WASHINGTON — Speaker Nancy Pelosi was at her wits’ end, and she let President Obama know it.
Scott Brown, the upstart Republican, had just won his Senate race in Massachusetts, a victory that seemed to doom Mr. Obama’s dream of overhauling the nation’s health care system. The White House chief of staff, Rahm Emanuel, once Ms. Pelosi’s right hand man on Capitol Hill, was pushing Mr. Obama to scale back his ambitions and pursue a pared-down bill.
Mr. Obama seemed open to the idea, though it was clearly not his first choice. Ms. Pelosi scoffed.
“Kiddie care,” she called the scaled-down plan, derisively, in private.
In a series of impassioned conversations, over the telephone and in the Oval Office, she conveyed her frustration to the president, according to four people familiar with the talks. If she and Harry Reid, the Senate Democratic leader, were going to stick out their necks for Mr. Obama’s top legislative priority, Ms. Pelosi wanted assurances that the president would too. At the White House, aides to Mr. Obama say, he also wanted assurances; he needed to hear that the leaders could pass his far-reaching plan.
“We’re in the majority,” Ms. Pelosi told the president. “We’ll never have a better majority in your presidency in numbers than we’ve got right now. We can make this work.”
Now, in what could become a legislative Lazarus tale — or at least the most riveting cliffhanger of the Obama presidency so far— the House is set to take up the health bill for what Democrats hope will be the last time.
For Mr. Obama, who vowed earlier this month to do “everything in my power” to see the bill to fruition, the measure’s passage would be an extraordinary triumph. Its defeat could weaken him for the rest of his days in office.
That Mr. Obama has come this far — within a whisper of passing historic social legislation — is remarkable in itself. But the story of how he did it is not his alone. It is the story of how a struggling president partnered with a pair of experienced legislators — Ms. Pelosi and, to a lesser extent, Mr. Reid — to reach for a goal that Mr. Obama has often said had eluded his predecessors going back to Theodore Roosevelt.
Their journey over the last two months, interviews with White House aides, lawmakers, outside advisers, lobbyists and political strategists show, involved tensions, resolve, political spadework — and a little bit of luck.
When Anthem, a California insurer, notified policyholders of an increase in premiums of up to 39 percent, the move played right into the hands of a White House that had spent months demonizing the insurance industry.
A cross-Capitol feud erupted when Ms. Pelosi demanded that Mr. Reid provide a letter with the signatures of 51 senators willing to pass a package of legislative changes under the complex parliamentary procedure known as reconciliation. (On Saturday, the leader announced that he had a “significant majority.”)
And Mr. Obama’s decision to hold a bipartisan health care summit meeting proved a strategic success. The move privately mystified some Democrats. But it created an important cooling off period and helped shift attention to Mr. Obama and away from Capitol Hill, freeing the speaker to work on convincing recalcitrant members of her caucus that it would be politically disastrous for them simply to walk away.
Mr. Obama did not need any prodding from Ms. Pelosi, his aides say. The Scott Brown election came on the eve of his first anniversary in office, and he told aides he was irritated that his presidency appeared to be stalled. He was eager to do what he had done so often in the presidential campaign: cast caution aside in favor of bold action.
“We are this close to the summit of the mountain,” Mr. Obama told his close advisers in a meeting in late January, said one participant. “We need to try one more time.”
Responding to a Setback
The polls were still open in Massachusetts on Jan. 19 when Mr. Obama met in the Oval Office with David Plouffe, his top outside confidant and former campaign manager. Mr. Brown’s victory — he would take Senator Edward M. Kennedy’s old seat — was all but certain, and Mr. Obama’s 60-vote supermajority in the Senate had suddenly vanished.
Mr. Brown had made clear his objections to the health care legislation. “One thing is clear,” he proclaimed on election night, “voters do not want the trillion-dollar health care bill that is being forced on the American people.”
At that moment, the president did not know whether, or how, to proceed. The House and Senate had passed different versions of the bill and could not come to terms. Republicans were unified in their resistance. He considered his options, including Mr. Emanuel’s “skinny bill.” Whatever the course, aides said, Mr. Obama was insistent that health care not be put into a “time capsule,” never to be opened again in his tenure.
Tom Daschle, a close outside adviser, said Mr. Obama believed that health care would be his legacy. “This is what his presidency is about,” he said.
On Jan. 21, Representative Barney Frank, a Massachusetts Democrat and a powerful committee chairman, headed to the White House for a banking industry announcement. He had been openly skeptical about the prospects for the health measure.
Mr. Obama pulled him aside. “He said, ‘I have to talk to you,’ ” the congressman recalled. “He was very passionate about it, and he convinced me that we could put some fixes in.”
Others were not so easily convinced. “You have to let my colleagues work through their five stages of grief,” Representative Robert E. Andrews of New Jersey, a Pelosi adviser, told a friend. Asked what stage the House was in several weeks later, Mr. Andrews responded, “Still in denial.”
The speaker, though, was determined to go ahead. “We will go through the gate,” she said at a news conference on Jan. 28. “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.”
If there was one thing Ms. Pelosi knew she could not do, though, it was force the House to pass the Senate bill. (House liberals objected to its lack of a government-backed insurance plan, conservatives thought it too permissive on abortion financing, and the entire caucus felt queasy about special deals like the so-called Cornhusker kickback that would have given Nebraska extra money to pay for Medicaid.)
But House action on their bill was exactly what Democratic senators wanted when Mr. Obama addressed them at a policy retreat on Feb. 3.
The televised session was polite, with the talk centered on the economy; Mr. Obama, after bipartisan battering, had vowed to make “jobs, jobs, jobs” his new focus. But in an off-the-record panel discussion after the president left, Mr. Obama’s senior adviser, David Axelrod, got an earful over health care. Senator Al Franken, the freshman Democrat from Minnesota, led the charge.
“David, I’m doing a slow burn here — do you know what a slow burn is?” one participant recalled him saying. Mr. Franken demanded to know Mr. Obama’s plan, and then told Mr. Axelrod that the president needed to have the House pass the Senate bill.
“That’s fine,” Mr. Axelrod replied. “If you’ve got 218 votes in your pocket, we’ll do that.”
The session exposed the mistrust between the House and the Senate, tensions that Mr. Obama’s health care team worked mightily to smooth over. To the Senate Democrats in the room, it seemed as if Mr. Axelrod was brushing them off, and that Mr. Obama really had no plan.
The next day, the president invited the Democratic Congressional leaders to the White House. They had a blunt conversation, with Ms. Pelosi expressing dismay that Mr. Obama had yet to state publicly, in crystal clear terms, what he wanted to see in a health bill. The two had clashed in the past; once when Ms. Pelosi challenged the president, he snapped, “I’m not a stupid man,” said a Congressional aide, speaking on the condition of anonymity.
But the sense of urgency after the Democrats’ debacle in Massachusetts seemed to change the chemistry between the president and the speaker. “The two of them became real partners,” said one person close to both.
That night, Mr. Obama offered hints of his strategy, surprising even some of his closest advisers with his candor. In a question-and-answer session at a Democratic National Committee fund-raiser, Mr. Obama said he wanted Republicans, Democrats and health care experts to bat around ideas together. “And then,” he said, “I think that we’ve got to go ahead and move toward a vote.”
In early February, the White House got news from California that the administration would seize on.
Anthem Blue Cross had alerted customers that some would see a rate increase of nearly 40 percent by March 1. At a senior staff meeting, Mr. Axelrod, who learned of it by e-mail from a friend in Chicago, raised it with the president.
“I thought if we were in a trial,” Mr. Axelrod later told one associate, “I had just opened up my BlackBerry to Exhibit A.”
The president first mentioned the Anthem story in passing in a speech to the Democratic National Committee on Feb. 6. He repeated it again in a pre-Super Bowl interview with Katie Couric. By then, advisers knew they had finally latched onto a story line that might sell their plan: why people with insurance should care about the health care bill and its cost controls.
It also dovetailed with what Mr. Obama had been hearing from his unscientific sounding board: the 10 letters he reads every day from ordinary Americans, culled by junior aides in the White House mailroom. One letter, from an Ohio woman named Natoma Canfield, stood out.
A Crucial Meeting
Mr. Obama’s idea for a health care meeting at the end of February flabbergasted Democrats on Capitol Hill. He felt that such an event could be an antidote to some of the cynicism about Washington expressed by voters. Ms. Pelosi did not oppose it, but she was not enthusiastic. In the Senate, some Democrats thought the idea was pointless; convinced they would never get Republican support, they figured that each passing day made it more difficult to tackle a health care bill.
Some White House allies say the session proved critical in putting health care back on the national agenda. “When the history of this is written, it will be looked at as both a turning point and a brilliant idea,” said Chip Kahn, who as president of the Federation of American Hospitals has been one of the administration’s main supporters.
The event enabled Mr. Obama to claim the high ground on bipartisanship; after the Brown victory, he needed to be seen as reaching out to the other side. He also wanted to force Republicans to put their ideas on the table, so that the public would see the debate as a choice between two ways to attack a pressing problem, not just a referendum on what Republicans derisively called “ObamaCare.”
The meeting also gave the Democratic leadership the gift of time. While the spotlight shifted to Mr. Obama, Ms. Pelosi and Mr. Reid immersed themselves in figuring out their parliamentary options and, in Ms. Pelosi’s case especially, soothing her members’ jangled nerves.
“The main thing was Pelosi sticking with it and doing the quiet work of bringing people back to saying, ‘We’re doing this,’ ” said John D. Podesta, a former chief of staff to President Bill Clinton. “It was almost illusionist, drawing your attention to something that isn’t important, so that you’re not watching what’s happening, which really is important.”
And one day after the meeting, the White House deployed its secret weapon: Ms. Canfield.
In a meeting with insurance executives, Mr. Obama read her letter aloud. In seven poignant paragraphs, she wrote that 16 years after being treated for cancer, she could no longer afford her health insurance and was terrified she would get sick and lose the house her parents built.
From studying polls and focus groups, the White House knew public opinion seemed to be slowly shifting in favor of some elements of the bill. And Ms. Canfield’s story allowed Mr. Obama to personalize the debate, reminding Americans that it was not just about numbers, but lives. The president and his communications team had no way of knowing then that Ms. Canfield would soon receive a new diagnosis, leukemia.
The White House shared her letter with the news media. Within an hour, camera crews were at Ms. Canfield’s door.
The Push for Votes
Last week, with a vote drawing near and dozens of House Democrats still wavering — many terrified a vote for the bill would cost them their jobs — House leadership aides arrived at Ms. Pelosi’s office with a list of 68 lawmakers to lobby, turn or bolster. The aides presumed the Democratic leadership would divvy up the names.
“I’ll take all 68,” Ms. Pelosi declared.
By this time, the parliamentary path was clear: in a legislative two-step, the House would approve the original Senate bill and a package of changes through reconciliation. Republicans accused Democrats of procedural trickery and warned that the speaker was leading her caucus to political disaster.
“She is a strong speaker, there isn’t any question about that,” said Representative John A. Boehner of Ohio, the Republican leader. “So you pass a very unpopular bill. You shove it down the throats of the American people and you lose your majority. How good is that? How smart is that?”
Like Mr. Obama, Ms. Pelosi regards passing health legislation as a moral imperative, and sees herself making history if she can get it done.
Many Democrats say her upbeat, unflappable attitude buoyed them through the darkest days after Massachusetts. But faced with a member she considered intransigent, she could be “scary tough,” as one person involved in her strategy sessions said. She would stand up, her high heels and imperiousness exaggerating her height, and talk sternly.
On Wednesday, she spent 45 minutes listening and talking with Representative Marcy Kaptur of Ohio, a Catholic opposed to abortion coverage. Ms. Pelosi returned for another 40 minutes on Thursday, though on Saturday, the congresswoman remained undecided.
At the White House, Mr. Obama’s political arm was mobilizing, as Jim Messina, a deputy chief of staff, guided a team of party strategists. Fed by information from lobbyists, Hill aides and others, they tracked how every lawmaker intended to vote and prepared a television and radio campaign to counter the bill’s opponents, who were vastly outspending them.
The coalition of about 50 groups, from the AARP to labor unions — some of whom called themselves “Winter Soldiers” to describe their steadfast support — held daily conference calls. They isolated three dozen lawmakers and had influential people in their communities — doctors, insurance agents, business owners — reach out to them.
But it is the president, many Democrats say, who has made the biggest difference, by finally providing the sustained, deep personal involvement Ms. Pelosi and Mr. Reid had been yearning for. He crisscrossed the country for health care rallies and devoted hours to cajoling Democrats.
“Taking it out into the country, the speeches, the rallies, taking on the insurance companies has been important,” said Representative Raúl M. Grijalva, Democrat of Arizona. “That button had been on mute in the White House.”
Last week alone, Mr. Obama called or met with 64 lawmakers. He scored the vote of one reluctant Democrat, Representative Dennis J. Kucinich of Ohio, after an Air Force One ride from Cleveland.
On Saturday he went to Capitol Hill to make a last-minute appeal to House Democrats, telling them: “We’re a day away. After a year of debate, after every argument has been made, by just about everybody, we’re 24 hours away.”
In his private sessions with lawmakers, the president has drawn the consequences for himself in the starkest terms. In a meeting with members of the House Progressive Caucus, who are angry that the bill lacks a government-backed insurance plan, the president warned that his other priorities — jobs and immigration — would be tougher to achieve if the health bill does not pass. There was silence, Mr. Grijalva said, when Mr. Obama laid out the risks.
“If we fail at this,” Mr. Grijalva recalled Mr. Obama saying, “it’s going to be harder for us to pull the line on this other stuff. It is going to weaken our presidency.”
Jackie Calmes and Eric Lichtblau contributed reporting.