Living History (25 page)

I heard the warnings, but I didn’t fully realize the magnitude of what we were undertaking.

My work in Arkansas running the rural health care task force and the Arkansas Education Standards Commit tee didn’t rival the scale of health care reform. But both efforts were considered successful and made me excited and hopeful as I took on this new challenge. The biggest problem seemed to be the deadline that Bill announced. He had won the election in a three-way race with less than a majority of the popular vote―43

percent―and he couldn’t afford to lose whatever political momentum he had at the beginning of the new administration. James Carville, our friend, adviser and one of the most brilliant tactical minds in American politics, had given Bill this warning: “The more time we allow for the defenders of the status quo to organize, the more they will be able to marshal opposition to your plan, and the better their chances of killing it.”

Democrats in Congress were also urging us to move quickly. A few days after Bill’s announcement, House Majority Leader Dick Gephardt asked to meet with me. He was known on Capitol Hill for his Midwestern roots and sensibilities, as well as his command of budget issues. His compassion for people in need reflected his upbringing, and his commitment to health care reform was heightened by his son’s bout with cancer years earlier. Through position and experience, Gephardt would be a leading voice in any health care deliberations in the House. On February 3, Gephardt and his top health care aide came to my West Wing office to discuss strategy. For the next hour, we listened as Gephardt outlined his concerns about health care reform. It was an intense meeting.

One of Gephardt’s chief worries was that we would be unable to unify Democrats, who were seldom united under the best of circumstances. Health care reform widened existing divisions. I thought of the old Will Rogers joke:

“Are you a member of any organized political party?”

“No, I’m a Democrat.”

I knew of the potential divisiveness but hoped that a Democratic Congress would rally around a Democratic President to show what the party could accomplish for America.

Democratic members had already begun to outline their own models for reform in order to influence the President’s plans. Some proposed a “single payer” approach, modeled on the European and Canadian health care systems, which would replace the current employer-based system. The federal government, through tax payments, would become the sole financier-or single payer-of most medical care. A few favored a gradual expansion of Medicare that would eventually cover all uninsured Americans, starting first with those aged fifty-five to sixty-five.

Bill and other Democrats rejected the single-payer and Medicare models, preferring a quasi-private system called “managed competition” that relied on private market forces to drive down costs through competition. The government would have a smaller role, including setting standards for benefit packages and helping to organize purchasing cooperatives.

The cooperatives were groups of individuals and businesses forged for the purpose of purchasing insurance. Together, they could bargain with insurance companies for better benefits and prices and use their leverage to assure high-quality care. The best model was the Federal Employees Health Benefit Plan, which covered nine million federal employees and offered an array of insurance options to its members. Prices and quality were monitored by the plan’s administrators.

Under managed competition, hospitals and doctors would no longer bear the expense of treating patients who weren’t covered because everyone would be insured through Medicare, Medicaid, the veterans and military health care plans or one of the purchasing groups.

Perhaps most important, the system would allow patients to choose their own doctors, a non-negotiable item in Bill’s view.

Given the multitude of approaches to health care reform, feelings in Congress ran deep, Gephardt told us. Just a week earlier, he had held a health care meeting in his House office in which two members of Congress disagreed so violently that they nearly came to blows. Gephardt was emphatic that our best hope for passage was to attach health care reform to a budget bill known as the Budget Reconciliation Act, which Congress usually voted on in late spring. “Reconciliation” combines a variety of congressional budget and tax decisions into one bill that can be approved or disapproved by a simple majority vote in the Senate without the threat of a filibuster, a delaying tactic often used to kill controversial legislation, which requires sixty votes to break. Many budget items, particularly those relating to tax policy, are so complicated that debate can endlessly tie up proceedings in the full House and Senate. Reconciliation is a procedural tool designed to move controversial tax and spending bills through Congress. Gephardt was suggesting that it be used in an unprecedented way: to legislate a major transformation in American social policy.

Gephardt was sure that Republicans in the Senate would filibuster any health care package we put forward. He also knew that the Senate Democrats would have trouble mustering sixty votes to stop it, given that Democrats held only a fifty-six to forty-four advantage.

Gephardt’s strategy, therefore, was to circumvent a filibuster by putting health care reform into the budget reconciliation package. A simple majority would be required to pass the bill, and Vice President Gore could cast the tiebreaking fifty-first vote, if needed.

Ira and I knew that Bill’s economic team inside the White House would likely reject a budget reconciliation strategy that included health care because it could complicate the administration’s efforts on the deficit reduction and economic plan. We broke up our meeting, and I took Gephardt straight to the Oval Office to make his case directly to Bill.

Bill was convinced by Gephardt’s argument and asked Ira and me to explore the idea with the Senate leadership.

Armed with Gephardt’s suggestions and Bill’s encouragement, Ira and I trooped up to Capitol Hill the following day to meet with Majority Leader George Mitchell in his office in the Capitol. This was the first of hundreds of visits I made to members of Congress over the course of health care reform. Mitchell’s soft-spoken demeanor belied his toughminded leadership of the Senate Democrats. I respected his opinion, and he agreed with Gephardt. Health care would be impossible to pass unless it was part of reconciliation.

Mitchell was also nervous about the Senate Finance Committee, which would otherwise have jurisdiction over many aspects of health care legislation. He was particularly worried that committee Chairman Daniel Patrick Moynihan of New York, a veteran Democrat and a skeptic about health care reform, would react badly to the plan. Moynihan was an intellectual giant and an academic by training―he had taught sociology at Harvard before running for the Senate―as well as an expert on poverty and family issues. He had wanted the President and Congress to take up welfare reform first. He wasn’t happy when Bill announced his one-hundred-day target for health care legislation―and he let everyone know it.

At first I found his position frustrating, but I began to understand. Bill and I shared Senator Moynihan’s commitment to welfare reform, but Bill and his economic team believed that the government would never get control of the federal budget deficit unless health care costs went down. They had concluded that health care reform was essential to his economic policy and that welfare could wait. Senator Moynihan anticipated how hard it would be to get health care through his committee. He knew he was going to be responsible for shepherding Bill’s economic stimulus package through the Finance Committee and onto the Senate floor. That in itself would require extraordinary political skill and leverage. Some Republicans were already publicizing plans to vote against it, no matter what it contained. And some Democrats might need convincing, particularly if the package involved a tax increase.

We left Mitchell’s office with a clearer sense of what needed to be done, particularly on reconciliation. Now we had to convince the economic team―notably Leon Panetta, Director of the Office of Management and Budget―that including health care reform in reconciliation would serve the overall economic strategy the President was pursuing, not divert attention from the deficit reduction plan. Bill only had so much political capital to work with, and he had to use it to get the deficit down, one of his central campaign promises.

The thinking in some quarters of the West Wing was that Bill’s focus on health care would divert Americans from his economic message and muddy the political waters.

We also had to convince Senator Robert C. Byrd of West Virginia that health care reform belonged in reconciliation. The Democratic Chairman of the Senate Appropriations Committee, Byrd had served in the Senate by then for thirty-four years. Stately and silver-haired, he was the unofficial historian of the Senate and a parliamentary genius, famous for standing in the well of the chamber and dazzling his colleagues with quotations from the classics. He was also a stickler for procedural rules and decorum and had invented a procedural hurdle called the “Byrd rule” to ensure that items placed in the Budget Reconciliation Act were germane to budget and tax law. Democracy was undermined, in his view, if reconciliation was cluttered with bills that had little to do with passing the nation’s budget. Health care, arguably, was a budget bill, as it affected spending, taxes and entitlement programs. But if Senator Byrd thought differently, we would need a waiver of his rule to allow the measure into reconciliation.

Slowly, I was learning what a steep mountain we were climbing. In the absence of an overwhelming crisis like a depression, passing either the economic or the health care plan was going to be difficult; passing both seemed almost insurmountable. Health care reform might be essential to our long-term economic growth, but I didn’t know how much change the body politic could digest at one time.

Our goals were simple enough: We wanted a plan that dealt with all aspects of the health care system rather than one that tinkered on the margins. We wanted a process that considered a variety of ideas and al lowed for healthy discussion and debate. And we wanted to adhere to congressional wishes as much as we could.

Almost immediately, we hit turbulence.

Bill had assigned Ira the task of setting up the process for health care reform, which turned out to be an unfair burden for someone who was not a Washington insider. In addition to the President’s Task Force, which consisted of me, the cabinet secretaries and other White House officials, Ira organized a giant working group of experts divided into teams that would consider every aspect of health care. This group, comprising as many as six hundred people from different government agencies, Congress and health care groups, and including physicians, nurses, hospital administrators, economists and others, met regularly with Ira to debate and review specific parts of the plan in detail. The group was so large that some members concluded they were not at the center of the action where the real work was getting done. Some got frustrated and stopped coming to meetings. Others became narrowly interested in their own piece of the agenda, rather than invested in the outcome of the overall plan. In short, the attempt to include as many people and viewpoints as possible―a good idea in principle―ended up weakening rather than strengthening our position.

On February 24, we were dealt a blow that none of us anticipated. Three groups affiliated with the health care industry sued the task force over its composition, claiming that because I was not technically a govemment employee (First Ladies derive no salary), I was not legally allowed to chair or even attend closed task force meetings. These groups had seized on an obscure federal law designed to prevent private interests from surreptitiously influencing government decision making and usurping the public’s right to know.

There was certainly nothing secret about hundreds of people participating in this process, but the press, which was not invited to meetings, jumped on the issue. If I was allowed in the meetings, the lawsuit claimed, government sunshine laws required that the closed meetings be opened to outsiders, including the press. It was a deft political move, designed to disrupt our work on health care and to foster an impression with the public and the news media that we were conducting “secret” meetings.

Soon thereafter, we got more bad news, this time from Senator Byrd. Every Democratic emissary we could think of, including the President, had asked him to allow health care reform into reconciliation. But on March 11, in a phone call with the President, the Senator said he objected on procedural grounds and that the “Byrd rule” would not be waived. The Senate was permitted to debate reconciliation bills for only twenty hours, which he viewed as insufficient time on a health care reform package of such magnitude.

It was just too complicated an issue for reconciliation, he told Bill. In retrospect and based on my service in the Senate, I agree with his assessment. At the time, it was a political setback that forced us to refocus our strategy and figure out how to get health care reform through the normal legislative process. Hastily, we held meetings with members of the House and Senate to nail down elements of the plan we would deliver to Congress.

We didn’t see that Byrd’s opinion on reconciliation was a giant red flag. We were trying to move too quickly on a bill that would fundamentally alter American social and economic policy for years to come. And we were already losing the race.

In this climate, and with Bill weathering controversies over gays in the military and his nominations for Attorney General, we savored any successes that came our way. In the middle of March, the House passed Bill’s economic stimulus package, and my staff and I decided to have our own small celebration. On March 19, about twenty of us gathered for lunch in the White House Mess. The room, with its oak-paneled walls, Navy memorabilia and leather-cushioned chairs, was a perfect setting for private conversation and as much laughter as we could muster. The gathering offered me a rare opportunity to let my hair down with trusted aides and speak my mind about whatever topic was under discussion. From the moment I set foot in the room, I could feel my mood lighten and my mind relax for the first time in days.