Exclusive: How Ted Kennedy and Nancy Pelosi pushed Barack Obama to go big on health care

This story is adapted from “Madam Speaker: Nancy Pelosi and the Lessons of Power,” which will be published April 20 by Twelve Books. Author Susan Page, the Washington Bureau chief of USA TODAY, conducted 10 interviews with Pelosi for this biography and interviewed more than 150 other friends, family members, political allies and adversaries.

The morning after Republican Scott Brown unexpectedly won the 2010 special election election to fill Ted Kennedy's Senate seat in Massachusetts, President Obama called House Speaker Nancy Pelosi, a pivotal and private conversation that wasn’t disclosed.

At the time, some White House advisers were urging Obama to cut his losses on a comprehensive health care bill. Chief of Staff Rahm Emanuel had made it clear from the start that he was skeptical about going big; now he raised his objections more loudly. Democrats had lost their filibuster-proof majority in the Senate, and it wasn’t clear what would or could happen next. Their plan for passing the legislation had just been blocked by the election of a 41st GOP senator.

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That said, strategists on the Hill and the White House had devised a legislative escape hatch for just this situation, designed to be deployed if their Senate supermajority didn’t hold – either because of the election of a Republican or the defection of a Democrat. That was always a risk; some moderate Democratic senators had voted for the bill only reluctantly. That’s why Massachusetts senator Ted Kennedy and Nancy Pelosi had insisted at the start that the legislation include a provision that permitted budget reconciliation. At the time, Budget chairman Kent Conrad of North Dakota and Finance chairman Max Baucus of Montana had adamantly opposed including the procedure, arguing that it was provocative to Republicans and unnecessary.

In their phone call, Obama told me that he and Pelosi were in sync: Better to fight for a big bill than to scale back their goals. Despite its complications and limitations, the tool to do that would be reconciliation.

“My attitude is that, for us to take a quarter of a loaf or a half a loaf is missing an opportunity, that it would leave millions of people running short,” Obama said. “And I’ll be honest, it wasn’t even clear at that point that the Republicans would in fact take a smaller bill because they had been moving the goalposts consistently throughout this process. So it wasn’t as if there was a ready compromise to be had, anyway. So my strong belief, as I’ve told my staff, is we’re going to go forward with this if we have any opportunity left to do it.”

That would depend on Pelosi.

“The only way for us to do it was if the House was, at some point, going to hold its nose and pass the Senate version,” Obama said. That was legislation House leaders had been describing as unacceptable just a few days earlier. “I essentially said to Nancy, ‘Look, this is the debate that’s been had in the White House. My strong preference is that we go with a robust, full package, but the only package, at this point, we can get passed is the Senate bill. We could potentially bleep some provisions that you guys consider particularly obnoxious, [but] there’s only going to be so much we can do.

“ ‘And, Nancy, I can’t do this without you. If you are not willing to work with me to work your caucus, to get them to pass the Senate version, we don’t have a path.’”

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Pelosi first took the opportunity to vent about the folly of the other side of the Capitol. This may have had less to do with her admittedly dyspeptic views of the Senate than with the responsibility she felt to articulate the views of her caucus. Obama saw her complaints as tactical, not peevish.

“She wasn’t going to right off the bat come out and say, ‘Yeah, I guess we just have to pass the Senate bill,’ because this is an example of her savvy,” Obama told me. “After spending about half an hour describing how feckless and incompetent the Senate was, she then proceeded to say, ‘Well, of course we have no choice but to go ahead and get the whole thing done.’ Then it became a strategy and tactical conversation.”

Pelosi didn’t need Obama to explain reconciliation to her, of course. Two senior White House advisers told me it was Pelosi who first recognized and advocated using the parliamentary maneuver to the president, not the other way around. While the Senate bill would have to be the vehicle, under reconciliation she could negotiate some significant changes in it through a bill of amendments known in Hill-speak as a “sidecar.” She would have to brainstorm a creative way to reassure House Democrats that they could count on the Senate to deliver that.

A few days later, Obama and Pelosi would have another crucial conversation, this time in person and in front of others. The president convened a meeting in the Oval Office with Pelosi, Harry Reid, and top White House and congressional staffers. Emanuel began to make the case for a more limited bill. He thought the realistic option was to scale back – not to cover everyone, for instance, but just focus on children. Not to mandate the difficult steps necessary to ensure affordable coverage to everyone with preexisting conditions, health problems that made them unappealing to insurance companies.

Some of those in the room were dismayed that Obama allowed his chief of staff to continue lobbying against a comprehensive bill, something the boss presumably could have stopped in an instant, with a few words. The president may have settled on going big, but his willingness to let his top aide keep arguing for going small was interpreted by some, accurately or not, as signaling ambivalence in the White House.

In the meeting, it was Pelosi who pushed back hard, going further than previous accounts have reported. She was determined to cut off any exit ramp, to make it impossible for the White House to trim ambitions for the health care bill. Harry Reid, who often remained quiet during such confrontations, backed her up at this key moment.

The president had told her he couldn’t get the big bill through Congress without her. Now she told the White House that she wouldn’t work for anything except a big bill. A more modest Plan B? “I said, ‘We’re not going there,’ ” Pelosi told me. Regardless of the qualms of Emanuel, she gave the administration only two options: Go big or get nothing. It was an extraordinary demonstration of political hardball.

Her chief of staff, John Lawrence, who attended the meeting, described it this way. “I remember her turning to the president and saying, ‘I know that there are people who are telling you that we should go for just a very minor bill, and I’m just telling you, we’re not going to do that in the House of Representatives,’ ” Lawrence recalled. “ ‘We won’t accept that.’ And I remember the president looking at her and saying, ‘Okay.’ And I think that was sort of the key moment where the decision was made that we weren’t going to go for what I think Mrs. Pelosi called the ‘eensy-weensy’ approach. We were going for the big bill.”

There was no guarantee they would succeed, but the course was set.

Now Pelosi was responsible for achieving what many others saw as an impossible task. Senate Democrats no longer had the votes to end a filibuster and bring a new bill up for a vote. House Democrats had spent nearly a year painstakingly working out their plan, one she called “as near perfect as any bill could be.” In comparison, she told me, “The Senate bill was terrible.” Even so, House Democrats would have to be convinced to accept it with the promise of then being able to amend some of its provisions.

In a conference call with the Democratic leadership and the chairs of key committees, Pelosi made their marching orders clear. She described Emanuel as an “incrementalist” and said they weren’t going to pursue an “eensy, weensy spider, teeny tiny” bill. Her message to nervous House Democrats was the same as it had been to reluctant White House officials: We’re doing this. She simply dismissed the idea that they might fail.

“We will go through the gate,” she told reporters the week after the Massachusetts election. “If the gate is closed, we will go over the fence. If the fence is too high, we will pole-vault in. If that doesn’t work, we will parachute in. But we are going to get health care reform passed for the American people for their own personal health and economic security, and for the important role that it will play in reducing the deficit.”

Republicans who caricatured Pelosi as a “San Francisco liberal” were only half right. It’s true that she was a committed partisan, a New Deal Democrat in the mold of her father, three-term Baltimore mayor Tommy D’Alesandro Jr. Ensuring health coverage for all Americans was also a mission she saw as consistent with the lessons she learned from the nuns who had taught her at the Institute of Notre Dame in Baltimore and Trinity College in Washington. It was a matter of social justice, of following Jesus’s imperative to care for the least among us. (Kathleen Sebelius was another Trinity graduate; they dubbed themselves “the Trinity sisters,” at one point to the confusion of Obama, who looked around a meeting to find the nuns they were discussing.)

But what that description missed was the fact that there were two sides to Pelosi’s political core: the progressive and the pragmatist. She was not only a San Francisco liberal; she was also a Baltimore pol. In that, she was following in her father’s footsteps as well. No other battle during her political career illustrated that duality more clearly than the debate over the Affordable Care Act. She insisted on a sweeping bill, despite the long odds. But she was willing to push through a version she saw as flawed when it became the only prospect available.

She understood “that you get as much as you can when you can get it, and then you keep moving on and build on that,” Obama told me. By then, he said, they both knew the 2010 midterm elections were going to be tough for congressional Democrats. Winning on the Affordable Care Act could mean losing her Speakership.

“She did not blink from guiding her caucus in a very controversial issue,” Obama said. “That is the thing about her that I have always loved and admired the most. She is a politician. She is tough. She likes to win. But at the end of the day, she hasn’t forgotten the whole point of office, which is actually to get stuff done and do things for people you care about.”

With no other options, Pelosi and Reid began budget reconciliation. Under Senate rules, it usually took a supermajority of sixty votes to cut off a filibuster. But if the legislation was about financial issues, a simple majority of fifty-one votes could end debate. They could force consideration on a bill that amounted to a set of amendments to the legislation they already had passed – a sidecar – if the provisions were about financial matters, about imposing taxes and spending revenue.

Kennedy played another key part in the closing chapter of the debate, one never before fully explained. In May 2009, when it was clear that he was going to die before the legislation had been passed, Kennedy wrote a dramatic, emotional letter to Obama with the idea that it would be revealed at some critical moment. Kennedy’s widow, Vicky, delivered the letter to the White House. Kennedy’s closest adviser, Lawrence Horowitz, delivered a copy to Pelosi.

The letter was a sort of insurance policy, “a fail-safe” to ensure that the biggest ambitions for the bill were followed, he told her. Kennedy knew Obama sometimes had cautious instincts. He believed he could count on Pelosi to have bold ones. Pelosi had cut off the exit ramp for other options in the Oval Office meeting. Now Kennedy moved to do the same.

The president would make the letter the emotional centerpiece of an address to Congress pushing for passage on Sept. 9, 2009. Seven months later, he would sign the Affordable Care Act into law.

This article originally appeared on USA TODAY: How Pelosi and Kennedy pushed Obama's biggest ambitions on health care