By Michael D. Shear and Ceci Connolly
Washington Post Staff Writers
Wednesday, September 9, 2009
From a back-row seat in the Illinois Senate chamber, Barack Obama listened silently as political adversaries mocked his health-care reform bill: Socialized medicine. Hillarycare redux. Too expensive. Back-door route to a single-payer system.
Then, as now, the fate of Obama's health-care-for-all vision rested largely on whether he could deflect the attacks and hold together a fragile, unlikely coalition in support of change. The 2004 fight for the Health Care Justice Act in Illinois tested not only his skills as a legislator and community organizer, but his powers of persuasion as well.
It was, in a sense, a practice run for this year's health-care campaign.
On Wednesday night, Obama will rise once again to defend a major policy initiative in jeopardy. What began as a popular idea from an even more popular president has bogged down in bitter talk of "death panels," anxiety about the nation's soaring deficit and splits within the Democratic Party over the role of government.
The president brings to the current battle skills honed five years ago -- the last time he heavily invested political capital in the treacherous issue. Just as he did in Springfield, Ill., Obama has approached this year's debate with an appetite for broad consensus, even if compromises along the way have disappointed some of his most loyal backers.
Obama has reached out to doctors, Republican lawmakers and even the industry players he often denounces. He has moved methodically -- some say ploddingly -- and has framed even modest achievements as major advances. And he has so far declined to clearly spell out his specific desires.
All were also hallmarks of his first major health-care fight, according to interviews with more than three dozen friends, adversaries and former colleagues. But with time running out to get something done this year, the president finds himself under enormous pressure to engage.
When he spoke on the floor of the Illinois Senate five years ago, Obama's 18 months of work had reached a critical juncture. In much the same way, his address to a joint session of Congress on Wednesday is a signal moment in a cliffhanger drama that could go either way.A New Focus
The telephone on Jim Duffett's desk rang. It was a week after the 2002 elections, and Democrats in Illinois had taken control of the legislature. He picked up the phone and heard Barack Obama's voice.
Obama wanted to discuss health care with Duffett, the head of a liberal coalition advocating a single-payer health-care system in Illinois. Obama was about to become the chairman of the state Senate's health committee.
"He said: 'I want to do public hearings. I'm now the chair. I want to do public hearings on affordable, accessible, guaranteed access," Duffett recalled in an interview recently.
At that moment, they were a pair made for each other. But little in Obama's past had signaled that he would try to make health care his legacy.
As an organizer on the streets of Chicago in the mid-1980s, Obama saw health care through the prism of larger economic woes as Midwestern steelworkers lost their jobs and health insurance. Later, in 1995, he watched in frustration as his mother battled both uterine cancer and her insurance companies.
But as a public policy matter, the issue rarely animated Obama. Friends and former professors at Harvard Law School say the topic did not come up during Obama's three years there. Elected to the Illinois Senate in 1997, he made his mark with issues such as racial profiling and the death penalty. Health care was a modest part of his portfolio, focusing on efforts to expand insurance coverage for children and low-income parents.
As 2002 drew to a close, Duffett's group, the Campaign for Better Health Care, was starting a new push for universal coverage and needed a champion. After visiting with Obama, Duffett knew he had found one.
Obama had decided to run for the U.S. Senate, and just a few weeks earlier, in a newspaper column, he bragged about being the "chief sponsor" of a state constitutional amendment named after the late Chicago Cardinal Joseph Bernardin. If enacted, he wrote, it "would change Illinois to a single-payer system where everyone received health benefits."
Soon, Obama and Duffett were in Carbondale, in southwest Illinois, for a meeting to plot strategy on the Health Care Justice Act.
In its original form, the legislation was a far-reaching effort to require Illinois to cover each of its 12 million residents -- at a potentially huge cost. It would direct the state to implement broad reforms to insurance regulation and health-care delivery. And if it worked in Illinois, larger efforts were possible.
"Barack saw a concept he could take nationally," said William Delgado (D), the bill's chief sponsor in the House, who attended the Carbondale meeting.
Passing such an ambitious measure would require broad buy-in, and Obama spent much of the next year courting special interest groups with stakes in health-care reform.
One of his targets was Phil Lackman, a poker buddy and lobbyist for the Independent Insurance Agents of Illinois. Lackman complained that the bill was "very one-sided" and that it read as though a move to European-style, single-payer health system was "predetermined."
Seated alone with Lackman in his statehouse office, Obama "listened a lot," Lackman recalled. "He acknowledged these were not unreasonable concerns."
Obama was patient but persistent. One day on the Senate floor, he approached fellow Democrat Denny Jacobs, an ally of the powerful insurance industry. Jacobs, the conservative river-town senator, predicted the bill would bankrupt the state; Obama, the urban liberal, argued that covering everyone was the only way to reduce costs.
"He worked it slow but sure," Jacobs said. "Barack doesn't let too much grass grow under his feet. If he's got an idea that he thinks is good, he's going to push it."Grass-Roots Strategy
Central to Obama's Illinois strategy was an effort to choreograph grass-roots activities across the state, much as his White House has tried to mobilize support for the current health-care initiative with town hall forums and online organizing. Obama understood then, as he believes now, that to win lawmakers' votes, he had to show how the issue resonates with constituents back home.
"I need to see that there is broad, widespread support in all these districts," Obama told organizers such as William McNary of Citizen Action/Illinois. "He was an organizer on the inside of the Senate," McNary recalled.
Despite those efforts, Obama made little headway in winning support from insurance companies and other industry players.
When cajoling did not work, Obama gave ground. To secure votes, he had stripped out most of the bill's teeth, dropping the mandates that might have forced action. His desire to build a coalition had meant largely abandoning the legislation's early, lofty goals.
The original concept of creating a task force with the power to draw up a plan for covering everyone gave way slowly to a more modest proposal. In the end, the bill would do little more than study the problem.
With not much hesitation, Obama accepted "technical changes which allowed the special interests more buy-in," McNary said. When industry demanded representation on the task force, for example, Obama capitulated. Even the title of the task force was subject to compromise. Obama's legislation called it the Health Care Justice Task Force. But when one Republican took offense at the name, griping that it implied there was no justice in the existing health-care system, Obama agreed to call it the Adequate Health Care Task Force, McNary recalled. "Stuff like that, Barack understands you just do to get it done."
The process revealed a side of Obama that supporters say characterizes his governing style. "His reputation was always one to be inclusive and to figure out ways to gain support from people not intuitively on board," said Valerie Jarrett, a senior White House adviser who has been close to Obama since the early 1990s.
"He's always been very methodical about the legislative process, in terms of allowing there to be an airing of views and then pulling together something that can work," said David Axelrod, a senior White House adviser who was then one of Obama's chief political strategists. "One of the things you have to judge is what you can achieve, and he made a judgment at the time that was what was achievable."
As the months stretched on and the end of the 2004 legislative session approached, Duffett and one coalition partner, Robyn Gabel of the Illinois Maternal & Child Health Coalition, grew weary of Obama's slow pace and endless quest for support from the most unlikely quarters. The pair doubted that the insurers would ever come on board.
"I kept saying, 'Stop trying to see both sides and just move this thing forward,' " Gabel said.An Impassioned Speech
Even with all of his concessions, Obama still faced opposition to the watered-down measure. On May 19, 2004, as the legislative session in Springfield drew to a close, Republican Sen. Pete Roskam derided Obama's bill as "socialized medicine" and "a bill with an agenda."
Then it was Obama's turn.
As he rose to rebut the critics, he had much riding on his ability to counter the attacks. His success as a national politician depended, at least in part, on his performance.
"I would challenge you to find something in there that suggests anything remotely close to socialized medicine," Obama began, scolding Roskam. ". . . If you want to debate Hillary Clinton's bill from 1992, that's fine. But the notion that you would blatantly characterize this bill as being that is dishonest."
Gathered in the chamber, under the bas-relief sculpture of Manifest Destiny, were the senators who would vote that evening. Watching from the gallery was Delgado, who had begun the quest with Obama 18 months earlier and pushed the bill through the House.
Obama was known as a cool -- some say detached -- politician, rarely prone to emotion. But lawmakers saw another side of him that evening.
"He's nonconfrontational, non-antagonistic," Delgado said. "But when all of a sudden he lets it out like he did on that last day, people say, 'Wow, he really cares about this.' "
Obama hit back hard.
"There have been some back-and-forths between myself and the insurance industry, which was originally concerned that somehow this was a Trojan horse to introduce single-payer," he said, responding to Roskam's critique. "I want to say on record that I am not in favor of a single-payer plan. I don't think that we can set up that kind of plan, and if we were going to even attempt to some sort of national health care, that would have to, obviously, be done at the federal level."
Summoning a story he would repeat during his 2004 speech at the Democratic National Convention, Obama talked about a father he met who would soon lose his job and health insurance after being laid off from a plant in Butler, Ill. His son needed $4,500 worth of drugs because of a liver transplant, Obama said.
"And he's trying to figure out, once he loses his job and his health insurance, how in the heck he's going to be able to provide drugs to keep his son alive," Obama said, his passions rising.
"The notion that somehow that all is hunky-dory and we can characterize this with a bunch of ad hominem attacks and play politics with this situation is not going to satisfy that man and -- and -- and his wife," he continued. ". . . If you want to vote no on this bill, vote no on it, but don't lie about it."
He closed with a refrain that is likely to be echoed in his speech Wednesday in Washington, bluntly warning about the dangers of inaction and pleading for pragmatism.
"Now, we can choose to do nothing," Obama said. "That is an option. We can say that, you know, we're just going to muddle through, primarily because everybody in this chamber has health insurance. I don't think that's an option. I don't think muddling through and pretending as if the problem doesn't exist or characterizing attempts to deal with the problem, in broad strokes, as socialized medicine is going to address the real needs of these families."
Obama's speech that night barely acknowledged how his original vision for universal health coverage had evaporated. "So what I've done," he said, winding down, "is I've put together a bill that suggests, let's all sit down and actually try to figure out how to solve a problem."
When the roll was called, the tally was 31 to 26. Obama's bill had passed.
The task force created by the legislation recommended that the state aim to cover 90 percent of the uninsured by requiring everyone to buy insurance and offering subsidies to those who couldn't afford it. Many of those changes were embraced in proposals offered by then-Gov. Rod Blagojevich (D).
Those hopes remain unfulfilled. The cost of the proposals and the governor's personal scandals doomed them, leaving Illinois residents to wait with the rest of the country as Obama pursues similar goals once again.
Still, Axelrod called the result in Illinois "a step forward, certainly better than nothing. He's very much of a mind that, you know, that achieving something is better than achieving nothing."
Research editor Alice Crites and staff researcher Madonna Lebling contributed to this report.