Each time I met a parent struggling to come up with the money to get treatment for a sick child, I thought back to the night Michelle and I had to take three-month-old Sasha to the emergency room for what turned out to be viral meningitis. I remembered the terror and the helplessness we felt as the nurses whisked her away for a spinal tap, and the realization that we might never have caught the infection in time had the girls not had a regular pediatrician we felt comfortable calling in the middle of the night.
Most of all, I thought about my mom, who had died in , of uterine cancer. In mid-June, I headed to Green Bay, Wisconsin, for the first in a series of health-care town-hall meetings we would hold around the country, hoping to solicit citizen input and educate people on the possibilities for reform. Introducing me that day was a local resident named Laura Klitzka, who was thirty-five years old and had been diagnosed with aggressive breast cancer that had spread to her bones.
Over the objections of her husband, Peter, she was now pondering whether more treatment was worth it. Sitting in their living room before we headed for the event, she smiled wanly as we watched Peter doing his best to keep track of their two young kids playing on the floor.
The unspoken regrets. It would probably come too late to help Laura Klitzka and her family. And that was worth fighting for. The question was whether we could get it done. Any major health-care bill meant rejiggering a sixth of the American economy. Legislation of this scope was guaranteed to involve hundreds of pages of endlessly fussed-over amendments and regulations. A single provision tucked inside the bill could translate to billions of dollars in gains or losses for some sector of the health-care industry.
A shift in one number, a zero here or a decimal point there, could mean a million more families getting coverage—or not. Across the country, insurance companies were major employers, and local hospitals served as the economic anchor for many small towns and counties. People had good reasons—life-and-death reasons—to worry about how any change would affect them. There was also the question of how to pay for the changes. In theory, that was true. In other words, both the politics and the substance of health care were mind-numbingly complicated.
I was going to have to explain to the American people, including those with high-quality health insurance, why and how reform could work. One thing Rahm and I did agree on was that we had months of work ahead of us, and we needed a topnotch health-care team to keep us on track. Luckily, we were able to recruit a remarkable trio of women to help run the show. Jeanne Lambrew, a professor at the University of Texas and an expert on Medicare and Medicaid, became the director of the H.
Office of Health Reform, basically our chief policy adviser. I did know that when she was seventeen her mom died of lung cancer.
Our team began to map out a legislative strategy. Based on our experiences with the Recovery Act, we had no doubt that Mitch McConnell would do everything he could to torpedo our efforts, and that the chances of getting Republican votes in the Senate were slim.
We could take heart from the fact that, instead of the fifty-eight senators who were caucusing with the Democrats when we passed the stimulus bill, we were likely to have sixty by the time any health-care bill actually came to a vote. Al Franken had finally taken his seat after a contentious election recount in Minnesota, and Arlen Specter had decided to switch parties after being effectively driven out of the G. Beyond wanting some margin for error, I also knew that passing something as monumental as health-care reform on a purely party-line vote would make the law politically more vulnerable down the road.
So we thought it made sense to shape our legislative proposal in such a way that it at least had a chance of winning over a handful of Republicans. Fortunately, we had a model to work with—one that, ironically, had grown out of a partnership between Ted Kennedy and the former Massachusetts governor Mitt Romney. A few years earlier, confronting budget shortfalls and the prospect of losing Medicaid funding, Romney had become fixated on finding a way to get more Massachusetts residents properly insured, which would then reduce state spending on emergency care for the uninsured and, ideally, lead to a healthier population in general.
With a huge new pool of government-subsidized customers, insurers no longer had a financial incentive for trying to cherry-pick only the young and the healthy for coverage.
And the mandate would prevent people from gaming the system by waiting until they got sick to purchase insurance. Had we been starting from scratch, I would have agreed with them; the evidence from other countries showed that a single, national system—basically, Medicare for All—was a cost-effective way to deliver health care.
But neither Massachusetts nor the United States was starting from scratch. Teddy, who despite his reputation as a wide-eyed liberal was ever practical, understood that trying to dismantle the existing system and replace it with an entirely new one would be both a nonstarter politically and hugely disruptive to the economy.
Teddy had used it as the basis for draft legislation he had started preparing many months ahead of the election, in his role as the chair of the Senate Health and Education Committee.
People still differed on the details of what a national version of the Massachusetts plan might look like, and a number of advocates urged us to settle these issues early by putting out a specific White House proposal for Congress to follow. We decided against that. On the House side, this meant working with old-school liberals like Henry Waxman, the wily, pugnacious congressman from California and the head of the Energy and Commerce Committee, which had jurisdiction over health care.
Every job has its share of surprises. A key piece of equipment breaks down. A traffic accident forces a change in delivery routes. No matter where you work, you need to be able to improvise to meet your objectives, or at least to cut your losses. The Presidency was no different.
In the course of the spring and summer of that first year, as we wrestled with the financial crisis, two wars, and the push for health-care reform, another unexpected item got added to an already overloaded agenda.
In April, reports surfaced of a worrying flu outbreak in Mexico. The flu virus usually hits vulnerable populations like the elderly, infants, and asthma sufferers hardest, but this strain appeared to strike young, healthy people—and was killing them at a higher than usual rate.
Within weeks, people in the United States were falling ill with the virus: one in Ohio, two in Kansas, eight in a single high school in New York City. By the end of the month, both our own Centers for Disease Control and the World Health Organization had confirmed that we were dealing with a variation of the H1N1 virus.
In June, the W. I had more than a passing knowledge of H1N1 after working on U. What I knew scared the hell out of me. In Philadelphia alone, more than twelve thousand died in the span of a few weeks. The effects of the pandemic went beyond the stunning death tolls and the shutdown of economic activity; later research revealed that those who were in utero during the pandemic grew up to have lower incomes, poorer educational outcomes, and higher rates of physical disability.
It was too early to tell how deadly this new virus would be. On the same day that Kathleen Sebelius was confirmed as H. Secretary, we sent a plane to pick her up from Kansas, flew her to Washington to be sworn in at a makeshift ceremony in the Oval Office, and immediately asked her to lead a two-hour conference call with W.
A few days later, we pulled together an interagency team to evaluate how ready the United States was for a worst-case scenario. Over the course of the next six months, we did exactly that. A summertime dip in H1N1 cases gave the team time to work with drugmakers and incentivize new processes for quicker vaccine production. They pre-positioned medical supplies across regions and gave hospitals increased flexibility to manage a surge in flu cases.
They evaluated—and ultimately rejected—the idea of closing schools for the rest of the year, but worked with school districts, businesses, and state and local officials to make sure that everyone had the resources they needed to respond in the event of an outbreak. Although the United States did not escape unscathed—more than twelve thousand Americans lost their lives—we were fortunate that this particular strain of H1N1 turned out to be less deadly than the experts had feared.
Still, I took great pride in how well our team had performed. Without fanfare or fuss, they not only helped keep the virus contained but strengthened our readiness for any future public-health emergency—which would make all the difference several years later, when the Ebola outbreak in West Africa triggered a full-blown panic.
This, I was coming to realize, was the nature of the Presidency: sometimes your most important work involved the stuff nobody noticed. The slow march toward health-care reform consumed much of the summer.
As the legislation lumbered through Congress, we looked for any opportunity to help keep the process on track. The good news was that the key Democratic chairs—especially Baucus and Waxman—were working hard to craft bills that they could pass out of their respective committees before the traditional August recess.
The bad news was that the more everyone dug into the details of reform, the more differences in substance and strategy emerged—not just between Democrats and Republicans but between House and Senate Democrats, between the White House and congressional Democrats, and even between members of my own team. Most of the arguments revolved around the issue of how to generate a mixture of savings and new revenue to pay for expanding coverage to millions of uninsured Americans.
Baucus, given his interest in producing a bipartisan bill, hoped to avoid anything that could be characterized as a tax increase. Instead, he and his staff had calculated the windfall profits that a new flood of insured customers would bring to hospitals, drug companies, and insurers, and had used those figures as a basis for negotiating billions of dollars in up-front contributions—through fees or Medicare-billing reductions—from each industry.
To sweeten the deal, Baucus was also prepared to make certain policy concessions. Politically and emotionally, I would have found it a lot more satisfying to just go after the drug and insurance companies and see if we could beat them into submission.
They were wildly unpopular with voters, and for good reason. We had no way to get to sixty votes in the Senate for a major health-care bill without at least the tacit agreement of the big industry players. It was a big hurdle to clear, a case of politics as the art of the possible. But for some of the more liberal Democrats in the House, where no one had to worry about a filibuster, and among progressive advocacy groups that were still hoping to lay the groundwork for a single-payer health-care system, our compromises smacked of capitulation, a deal with the devil.
Quick as the House Democrats were to mount their high horse, they were also more than willing to protect the status quo when it secured their prerogatives or benefitted politically influential constituencies. Otherwise, any new money put into the system would yield less and less care for fewer and fewer people over time. House Democrats hated the idea. And so long as the unions were opposed to the Cadillac tax, most House Democrats were going to be, too.
The squabbles quickly found their way into the press, making the whole process appear messy and convoluted. By late July, polls showed that more Americans disapproved than approved of the way I was handling health-care reform, prompting me to complain to Axe about our communications strategy. Toward the end of the month, versions of the health-care bill had passed out of all the relevant House committees. The Senate Health and Education Committee had completed its work as well.
Once that was done, we could consolidate the different versions into one House and one Senate bill, ideally passing each before the August recess, with the goal of having a final version of the legislation on my desk for signing before the end of the year.
As the summer wore on, his optimism that he could produce a bipartisan bill began to look delusional. From that point on, conservatives followed the script, repeating the phrase like an incantation. Unsurprisingly, given the atmosphere, the group of three G. My team and I did everything we could to help Baucus win their support. But was such opposition set in stone? That left Republicans to be wooed by a new and charismatic Democratic president—far fewer than what was needed to break gridlock.
But a president who would not court members of his own party was not likely to try or to be successful at courting members of the other party, either. In the summer of , for example, Obama tried to pass a comprehensive cap-and-trade bill to combat climate change.
It was replaced by an aggressive strategy of executive actions, from the Clean Power Plan to the Paris climate accords. Obama, for instance, presided over a Justice Department that made meaningful gestures toward reducing incarceration and demanding accountability for police violence. But these moves can be undone by the current attorney general, Jeff Sessions, leaving Peniel E. As Sarah R. Of course there were successes in the Obama administration that appear to be sustainable.
The fact that the Affordable Care Act escaped congressional repeal by the skin of its teeth is one bright spot in an otherwise dreary picture, even though the Trump administration continues to undermine it at every step. Meaningful, sustained progress on policy requires some continuity in the political base. Rather than remake the Democratic Party from top to bottom, Obama opted to focus his political hopes on the continued success of his campaign, Obama for America.
The Presidency of Barack Obama is a good example of how hard it is to write history quickly. In the end there are only two ways a president can forge a legacy in U. For him, the first path was difficult—and some would say impossible. In the primaries, candidates sought out the sweet spot within their own parties, whether through winning support from party insiders — or, with the reforms that began after , through winning the votes of party members in state primary and caucus elections.
But in the general election, the two sides competed to find the center of public opinion in the country as a whole. Each party's presidential ticket did this by making a pitch for the whole: This is how I see America. This is what I think of our ideals, our history, our actions in the past and present, and our destiny moving forward into the future.
The candidate who got the most people to endorse his comprehensive vision of the nation would win the presidency, with the victor usually earning a majority of the popular vote, and sometimes an overwhelming majority, as happened in , , and But as the GOP vote share in national elections has declined since , the Republican nominee has won a majority of the popular vote in a presidential contest only once, in , and then with just George W.
Bush experimented with this approach in his re-election bid , but it is Trump who deployed it to greatest effect in , and who has governed that way since taking office. It's the politics of populism that provides the rationale and playbook here. Populism differs from democratic majoritarianism in treating only some of the people — one's own supporters — as the real people.
Those who vote for the Republican are the true Americans. Those who oppose the Republican are false or fake Americans. This approach to gaining and holding power can be remarkably effective in the right political circumstances. But it is vulnerable to a moral critique because it actively pursues the exercise of political rule by appealing to a part of the country rather than the whole of the country. That's why, when someone of Barack Obama's stature speaks eloquently in the name of a greater and broader democratic, majoritarian whole, it stings.
Interestingly, the Republican response to such criticism isn't a pledge to broaden its appeal but an angry denial of the criticism's moral gravity based on a furious effort to denigrate the messenger — to reduce the critic to the same level of partisanship, to deny his elevation and pull him down to the same moral level of the populist. One could imagine them inverting an old line from the Obama years: "When they go high, we go low.
That's the low ground on which Republicans think they can compete and win. Which is why their surest path to victory necessitates that they deny the possibility of elevation altogether. That's also why Democrats need to follow Obama's example and keep aiming higher — and broader, electorally. In striving to speak for more of the country than present-day Republicans, Democrats validate their aspiration to speak also for what's right for the country, and to lead the effort to make it better and more perfect — and to expose their opponents' efforts to do the reverse.
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