Obamacare

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    David Axelrod   Senior strategist, Obama 2012 campaign

    (Text only) He was a senior White House political adviser until 2011, when he left to serve as a senior strategist on Obama's re-election campaign. This is the edited transcript of an interview conducted on July 26, 2012.

    Read the full interview »

    ... There's a pivot to health care. The question is why, especially when some political folk, I think including yourself, as well as the economic team were warning that there were problems, that there were risks.

    I think the president knew -- he went in eyes wide open on health care -- that it was not a great political play on his part, that it would be difficult, it would be tough and ultimately could cost him politically for having done it.

    But his attitude was that this was a problem that had plagued the country for generations. Presidents back to Roosevelt had tried to tackle it. And now it was becoming a matter of critical urgency because not only were more and more people uninsured, but the cost of health care was bankrupting the government, straining businesses and families. And his belief was that if we didn't take it on now, it probably wouldn't happen, and the system would implode.

    He was presented with all the political arguments, and he said, "I get the politics of this, but if we don't do this now, it probably doesn't get done, and the system will implode." And he said: "What are we doing here? Are we going to put our approval rating on the shelf and admire it for eight years, or are we here to spend our political capital and try and do things of lasting importance for the country?" He said, "I think we have to go forward."

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    Rahm Emanuel   White House chief of staff (2009-2010)

    He was Obama's chief of staff from 2009 to 2010 before he left the White House to run for Chicago mayor. Here, Emanuel discusses why the president ran into trouble in his attempts to create "a post-partisan environment and more productive Washington." This is the edited transcript of an interview conducted by producer Jim Gilmore on July 26, 2012.

    So let's talk a little bit about health care. We're going to jump around a little bit here or I won't get as much coverage as we need from you.

    Or you won't get the answers you want. (Laughs.)

    The answers you will give. The pivot to health care. What were you and the economic team warning about as the pivot is made?

    Well, look, I mean, this is written, so I'm not saying anything. The president had, post the stimulus bill, post-auto and post-first part of financial, which was stress tests and other aspects administratively, the president had three -- and he had other things, you know, kids' tobacco, which was stuff. He had three major initiatives: financial reform, so the regulatory architecture was up to speed with the market, which was not true post-Glass-Steagall; two, health care reform; three, energy/climate change.

    Now, first of all, on all three he made dramatic progress. Second is, it was my view -- and I advocated this, it's been written, so again, I tried to be careful about, one, we should do financial reform now. The problem is fresh. It's more likely to have bipartisanship. For a host of reasons. …

    On the health care, my argument was not -- I don't know what [Secretary of the Treasury] Tim [Geithner] and [Director of the National Economic Council] Larry [Summers] gave their advice -- my advice was, I had been through this. If you're going to do this, you should go with it eyes open, both on historical standards -- historical precedent, rather -- as well as fully conscious of how this plays out and what it will take, which is what he wanted his chief of staff to do, which is the chief of staff has got to advise both the politics, the policy and the kind of public communications, the press. So you've got to help the president weigh all those pieces.

    So how did you define the risks as what they were?

    Time. It's been 80 years. (Laughs.) Nobody came out of this successful. You're going to dedicate a huge amount of time you can't make up. The likelihood of success is -- 80 years will tell you.

    So I said, if you're going to do this -- and it was something he ran on -- go into it eyes open, know what the consequences are and what the potentiality for success is, and what are some of the alternatives here. …

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    Jonathan Gruber   Helped develop Romney and Obama health care plans

    A professor of economics at MIT, Gruber specializes in health care. He was involved in the development of Mitt Romney's Massachusetts health care plan -- aka "Romneycare" -- as well as the Affordable Care Act, or "Obamacare." This is the edited transcript of an interview conducted by producer Michael Kirk on June 13, 2012.

    So now let's do Obamacare. So a few years go by and what? Your phone rings again?

    So what happened is I had been working in a number of states, notably California. Some others had tried. And it was clear not much was going to happen without federal leadership.

    And then Obama gets elected, and on his health advising team is a number of my friends from the Clinton administration who worked on health care reform round one. I like to think of it as sort of the preseason of what became the ultimate -- I don't want to demean the amazing amount of work that went into that, but these are veterans of those wars who were now on the Obama team saying: "Look, we have the opportunity to do what we were unable to do under Clinton and get this done. We think the Massachusetts model is the way to go. We would like you to come help the administration put the numbers together just like you did for Massachusetts."

    So I went down shortly after the election. I worked with the transition team to help put the numbers together for the administration. And then, essentially, most of 2009 I was really on loan from the administration to Congress, particularly the Senate Finance Committee, to help them put the numbers together on what became the finance committee bill, which really became Obamacare. Yeah, that's what I did.

    How much did you feel like the Obama people -- I mean, did it feel like the kind of thing they had to do? They just felt like: "We need a big one. This is a big one. Let's get it going right away"? What was the impetus?

    No, no, I think they were very much torn about what the big one would be. They tried energy first. I think this was not a foregone conclusion that this is what they were going to do. I think they really came in curious and interested.

    You know, the big moment early on was when President Obama sent his first budget, he put a marker in it. He said, "Look, I'm going to set this aside for health care reform." ...

    This was a big leadership moment for him where his advisers as far as I know were split -- much as Romney's advisers were split -- on political grounds on whether this was the right thing to do.

    And the argument against it?

    Too bold. America is not ready. You know, look elsewhere. Basically political, just political expediency.

    The economy is crashing. Let's pay attention.

    Yeah, political expediency.

    And the arguments for it?

    The argument for it were a, this is sort of something he'd run on, and this is sort of a longstanding Democratic goal; b, we had the example in Massachusetts. And, you know, obviously it is self-congratulatory to believe this, but I really do believe and I've been told it wouldn't have happened if we hadn't succeeded in Massachusetts.

    And it's important to understand that we were a success in Massachusetts. And by the time he's considering this in 2009, what do we know? We know we covered over 60 percent of the uninsured. We know we lowered premiums in our non-group market by 50 percent. And we know we had done so with about two-thirds public support. So we had that under our belts. So I think that was another thing of saying, "Wow, it's an example we can point to that worked, a framework that worked."

    I think the third thing was that he really felt that ultimately, if we were going to control the government, that he knew that the long-run fiscal problem facing the government is all health care. ...

    If you add up everything we promise to spend in Medicare, Medicaid and everything versus what we were going to collect in taxes, we were, over the distant future, $100 trillion in the hole. Eighty-five trillion dollars of that was Medicare and Medicaid. The entire fiscal health of the U.S. is about health care costs. That's it. Social Security a little bit. Nothing else matters. You know, I like to say in the U.S. there are only two issues that matter, global warming and health care costs, because either way we are under water.

    Basically, the entire fiscal future of America was about controlling health care costs, and Obama realized that if he was going to start to tackle the deficit, start to tackle this problem, he had to take on health care costs, and that this law could be the vehicle for doing so.

    And we didn't do that in Massachusetts. This was a new step, ambition. So the idea was, look, let's make this the vehicle not only to successfully cover the uninsured, building what we did in Massachusetts, but to make this the vehicle for the first time to really take bold, new steps on cost control and start that ball rolling as well. ...

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    Jonathan Gruber   Helped develop Romney and Obama health care plans

    A professor of economics at MIT, Gruber specializes in health care. He was involved in the development of Mitt Romney's Massachusetts health care plan -- aka "Romneycare" -- as well as the Affordable Care Act, or "Obamacare." This is the edited transcript of an interview conducted by producer Michael Kirk on June 13, 2012.

    This is an idea that, as you say, in Massachusetts its genesis, at least some of its genesis, is from the Heritage Foundation and others from the right. How did the Obama people feel about the fact that it had lineage, its DNA was partially from the right?

    You know, look, I'm a Democrat; it's clear. But I think objectively, this to me shows why I think President Obama is a better leader than President Romney, which is Obama had an idea which wasn't from his lineage, saw it was the right thing to do, stuck by it and did it and has defended it in the face of enormous criticism.

    Romney did the thing that -- not that it wasn't bold and brave -- but then his party, for no reasons other than craven politics has switched on it, and he has completely caved. And look, this was a conservative idea that worked. How could you possibly deny that idea from your lineage that actually worked?

    You know, it is so rare that we have a bold idea we can run the experiment on, right? We actually ran the experiment on a theoretical concept. We ivory-tower types come up with concepts like this all the time. Here's one we came up with that we tested, and it worked. And yet the minute President Obama adopts it, the entire Republican establishment flips and says, "Oh, this was a bad idea," Romney with them. And that to me is just an incredibly distressing statement about both Romney and the Republican Party.

    Whereas Obama, who was opposed to the mandate in the election -- I mean, Hillary [Clinton] adopted it. And in the election -- in the campaign, to be fair, I was a Hillary supporter, not an Obama supporter, because I liked Hillary's plan better because I believed in the mandate. Hillary had the mandate in her plan; Obama did not. He was explicitly opposed to it. He actually criticized her for it.

    Then he gets elected. And to his credit he gets a lot of people, including myself, telling him, "Look, you cannot make this work without the mandate." And he says, "OK, let's do the mandate." And his advisers say, "This might not be the right thing to do." And he says: "You know, this is what the experts are telling me needs to be done. Let's make this happen." And so Ted Kennedy, who had been opposed to it, he came into that side. Obama came to that side because they saw it working. And ultimately that is what pragmatism is. You see what works, and you do it. ...

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    Jonathan Gruber   Helped develop Romney and Obama health care plans

    A professor of economics at MIT, Gruber specializes in health care. He was involved in the development of Mitt Romney's Massachusetts health care plan -- aka "Romneycare" -- as well as the Affordable Care Act, or "Obamacare." This is the edited transcript of an interview conducted by producer Michael Kirk on June 13, 2012.

    So were you ever in a room with Obama?

    Yes, twice.

    Tell me. Take me there.

    So the first time was in, I don't know exactly. You know, if I knew at the time how important it would be, I would have written down the date. It is like late 2006 maybe. It was right before he announced he was running. So maybe it was earlier than that, maybe spring 2006, right before he -- when people sort of knew he was thinking about it but he hadn't announced yet. I went down, basically did a tutorial for him on what we had done in Massachusetts and how it would work and basically thinking about expanding it to the national stage.

    Where were you? Where was it?

    This was in his Senate offices.

    And what was he like then?

    He was very interested. It was really just an information session. He was really interested in learning. He clearly was not interested in little incremental things. He wanted to be bold. That was clear. He said, "Look, I want to do big changes." He was really interested in what we had done in Massachusetts. The evidence wasn't in yet by the time I was meeting with him, but he was interested in what we had done. ...

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    Jonathan Gruber   Helped develop Romney and Obama health care plans

    A professor of economics at MIT, Gruber specializes in health care. He was involved in the development of Mitt Romney's Massachusetts health care plan -- aka "Romneycare" -- as well as the Affordable Care Act, or "Obamacare." This is the edited transcript of an interview conducted by producer Michael Kirk on June 13, 2012.

    The next time you see him?

    The next time I see him is summer 2009. The big issue there is that he really wants to make sure I'm moving forward on cost control. I think that at this point he sort of knew we had a good plan on coverage, but he was worried on cost control. So we had a meeting in the Oval Office with several experts, including myself, on what can we do to get credible savings on cost control that the Congressional Budget Office would recognize and score as savings in this law.

    And that was a meeting -- it was very exciting, once again, because the economists in the room all said the number one thing you need to do is you need to take on the tax subsidy to employer-sponsored insurance. We need one minute of background on this. The way employer-sponsored insurance works is, if you get paid in wages, you get taxed. If you get paid in health insurance, you do not. ...

    So this tax subsidy economists have been railing against for decades, it's super-expensive. We forego about $250 billion per year in tax revenues. It's regressive -- the richer you are, the bigger tax break you get. And it's inefficient because it causes people to buy excessive health insurance. So everyone in the room said, "You want something that is real cost control that we know it will work, go after this."

    Now, the problem is, it's a political nightmare, ... and people say, "No, you can't tax my benefits." So what we did a lot in that room was talk about, well, how could we make this work? And Obama was like, "Well, you know" -- I mean, he is really a realistic guy. He is like, "Look, I can't just do this." He said: "It is just not going to happen politically. The bill will not pass. How do we manage to get there through phases and other things?" And we talked about it. And he was just very interested in that topic.

    Once again, that ultimately became the genesis of what is called the Cadillac tax in the health care bill, which I think is one of the most important and bravest parts of the health care law and doesn't get nearly enough credit. I mean, this is the first time after years and years of urging -- and the entire health policy, there was not one single health expert in America who is setting up a system from scratch, would have this employer subsidy in place. Not one.

    So after years and years of us wanting to get rid of this, to finally go after it was just such a huge victory for health policy. And I'm just incredibly proud that he and the others who supported this law were willing to do it. ...

    Is there a difference in the Obama you see in 2006 and the Obama you see, especially in the summer of 2009? ...

    You know, I would have thought -- in one case I'm sitting in his Senate office; in the other I'm in the Oval Office. One case he is just a senator, and the other he is the president. He is just so relaxing to be around. It was not stressful. It's just people going by. I was a little nervous. It's the president, after all. But he's just kind of interested in what people had to say.

    The way these meetings work is everyone gives their little five-minute spiel, and then he would make a comment or two, and they would go around, and then we would have a discussion.

    And he had a couple of remarks after everybody's, and he was clearly interested, and he was clearly thinking about it. But once again, it felt sort of like an academic meeting, not academic in the pejorative sense, academic like in the academy. It was just a fun, intellectual conversation. ...

    If you really want to see publicly how Obama works, then the key thing to do is watch that Blair House meeting. That, to me, is one of the proudest moments. That was an incredibly intellectual exercise where Obama sat in front of a bunch of people, including people very opposed, and held his own and discussed the policy issues and really, he is just a smart guy and interested in getting it right.

    That was the Obama you recognized?

    That was the Obama I recognized, yes.

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    Rahm Emanuel   White House chief of staff (2009-2010)

    He was Obama's chief of staff from 2009 to 2010 before he left the White House to run for Chicago mayor. Here, Emanuel discusses why the president ran into trouble in his attempts to create "a post-partisan environment and more productive Washington." This is the edited transcript of an interview conducted by producer Jim Gilmore on July 26, 2012.

    The process, though, that you guys underwent, by putting it into Congress' hands, by dealing with [Sen. Max] Baucus [D-Mont.] basically taking the lead role, by the courting of the Gang of Six and such, time was lost. When you look back at it now, was that a mistake? Was that a trap that you guys kind of got caught in? Was that something that could have been done differently?

    Look, you have a couple models here. You could send up a totally drawn, drafted health care bill, and then every change is a change is to the president's bill. Or you can send them a send them a set of principles that guide the legislative.

    Now, I remember being in the White House till 2:00 in the morning around the Cabinet table. So it's not like this Congress was -- I don't know. I remember being up in the speaker's office trying to get it out of a committee right before August recess.

    So the White House was intimately involved setting out broad principles that shouldn't be violated. And I remember him telling, in the Roosevelt Room, when he told the Republican members of the House and Senate, "Without this, this or this provision, I won't sign it." There were some bottom-line principles that had to be done.

    So you could look at what happened in the Senate Finance Committee, OK. You can also look at the end product and look that he basically changed 80 years of history, where other presidents, from Truman forward, didn't get.

    So can you look at a legislative moment in a time and say you would have done it different? Yeah, I suppose. But I also know this: It got done.

    At the time, though, were you biting on the bit, basically wishing that he would go less bipartisan and maybe do more --

    (Laughs.) First of all, you act like there was a willing hand on the other side. I find that a very interesting perspective. I'm not sure I would agree with that perspective.

    It's not news that I advocated a more modest bill, based on a series -- and he asked me for my honest opinions, even while he was pursuing this to check on whether he was on the right course, not because I thought there was going to be great bipartisanship, but for all the consequences of time in this, and what that means for the rest of your agenda that you need to get through.

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    David Axelrod   Senior strategist, Obama 2012 campaign

    (Text only) He was a senior White House political adviser until 2011, when he left to serve as a senior strategist on Obama's re-election campaign. This is the edited transcript of an interview conducted on July 26, 2012.

    Read the full interview »

    The Congress comes back. The GOP has doubled down. They have been spurred on by the Tea Party and such. They're up till then willing to cooperate. What's the reaction at that point [of] Obama to the vehement opposition, the hopes that he could turn them around, that this opposition had just grown stronger?

    He's not one to brood. He's not one to wring his hands. He's certainly not one to panic. And generally when things get more challenging, he gets more focused.

    That's what happened. He was just focused on how to, step by step, get this done. And obviously the vehemence of the opposition on the right was a factor that we had to consider. But it was never, for him, a source of discouragement or a signal that somehow we should surrender on the fight.

    Was it a hard decision to use reconciliation?

    No, I think that it was important to complete this piece of legislation. We were so close to getting it done, reconciliation was appropriate as a vehicle. And so we took the avenue that we did. I think that it would have been unthinkable to come that far and walk away from finishing the job.

    ... Did [the president] totally understand that he was putting Democrats at risk when it came to the vote, that ... he had basically staked his presidency on health care reform?

    First of all, history will never be able to determine what element of the outcome in 2010 was a result of that or other factors. We've come through a very difficult economic period, so I don't want to lay too much on the health care vote.

    But when he appealed to both caucuses, he freely acknowledged that this was a difficult vote and maybe even a hazardous vote for some. But he appealed to that same notion in them that was driving him, which is that we've got larger responsibilities, and we're on the cusp of doing something that will make a real and lasting difference. And isn't that why we get into this work?

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    Valerie Jarrett   White House senior adviser

    A close friend of Barack and Michelle Obama from their early years together in Chicago, Jarrett is now a senior adviser to the president. This is the edited transcript of an interview conducted by producer Jim Gilmore on Aug. 20, 2012.

    The health care story, of him turning to health care at a point when a lot of people said, "You know, this is not the direction to go; we have to deal with the economy," but he decided that he needed to do that. That is a fascinating story. ...

    Well, first of all, I would say this: The president, since day one, has always focused on the economy. The fact that he took on health care in addition to his focus on the economy did not in any way diminish the fact that he had almost daily meetings with his economic team, focusing on the economy. So I think we should keep in mind that while the press focused a lot on what was going on with the Affordable Care Act, the president never took his eye off the ball on the economy.

    On the Affordable Care Act, obviously it was an uphill battle all along, and there was a point of time after the midterms and after we had the town hall meetings, when Congress went on break in August, where you had all the talk about death panels and a lot of misinformation that was being spread around to scare people. So there was a period of time where the hill was looking steeper and steeper.

    There was one time we were in the Oval Office having a meeting with the president, and everyone on the team was very discouraged. His head of legislative affairs, Phil Schiliro, said, "Mr. President, unless you are feeling lucky, I just don't think we're going to get this done."

    And the president got up out of his chair and he walked over to his desk, and he looked out the window and he said, "Phil, where are we?" And Phil says, "We're in the Oval Office." And the president said, "And what's my name?" And he said, "Barack Obama." And he said: "Well, of course I'm feeling lucky. Now, get back to work and figure out how to get this passed."

    And I think his willingness to use humor with his team that was feeling totally demoralized, that there was no light at the end of this tunnel, and his ability to read the room and realize that with lightness and humor he could motivate us, and to tell us, "I'm not giving up," I think says a lot about the kind of leader he is. There is a determination and a commitment to not take his eye off what's good for the American people that has served him and our country well.

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    Related topics:
    Obama's Motivation

    Valerie Jarrett   White House senior adviser

    A close friend of Barack and Michelle Obama from their early years together in Chicago, Jarrett is now a senior adviser to the president. This is the edited transcript of an interview conducted by producer Jim Gilmore on Aug. 20, 2012.

    If there's one story about this man that you know, that you don't think people get, understand, that motivates him to a second term, what is it?

    Well, I'll tell you a story. The night that the health care passed, we had figured out that the votes were there, and I actually went home to watch on television. And the president's assistant called and said, "The president wants everybody to come back to the White House and watch it together," and that means everybody from the most junior staff person who worked on it to the vice president. So everyone was together and watched the vote, and then he invited everybody up to the Truman Balcony to celebrate. And this is about midnight, 1:30, 1:00 in the morning.

    As the crowd started to weed out -- and the president was so happy that night, he was just totally joyful and in a great mood -- I asked him, you know, "How does this night compare to election night?," because election night was a warm evening, obviously; everyone was out in Grant Park in Chicago and watching from around the world.

    And he looked at me and said: "Valerie, there's just no comparison. Election night was just about getting us to a night like this." So he has never been motivated by the political victory in itself. He has always used politics as a means to improve the quality of life for people. And the Affordable Care Act was so important to him because he knew how dramatically it would change the lives of so many Americans. You know, his mom died at a very early age, in her early 50s, and he wondered whether if she had been diagnosed earlier, might there have been a treatment, and even if there hadn't been one for her, for so many people who die early because they don't get adequate health care.

    Or he thought about Sasha when she was very young, she was very ill, and I remember talking to him when Sasha was in the hospital, and he says: "I can't breathe. It's so hard to breathe when your child is sick." Well, anyone who has had a sick child knows that feeling. So Sasha got well very quickly, and she received excellent care, but there are just so many young children who don't receive that care.

    So his life experiences are really what has really motivated him to work so hard. And it's not the politics; it's not the fact that he wants to be president. It's the fact that he wanted to dramatically improve our health-care system. That's what I think has made him such a great leader.

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