Inside the Passage of Health Care Reform

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Jonathan Cohn may be the smartest, most well-sourced health care writer in the country. When I was first assigned to the health care beat in early 2009, his book Sick was among my required reading.

Today, he unveils the first in a series of five pieces that explain how the White House and congressional Democrats passed health care reform. Several others have attempted to tell this story, Frontline and Sam Stein among them. But Cohn is the master of explanatory reporting that combines health policy and politics. His series is worth reading in full.

It is the story of a president with transformational aspirations, a congressional party ill at ease with power, political institutions that have been roundly written off as sclerotic, and an experiment in government action that has only just begun.

One section of this first Cohn piece that caught my eye was about President Obama’s decision to buck his advisors, who worried health care reform was a political loser. Arrogance or bold leadership?

Obama had come to view this debate as a proxy for the deepest, most systemic crises facing the country. It was a test, really: Could the country still solve its most vexing problems? If he abandoned comprehensive reform, he would be conceding that the United States was, on some level, ungovernable. Besides, several aides recall him saying, “I feel lucky.”

After the meeting broke up, a few of his advisers milled in the hallways outside the Oval Office, pondering the prospect of taking up such a high-risk strategy because the president “felt lucky.” As one of them later told me, “It was like, holy sh*t.”

The story also lays out how President Obama played politics with health reform all the way to the White House. He opposed Hillary Clinton’s individual mandate – a requirement that all Americans maintain insurance coverage – and won the Democratic nomination. Then, in the general campaign, he hammered John McCain for suggesting the government eliminate the tax-free status of employer sponsored insurance. But once in office, Obama’s health care plan included both of these ideas – the reform includes an individual mandate and limits, although does not eliminate, the tax-free status of employer-sponsored insurance.

These look like shrewd political calculations, although Cohn points out something Karen has highlighted – Obama didn’t really understand the complexities of health care reform as a candidate. It was only once he became President that he buckled down to master the wonkery of health care policy.