This article is part of a series on Barack Obama’s presidency, nine years after he announced his White House bid on Feb. 10, 2007. To read the rest of the series click here.
Less than 48 hours before the final vote on the Affordable Care Act, President Obama was irritated.
Jason Altmire, a centrist Democratic congressman representing the Pittsburgh area, had just announced he would vote against ObamaCare. The White House needed every vote it could get, with the bill in serious jeopardy of dying on the House floor.
Altmire’s phone rang at 7:30 p.m. on Friday, March 19, 2010. It was the president.
“What’s the matter?” Obama asked. “We didn’t give you enough attention?”
{mosads}The administration had given Altmire plenty of attention in the first few months of 2010: trips to the White House, private conversations with Obama and Vice President Biden, as well as many long discussions with then-White House chief of staff Rahm Emanuel.
Altmire voted no on the House ObamaCare legislation in 2009 and had been undecided on the final measure, concerned about the bill’s cost-containment provisions. He was seen as a pivotal vote because of the 15 years he spent on healthcare policy, both as a congressional staffer or a hospital executive.
Obama was well aware that he wasn’t going to change Altmire’s mind that Friday night. But he had a pointed question for the lawmaker, who was a top target for Republicans in the 2010 election.
He told Altmire that every newspaper in the country would soon have front-page headlines after Congress passed the bill, the most significant change in social policy in decades. And Obama wanted to know how he would feel “not being part of the team.”
The tense moment showed how confident Obama was that the Affordable Care Act would pass. At that time, though, the legislation was teetering. And Obama knew he still needed more votes.
The drug lobby
Early on, the administration had to face reality: It could take on the pharmaceutical industry or the health insurance sector, but not both. Their combined lobbying power would be too much to overcome.
The White House struck deals with an array of health industry sectors, though the deal with the pharmaceutical industry was the most controversial.
Billy Tauzin, a former congressman from Louisiana, headed the Pharmaceutical Research and Manufacturers of America (PhRMA) at the time. He recalls a meeting in the White House Roosevelt Room where the president met with a number of influential healthcare leaders, including the CEO of a major drug company.
Obama went around the table, asking how to lower healthcare costs. When the pharmaceutical executive, whom Tauzin declined to name, responded with “innovation,” Obama pounced.
The president dismissed the answer, and accused him of “just wanting to make more money.” The meeting ended abruptly, Tauzin said.
“It was a seminal moment,” according to Tauzin. “It was clear to me at that moment that we had better be at the table or we were going to be the meal.”
The White House and PhRMA subsequently struck a deal. Tauzin quickly came under intense criticism from his former colleagues on Capitol Hill.
The health insurance industry was isolated as the boogeyman that Democrats needed. Then-Speaker Nancy Pelosi (D-Calif.) labeled the industry “villains” while mostly holding her fire on the drug sector.
Waiting for the Senate
For months in the spring and summer of 2009, the Senate’s Gang of Six, three Democrats and three Republicans, labored to try to find a bipartisan compromise.
It was an effort by then-Senate Finance Committee Chairman Max Baucus (D-Mont.) to find a bipartisan path on a bill that would become a defining point of conflict between the parties. While the group met in secret, liberals howled that the exercise was doomed to fail and wasting valuable time.
“Everyone was trying to hurry it up,” said then-Sen. Jeff Bingaman (D-N.M.). “And that made sense. We did take quite a while.”
Emanuel, known for his penchant for profanity, made repeated calls, often while the group was meeting, for them to pick up the pace. Senators would be called out of the room to talk to him.
Bingaman recalled one conversation when Emanuel told him: “We need to get this thing over with.”
Bingaman replied that he was indeed asking a lot of questions, for example, worrying that copays and deductibles would be too high.
“I thought they were questions we needed to have answers for,” Bingaman said. “He was not totally persuaded by that.”
Eventually, after a grueling August filled with vitriolic town hall meetings, Baucus decided he needed to move ahead without the support of the Republicans in the group. Some Democrats wondered if it was too late.
Pelosi, rounding up the votes
The White House played a major role in getting the votes for ObamaCare, but it couldn’t have passed without Pelosi.
Former White House deputy chief of staff Nancy-Ann DeParle called her “a force of nature” in convincing Democratic members to vote yes.
Days before the final vote on the House floor, Pelosi buttonholed then-Rep. Scott Murphy (D-N.Y.). It was clear they weren’t talking about the weather.
Minutes later, Murphy — who had narrowly won a special election a year earlier and was a major GOP target in the 2010 elections — refused to tell a reporter whether he had just committed to vote yes on the biggest roll call of his political career. Sure enough, he subsequently released a statement saying he was in the yes column. That fall, Murphy lost his race as Republicans picked up 63 seats and reclaimed control of the House.
Pelosi told The Hill she “never doubted” the bill would pass: “We had the opportunity of a generation, and we were not going to lose that opportunity.”
Looking back, the Democratic leader has no regrets.
She praised Obama for constantly pushing for a comprehensive approach and refusing to embrace a scaled-back bill. But she said the White House could have been far more helpful in pushing back at Republican critics, and she makes clear she had disagreements with the president’s top advisers.
“We needed more air cover from the White House,” Pelosi said, repeating a criticism from many House lawmakers who wound up losing reelection in the fall of 2010.
Former Health and Human Services Secretary Kathleen Sebelius blamed the troubled economy.
“The White House had turned their attention elsewhere,” Sebelius said. “People within the White House had spent plenty of time, plenty of energy on healthcare, and he needed to talk about the economy … the spotlight left healthcare but not for the adversaries.”
Pelosi, a frequent target of conservatives, warned her members in the spring of 2009 of what was coming from the other side of the aisle: “fire and brimstone” and “shock and awe.”
“They’re coming after us,” she told her House Democratic colleagues.
The Scott Brown earthquake
Days after the Senate’s Christmas Eve vote, Obama called a meeting with key Democrats in his Cabinet room. Worried about an upset victory by Scott Brown, a Republican running to fill the seat of the late Sen. Edward Kennedy (D-Mass.), Obama warned that he would need them to find a middle ground between their two very different bills.
“Look, you’ve got to work some of these things out because I may lose my 60th vote in the Senate,” he told the group, according to a lawmaker in the room.
House and Senate Democrats were able to hash out most of their differences, but they didn’t do it in time.
Brown had done the unthinkable: He had won Kennedy’s seat.
As soon as the polls closed in Massachusetts on Jan. 19, 2010, the White House began holding strategy sessions. Administration officials quickly realized the House bill was dead.
It was one of the lowest points of the entire debate for the Democratic Party. Brown’s victory was a death blow to the public option and more generous Medicaid provisions and subsidies, and many believed it would kill off ObamaCare completely.
The only way forward was a politically risky prospect: Use a budget process called reconciliation, which would not require a supermajority of 60 Senate votes, and have the House pass the more centrist Senate bill, with some refinements.
“The initial reaction in the House was ‘Hell no. Absolutely not. Never, ever,’ ” Sebelius said. “That had to settle in a while before there really was a final push to say, ‘You’re really going to let all this work go down the tubes?’”
It was a mourning period for House Democrats, who had spent weeks — and in the case of then-Energy and Commerce Committee Chairman Henry Waxman (D-Calif.), his entire career — aiming for the kind of healthcare reform included in their bill.
“We had to go along with it. We had to swallow hard and do the best we could,” Waxman said.
Reading the bill
Obama and his aides still had to convince their allies on Capitol Hill to back healthcare reform, with legislators on edge in the final stretch, particularly after Brown’s win.
“The ugliness can’t be underestimated,” said former Rep. Brian Baird, noting the Tea Party’s presence at town halls and security being increased in the wake of members receiving death threats.
Baird was a bit of an outlier on Capitol Hill for two reasons: The Washington state congressman liked to work with the other side of the aisle, and he insisted on reading bills before voting on them.
“I’m probably one of the few members who read the entire healthcare bill,” he said.
In order for the legislation to become law, Baird’s vote was important. The lawmaker didn’t have to worry about losing his seat — he had already announced he was retiring from Congress.
Baird, who rejected the House-passed healthcare bill and was known for his independent streak, made it clear he would vote yes if he was convinced the Affordable Care Act would be better than the status quo.
During an hour-long meeting in the Oval Office, Obama and his budget director at the time, Peter Orszag, went through the bill with Baird.
Unlike other Democrats, he wasn’t interested in trading his vote for something back home. That was refreshing to Obama, who had grown exasperated with the demands and personality quirks of Baird’s colleagues.
The president’s arguments resonated. Shortly thereafter, Baird announced he would back the bill, saying “this legislation will be much better than what exists today.”
The left
Obama needed Dennis Kucinich’s vote — badly. The Ohio liberal, who had long pushed for a government-operated, single-payer healthcare system, now had to decide on a bill that didn’t even have a public option.
For months, Kucinich, who had run for president in 2004 and 2008, appeared to be a firm no. Yet Obama and his aides kept trying.
At a rally in Ohio a week before the final vote, Obama publicly called for “courage” from Kucinich.
A man in the audience shouted, “Vote yes!”
“Did you hear that, Dennis?” Obama said, asking the man to repeat himself.
Kucinich voted for ObamaCare’s final passage but says Obama didn’t convince him.
“Frankly, he was not that persuasive,” the former congressman stated.
Like Altmire, Kucinich pointed out he was a member of the House of Representatives and listened closely to the people who elected him. But unlike Altmire, Kucinich’s constituents were overwhelmingly in favor of the bill.
To this day, Kucinich echoes frustrations with Obama that appear to resonate with grass-roots liberals energized by the Democratic presidential run of Sen. Bernie Sanders (I-Vt.).
Kucinich claims Obama didn’t push hard enough to challenge the private insurance market. Asked about the administration’s claim that the votes were simply not there for a single-payer system or public option, Kucinich responded, “Everything is just an excuse.”
Sanders also was not pleased with the bill at the time. He wanted single-payer and wielded a lot of power because he could take the whole bill down with a no vote.
A former senior White House official said Sanders “was one of the most difficult people I’ve ever had to deal with … he hated what we were doing.”
The 2016 White House hopeful has claimed that he helped write the Affordable Care Act, but Obama officials and fact-checkers have strongly disputed that. Sanders ultimately voted for the reform bill, but not before securing billions of dollars for community health centers, which he believed could help fill the void left by the failure to create a single-payer system.
Michael Behan, Sanders’s former chief counsel and legislative director, said his ex-boss was “a very active member of one of the two committees that wrote the Senate health bill” and that the expansion of community health centers has helped millions of people get the healthcare they need.
He added, “Sometimes staffers get uncomfortable when a senator sticks to his or her principles and makes sure good ideas get a fair hearing. Tough.”
All hands on deck
The administration’s push for uncommitted votes was extensive and unprecedented. Cabinet officials, including then-Secretary of State Hillary Clinton, were assigned specific lawmakers. Big donors called on-the-fence Democrats.
The pressure back home was just as intense. Anti-ObamaCare activists confronted Democrats at home and some of the videos went viral. Phone calls in swing districts were running 10 to 1 against the bill. Planes flew over Pittsburgh with a simple message for Altmire: Vote No.
The Tea Party was forming, and it quickly became a force. Protests were held on Capitol Hill, all the way up until the final House vote on a tense Sunday afternoon when Democrats claimed they were split.
The White House and leading Democrats insisted the Affordable Care Act would become popular by the 2010 elections. But many Democrats who backed the bill knew their political careers would soon be finished. Others who rejected the legislation were also washed away in the historic 2010 election.
The week before the final vote, Altmire and other undecided Democrats were at the White House to celebrate a new “pay as you go” law that stipulated Congress couldn’t fund initiatives by growing the deficit. Obama took Altmire aside, and then it was Emanuel’s turn.
By that point, Pelosi had given up on Altmire. She was very “frustrated” he had voted against the House bill in 2009, Altmire said.
“She basically didn’t talk to me for years after that vote,” he added.
(Pelosi rejects that characterization, saying she doesn’t hold grudges and understood that not every member of her caucus was going to vote yes.)
As he was talking to Emanuel, Altmire felt two arms on him from behind. It was Biden, who was now in his ear.
“Just do it,” the vice president said. “Just do it. If you just say yes, all this goes away.”
Zack Space of Ohio, one of 34 centrist “Blue Dog” Democrats who ultimately voted against the House bill, recalls sitting across from Pelosi, Waxman and Emanuel in meeting after meeting — many punctuated by slamming doors and shouts.
On the Wednesday before the final vote, Space met with Obama in the Oval Office, but he remained unconvinced. The next night, Space organized a town-hall-style phone call, with tens of thousands of people on the line, to announce he would oppose the bill. Less than 30 minutes later, Space got a call from Obama on his cellphone underscoring his disappointment.
Voting no didn’t save Space’s seat; he lost by double digits in the 2010 election.
Republican support for ObamaCare
Six years after passage of the Affordable Care Act, Obama aides still bristle at the fact that no Republicans backed the bill.
As the measure inched forward in late 2009, the White House still believed it could bring at least one Republican on board: moderate Sen. Olympia Snowe (Maine).
Snowe, who regularly bucked her party, had voted for the Senate Finance Committee bill in the fall of 2009.
Orszag, one of Obama’s chief economic advisers, spent hours in her personal office combing through drafts of the law, and occasionally bringing a White House-approved list of proposals to meet her demands.
The bill changed in the Senate, and Snowe ultimately voted no. Zeke Emanuel, Rahm’s brother and an architect of the health bill, stood in the gallery, feeling blind-sided after all the back-and-forths with her office.
“At the end of the day, we’d done all this work. We had done everything she had asked for,” he said.
Snowe, who retired in 2013, didn’t comment for this article.
On the other side of the Capitol, then-Rep. Joseph Cao (La.), who represented a heavily Democratic district covering much of New Orleans, had been the sole Republican to back the original House ObamaCare bill.
On final passage, he came under heavy pressure from GOP leaders to vote no. He did — and was then trounced in the 2010 elections.
Walking the plank
“I had to decide, OK, do I vote for it and end my political career or don’t I?” said then-Rep. Earl Pomeroy (D-N.D.).
About a week before the final vote, he called his political consultant. “I don’t think there’s any question you should vote no,” the consultant told him. “But I’ve got to tell you, if you do that, the bill might fail.”
As a senior Ways and Means committee member — and one facing a tough reelection race — if he voted no, others might follow.
In an Oval Office meeting ahead of the vote, Pomeroy showed Obama a poll indicating he had little chance of reelection in North Dakota if he voted yes.
But Pomeroy had already voted for the version of the bill that passed the House in 2009.
“I thought he was very effective in coming up with political arguments about why for me having voted for it the first time it would be a bad deal to vote [against it] the second time,” Pomeroy said of the president. “But for me at that point in time it was about conscience.
“I didn’t come to Washington for reelection, I came to do stuff,” Pomeroy said of his mindset at the time. He would vote for the bill and end up getting crushed that November.
While Pomeroy wasn’t troubled by his vote, he says he believes Obama could have done more to save him and other Democrats who ended up losing their jobs for supporting the healthcare law. And if Obama hadn’t lost the House, who knows what more the president could have gotten done?
In the Oval Office meeting, Pomeroy made his views known.
“I also expressed my frustration that the bill had not been explained more clearly, that the largest microphone in the country, the White House, had not been used to set the stage more effectively for what we were being asked to do,” he said.
Stupak dozen
Bart Stupak was one of the most important figures to decide whether ObamaCare would live or die. The tall and amicable Michigan Democrat, who had started his public services career as a police officer, was now in the line of fire.
He led a group of about a dozen Democrats in pressing for changes in the bill to prevent federal subsidies from being used for abortions. Without the dozen votes, there was no chance the Affordable Care Act would pass the House.
His office was inundated with phone calls, faxes and emails. He told The Hill in March of 2010 that his life was “a living hell.” Stupak said his wife disconnected the phone in their home to avoid harassment and wouldn’t watch television.
Obama and his aides struck a last-minute deal with the “Stupak dozen” on the day of the vote. But Pelosi and administration officials say the biggest obstacle to getting the bill over the top was not Stupak — it was federal reimbursements for different parts of the country. Members wanted to make sure the bill wouldn’t shortchange their districts.
Pelosi huddled with a dozen or so members to deal with the regional disparity issue in the Speaker’s conference room on the Friday night before the Sunday vote. The meeting went well beyond midnight, DeParle said. A deal was struck.
Epilogue
The bill passed 219-212 on March 21, 2010.
Biden later famously called the passage “a big fucking deal.” And it was, in many, many ways.
Obama called Pelosi after the vote and told her, “I’m happier tonight than the night I was elected president of the United States.”
Democrats credit Obama for pushing full steam ahead, rejecting calls to scale back the bill after Brown’s win and juggling healthcare with other top priorities such as the faltering economy, reining in Wall Street and trying to pass climate change legislation.
Phil Schiliro, a former senior aide to Obama, said, “Throughout the process, the president was all in so long as we had a realistic chance. It was a steep, hard climb, but we always had a good shot at getting it done.”
Obama was intent on getting to the finish line one way or the other.
“This bill is like a Rubik’s Cube,” he said, according to DeParle. “We can solve it, but we have to be patient and keep twisting it to get all the pieces to line up.”
Champagne flowed at the White House after the bill passed. But the new law would face a number of problems and obstacles.
ObamaCare opponents pounced on exaggerated and false claims made during the debate, most notably, “If you like your healthcare plan, you can keep it.” That promise was dubbed by PolitiFact as “the lie of the year” in 2013.
The implementation of the Affordable Care Act was a disaster when the government’s website simply didn’t work, and it was lampooned on “Saturday Night Live.” Republicans put the law front and center in their argument to win control of Congress. They captured the House in 2010 and the Senate in 2014.
ObamaCare, however, has proven to be resilient. It is now six years old and has helped more than 16 million people gain health coverage, after surviving the 2012 presidential election when then-GOP nominee Mitt Romney vowed to eradicate it.
The conservative-leaning Supreme Court twice had the chance to gut the Affordable Care Act and ruled in favor of the Obama White House.
Every Republican candidate for president is vowing to repeal and replace ObamaCare, though the GOP has struggled to coalesce behind a replacement plan. Polling has shifted on the law over the last several years.
In a poll last fall, Public Policy Polling stated, “Evidence continues to mount that the Affordable Care Act is just not a liability for Democrats anymore. Nationally we find that 42 percent of voters support it to 40 percent who are opposed. … It’s a far cry from when we used to consistently find voters opposed to it by a 10-15 point margin nationally and in key states.”
Altmire ended up narrowly winning his 2010 reelection but was beaten in his Democratic primary in 2012. His opponent repeatedly noted on the campaign trail that Altmire had voted against the Affordable Care Act.