on your side, both because of what the interest group can do to you if they're in the opposition and the fact that they can help you if they're there. They put a lot of money into advertising, as I'm sure you know. …

[And] what do you lose? You lose a little bit of revenue to finance the thing, which you might have gotten if you'd hit them harder. But balance that against all the political support that it brings to make the deal. Plus, they gave up something. It wasn't like they got off, like they're not contributing in some degree to the cost of the reform. To me, it's not even a close call. You get all that money. You get all that power. You get the momentum. You get the advertising. I mean, what better deal could you --

I suppose if you're an idealistic Democrat who says, "Wait a minute, I heard Barack Obama during the campaign say Billy Tauzin and Big PhRMA is a terrible group. We should never negotiate with them. We should never -- "

Well, he actually didn't say that.

But whatever he said, right? …

Do you think it affected his credibility? I don't. To me, it was not a close call. ... And I'm sure Sen. Kennedy would have taken exactly the same attitude. …

John Podesta Co-chair, Obama transition, 2008-'09

John Podesta

The problem with that was that all the parties weren't in the room when that deal got cut. So it was essentially cut in discussions with the Finance Committee, but with participation by the White House and with the blessing and with the acknowledgement of the White House that they had made a deal. …

But in the end of the day, I think this has been a more open process. I think the dialogue that the White House has undertaken, beginning with the health care summit in the spring, and bringing everybody into the room, being open to talking to the political opponents, as well as their political friends, has been a pretty open process.

And this is a case in which they, I think, decided they needed to lock down one piece of very complex Rubik's cube, and they decided to lock it down. They did that privately. And we'll see if they pay a price for it.

Ken Vogel POLITICO

Ken Vogel

[The White House] makes a calculation, as we understand it from people we've interviewed, not to be a kind of MBA presidency, but to be a legislative presidency. In other words, let Baucus, let [Speaker of the House Nancy] Pelosi [D-Calif.], [Rep. Henry] Waxman [D-Calif.] and others, bring it sort of along -- as you say, wait in the background, wait to strike, wait to come up with their own ideas.

They do the same with stakeholders, AHIP [America's Health Insurance Plans], PhRMA, others, [right?]. ...

We wrote about this April meeting that was called by Baucus's staff, but attended by Jim Messina [White House deputy chief of staff for operations; former Baucus chief of staff], who, of course, worked with Baucus's chief of staff previously, in which they brought in a number of these stakeholders who were going to be major players one way or another in this debate, including the doctors, the American Medical Association, including PhRMA, including the health insurance plans, including the U.S. Chamber of Commerce, including AARP.

They brought them to the table, and they said, "We want your buy-in," basically. Jim Messina gave a little pep talk, left. Afterwards, there was a little discussion of strategy. …

And in the days after this meeting, a longtime veteran Democratic operative, Nick Baldick, who had worked with John Edwards' campaign, who had worked at the highest levels of Democratic politics, although interestingly not with this White House, and not with Barack Obama's presidential campaign, started calling these stakeholders, particularly the ones who had seemed to be amenable to working with this coalition, and asked them, basically, for money to air ads supporting the White House's, at that point, still very vague and undefined plans.

Now, a number of them, most notably PhRMA, went in. They ended up raising $24 million for this coalition and a successor coalition to air ads basically advocating the need for health reform. At the time, there was really an outcry. At the time when this deal was revealed, folks on the right [were] saying, "This is a pay-to-play type thing." These groups are going in. The White House is giving them something, and they're giving the White House something in return.

And from the left, particularly in regards to PhRMA's involvement, a number of prominent liberal bloggers, who have really quite an influence over sort of the progressive base of the Democratic Party, [were] saying that this was letting PhRMA off the hook, that PhRMA, after all these years of these huge profits, should be expected to go in for something more than the $80 billion which they promised to sort of sacrifice from their potential future earnings over 10 years in order to make this deal palatable to the White House and get this through.

Is there anything inappropriate about Messina's attendance at the meeting?

Certainly there were some ethics watchdogs who we talked to who said that whether Messina actually offered some kind of quid pro quo or not, the very fact that he was there with Baucus's chief of staff and all these stakeholders, and then, in the days following, there was a Democratic operative who reached out to try to raise money from these stakeholders, would present the appearance that this was a sort of officially endorsed White House deal. And Messina was playing the role of sort of the offerer of the deal.

Messina, for his part, and the White House said nothing of the sort happened. Messina did not even stay through the meeting, through the discussion of any kind of strategy. So the perception that some of these groups may have had, that they were being pressured to do something by the White House, the White House is saying that impression is completely false and baseless.

Paul Blumenthal Sunlight Foundation

Paul Blumenthal

I think [the PhRMA deal] sort of shows that lobbying is a dominant force. It's almost another branch of government here in Washington. You have the Obama administration coming in, talking about changing the culture in Washington, but realizing the only way they could get a bill passed is to buy off a huge segment of the health lobbying sector, PhRMA. They have so much money, and they were willing to fight if they didn't get what they wanted.

And so the White House gave away the farm so that they could save face and get advertising on their side rather than against their side. And they worked through the White House, through Jim Messina with Max Baucus. Messina is another former chief of staff with Max Baucus who is now the deputy chief of staff at the White House under Rahm Emanuel. And through this combination, you can see that the White House never really had any intention of working with any other committee aside from the Senate Finance Committee.

Sen. Sherrod Brown (D-Ohio) Senate Health Committee

Sen. Sherrod Brown (D-Ohio)

I think that this place frankly sings way too much with an upper-class accent. This Congress, Republicans, overwhelmingly are too close to the drug companies and the insurance companies. And too many people on my side of the aisle are too close to the drug companies and insurance companies. …

How much influence do they have? And why is that dangerous?

They're influenced. The drug and the insurance companies are more subtle than [just] campaign contributions or family connections or whatever. … The reason that this place too often sings with an upper-class accent is that most House members, most senators spend most of their time with people in their social class. Most of the people we interact with, most of the people we see, are not at a local union hall, or in a high school football game, or just regular people. …

In terms of Medicare, too many senators and too many House members -- almost all Republicans and some number of Democrats -- they hear negative things about Medicare because they talk to doctors about reimbursement; they talk to medical device manufacturers, or drug companies, or just rich people that don't like government. They're not talking to the 80 or 90 percent of the public that thinks Medicare is a great program that's helped older people live longer, healthier lives. …

Jonathan Cohn Senior editor, The New Republic

Jonathan Cohn

PhRMA can walk up to you and say, in not so many words: "That's a nice health care reform bill you have there. It'd be a shame if something happened to it." PhRMA had the ability to flip a switch, flood the airwaves, flood congressional offices. If they wanted to come out swinging. …

And I think, really, the deal the [White House] made, at the end of the day, was they were buying political peace from PhRMA. And, in fact, PhRMA, in the end, in the day, instead of running ads against health care reform spends $150 million on ads for health care reform. …

PhRMA, to this day, is not coming out swinging against health care reform. … I was watching a few minutes ago, on CNN, an ad against health care reform. It was not from PhRMA. That was the deal, the bargain.

Ceci Connolly The Washington Post

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."

The "Cornhusker Kickback"

Editors' Note: FRONTLINE wants to note that Sen. Ben Nelson [D-Neb.] vigorously defends his role in the negotiations over health care reform and that the morning after FRONTLINE's broadcast, Sen. Nelson sat for his first detailed tv interview in which he repeated his insistence that "there was no quid pro quo, no effort at all to buy my vote."

Here, too, are other documents, statements and opinion pieces published by the senator, explaining his side of the story:

Chronology of Senator Ben Nelson Blowing the Whistle on Unfunded Mandate on All States in Health Reform

http://bennelson.senate.gov/press/speeches/012510-02.cfm

http://bennelson.senate.gov/press/press_releases/010710-01.cfm

http://www.mccookgazette.com/story/1598227.html

Sheryl Gay Stolberg The New York Times

Sheryl Gay Stolberg

The famous "Cornhusker [Kickback]" deal with Sen. [Ben] Nelson [D-Neb.]. Can you take us into the story of what happened there and who was involved?

It had come down to Harry Reid [D-Nev.], the Senate majority leader, the Democratic leader, was struggling to get the 60 votes that he needed to pass this bill. And he had a couple of holdouts. One of them was Sen. Ben Nelson, the Democrat from Nebraska. He's probably the most moderate, centrist Democrat in the Senate. He was uneasy about this bill, and especially about the burden that it would impose on states who have to pick up a share of Medicaid, the government insurance plan for the poor.

Ben Nelson was wavering, and Harry Reid needed to get his vote. Nelson said what he wanted was for the federal government to pick up the entire share of the Medicaid costs for Nebraska for a set period of time. And Reid agreed to it, and they got their 60th vote. It was a big deal, because it meant that this bill was going to pass the Senate.

But it was in retrospect probably a bad deal, a very bad deal, because people saw that a special deal was being cut. That one state, Nebraska, got this deal because Harry Reid needed the vote. Obama stayed kind of distant from it, but he certainly didn't stop it. But it was exactly the kind of thing that Obama had campaigned against -- no more special deals, backroom dealing. He wanted his presidency and legislative process to be open. And now we had this sort of smarmy, sort of horse-trading going on in exchange for votes. It kind of smelled. And people recognized it around the country. I think people in Massachusetts recognized it.

Do we know what Obama's or the White House's role was in that deal?

We know that all the way through in the Senate dealings, in the negotiations, top White House officials, were literally side by side with Harry Reid. I don't think that President Obama was personally involved in cutting that deal, but clearly he was being apprised of what was happening. And clearly nobody in the Obama White House stood up and said, "Hey, this isn't right."

Who in the White House would have been making the phone calls to Harry Reid?

... Those were closed-door meetings. Some congressional correspondents may know better, because they might have been seeing who was coming in and out of the room. But, clearly Nancy DeParle, the health care czar, and [Chief of Staff] Rahm Emanuel were keeping very, very close watch on these negotiations.

Ryan Lizza The New Yorker

Ryan Lizza

The problem with the Senate -- and the problem with having to get 60 votes [with] 60 Democrats, or 58 Democrats and two independents that caucus with the Democrats -- [is] any single senator can hold the legislation hostage for their own personal concerns. And there is a legitimate policy issue here. The way that Medicare reimburses rural and non-rural areas is unfair to some of the rural areas, so Nelson argued, and he wanted this fixed. And he had a legitimate argument, it's just that it was fixed only for Ben Nelson, it was fixed only for his state.

And whatever the merits of his proposal, it becomes a symbol in the debate for the worst of this process. One of the interesting aspects of this health care debate, if you look at the polls, the public had a very high degree of awareness of what's going on in the health care debate; [that's] unusual for the legislative process and for what Congress does.

If you asked people last year, were they paying a lot of attention to health care, the numbers were off the charts. And there was a level of media coverage to the health care debate and to the ins-and-outs of the negotiations that was very, very high as well. So maybe in a previous era, the Cornhusker Compromise wouldn't have got as much attention. But when you have Fox News and you have an aggressive opposition and an aggressive press corps really paying attention to every detail, something like that gets blown up and the public learns about it and learns about it very quickly.

So in a process that was taking a long time, that was frustrating a lot of Americans because they thought Obama should have been paying more attention or talking more about the economy, the Ben Nelson deal becomes a symbol of the worst aspects of the sausage-making process. … It also becomes a rallying point for opposition to the health care bill and becomes part of the debate in Massachusetts and in Scott Brown's campaign. "And I'm going to Washington so we don't cut deals like this."

So it's something of a catch-22. The legislation wouldn't have passed the Senate without it. But it also helps Brown win and his victory stops health care in its tracks.

Part of the strength of the argument is it is also something that Obama had railed against himself.

Deal making, yeah. Obama railed against this stuff except when he didn't, and railed against this stuff except when he put his sort of pragmatic hat on and worried about getting stuff done. And look, he's president of the United States; he's not president of the United States Senate. And you can't necessarily hold the president responsible for every crazy deal that's made up in Congress.

I frankly don't know how involved the White House was with the Nelson deal. They may be more to blame than I know. The truth is that's how Congress works. …

The other thing to say is this isn't the first time where that issue and Ben Nelson held up a major part of the Obama agenda. ... Nelson was also the last senator to support the stimulus package. There's a moment at the end of the stimulus negotiations where Rahm Emanuel, White House chief of staff, [Sen.] Arlen Specter [D-Pa.], Ben Nelson and maybe one or two other senators, are in a room negotiating the final details. And again, Ben Nelson says: "Wait a second. I need something for Nebraska." And again, the issue is Medicaid and reimbursement rates.

Now Specter believes that this issue has already been resolved, that there were two sides on this issue and they cut a deal right in the middle in how they massaged this reimbursement rate. And Nelson says: "No, that's not good enough. I want the rate to be more advantageous to my state." The negotiations sort of break down at that point. Emanuel, according to Emanuel in an interview with me last year, brings Nelson outside. They have a discussion, and once they come back in the room, Nelson tells Specter that he'll agree to what was on the table previously. …

So, one, this is an issue obviously that's very important to Nebraska and Ben Nelson. And two, it shows you that Nelson knows how to use his position as a single senator that can scuttle any legislation pretty effectively.

Dan Pfeiffer White House Communications Director

One of the things that [Sen. Scott] Brown [R-Mass.] focused on a lot was the "Cornhusker [Kickback]" deal with Nelson. 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. ...

posted april 13, 2010

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