How Nancy Pelosi Saved the Affordable Care Act

As she pleaded with her Democratic sisters, House Speaker Nancy Pelosi had tears in her eyes. She knew they hated what they were being asked to do. She hated it, too. But if they didn’t relent, the whole thing could fall apart.

They had a once-in-a-lifetime chance to accomplish something truly monumental, a goal that had eluded Democratic presidents for nearly a century: the creation of a universal health care program. But the only way to get there, she was telling them, was to compromise one of their most cherished principles: a woman’s right to choose abortion.

It was Friday, November 6, 2009. The House was scheduled to vote on its health care bill the following day. For months, Pelosi had been immersed in negotiations on the massive, complicated legislation. Now it had come down to the final sticking point, one that could not have been more personal or painful for Pelosi. The U.S. Conference of Catholic Bishops had announced that while it supported expanding health care, it would not endorse the bill unless it sharply restricted access to abortion, and a small group of pro-life members would not commit to vote for the bill unless the bishops signed off.

All day, Pelosi had been in meetings and on the phone, trying to get the bishops to compromise, the women to relent. But neither group was budging. Now it was evening, and she had run out of tactics. The only thing left was to lay her cards on the table with the members who most counted on her to speak for them and protect their interests—the liberal women. “I don’t know what to do,” she told them—a rare, or perhaps strategic, admission of weakness by Pelosi, who always seemed to know what to do.

The women were irate. Louise Slaughter, the eighty-year-old chair of the House Rules Committee, had grown up in Kentucky keeping the secret of a friend’s illegal abortion. She marched in abortion rights protests in her youth, pushed for reproductive rights in Congress and was a founding member of the Pro-Choice Caucus. She arrived in Washington in 1987, just a few months before Pelosi, and cheered Pelosi’s rise through the ranks as a victory for women everywhere. For Slaughter and the other liberal women, the abortion issue was about a woman’s inviolable right to determine what happened to her body. It was nonnegotiable.

Now, in a bitter irony, the first woman Speaker of the House was asking them to cave.

Pelosi listened patiently as the women vented. The vast majority of House Democrats were members of the Pro-Choice Caucus, and yet they were being told that they were the ones who had to give in to a stubborn minority. This, Slaughter said, was a betrayal—of not just the women in Congress, but the women of America.

Pelosi pushed some papers across the table: her tally sheets. The story they told was more powerful than any argument she could make. Without the bishops’ amendment, she said, “I don’t have the votes.”

Ever since the New Deal, Democratic presidents had been trying to create a national health care program. FDR twice proposed universal health insurance, but both times he stopped short of putting it to Congress. His successor, Harry Truman, also favored universal coverage, but never made it a priority. John F. Kennedy pushed for a program to insure the elderly, Medicare, but fell short, leaving it to Lyndon B. Johnson to get the job done. Johnson also created Medicaid, which partially funds state programs to provide health care to the poor.

After taking office in 1993, Bill Clinton assigned health care policy to his wife, Hillary. She worked on the legislation in near secrecy, then presented the giant bill to Congress as a fait accompli. Hillarycare, as it became known, would have eliminated the system of employer-based health insurance, replacing it with networks of health maintenance organizations. Republicans argued that the plan would give the government too much control, driving up costs and giving people fewer choices. The health care industry flooded the airwaves with frightening television ads.

Democrats in Congress also didn’t think much of the massive legislation they’d been cut out of. Multiple committee chairmen produced competing proposals. Pelosi was part of a group of progressives who introduced legislation to create a government-run “single-payer” system. The Clinton plan was never voted on, and what followed was the 1994 Republican landslide, killing health care reform’s prospects for more than a decade.

But the problem only got worse. Most people got health insurance through their employers, but if they lost their job, they were at the mercy of the lightly regulated private market. Insurers were free to pick and choose their customers, which meant they would refuse to cover anyone who was already sick, and charge women more than men for coverage. Insurance companies hunted for excuses to deny claims, drowning doctors in paperwork and making sick people fight for the care they needed. And as costs spiraled upward, premiums and deductibles ate up more and more of businesses’ budgets and families’ paychecks. Many Americans were just one accident or diagnosis away from bankruptcy.

Health care hadn’t been a priority for President Obama during his brief time in the Senate, but when he started running for president, polls showed it was voters’ top issue. By the time he accepted the Democratic nomination, reforming health care had become a central promise of his campaign. In ads and speeches, he spoke emotionally of his mother, Ann Dunham, who had died of ovarian cancer at age fifty-two in 1995. Her final months, Obama said, were consumed not by reflecting on her life and family but by fighting with medical billers and worrying about her insurance.

The Obama team had studied Clinton’s experience and was determined to learn lessons from it. They wanted Congress to craft the legislation rather than having the president hand it down on “stone tablets,” as Obama’s political adviser David Axelrod put it, and they wanted the health care industry on board if possible. Obama proposed leaving the employer-based system intact, so that most people with insurance wouldn’t be affected. New regulations would stop insurers from engaging in abusive practices. People without employer-based insurance would be able to shop for a plan on state marketplaces, and companies would compete to offer the best deal. An “individual mandate” would require that everyone get covered. Those who couldn’t afford to would get subsidies, while the poor would get insurance from the government through an expansion of Medicaid, which the federal government would fund.

A proposal to remake the health care system would have been a heavy lift for any president under the best of circumstances. But it was being put forward by a congressional neophyte in the middle of an economic collapse. Axelrod understood the issue’s importance—his daughter’s chronic epilepsy had nearly bankrupted his family—but he warned Obama as the new president took office that perhaps the time wasn’t right. Obama disagreed. If they didn’t do it now, he argued, it might not get done for another decade or more. “What are we supposed to do,” he said, “put my approval rating on the shelf and admire it for eight years?”

This was the Obama that Pelosi liked: the gambler, the dreamer, the president who believed, in the words he often quoted from Martin Luther King Jr., in “the fierce urgency of now.”

By July 2009, there were 60 Democrats in the Senate, the largest majority for either party since the 1980s. But the health care bill was stalled, bottled up in the Finance Committee as the White House courted moderate Republicans who Obama and his aides thought they could win over.

Pelosi thought wooing Republicans was a fool’s errand. From the beginning, she predicted the legislation would get zero GOP votes. “Does the president not understand the way this game works?” she asked Rahm Emanuel, the White House chief of staff. “He wants to get it done and be beloved, and you can’t have both—which does he want?”

Rather than waiting for the Senate, the House got started on its own. Pelosi ordered three committees to work together, forming a “Tri-Com” that had its own logo and tote bags. Single-payer wasn’t on the table, but House liberals sought to include a “public option,” a government-run health insurance plan that would sell policies to the public and compete with the insurance companies. Insurance companies naturally saw the public option as a mortal threat. While the Senate continued to dither, the House bill was out of committee by the end of July.

Then came August. Congress traditionally takes the month of August off, giving members a chance to relax, recharge and reconnect with their constituents. But August 2009 was not shaping up to be much of a vacation. At town hall meetings in their districts, Democratic lawmakers faced a furnace blast of anger. Hundreds of activists stormed the meetings. The push was calculated to bring down the bill—and the president. “If we’re able to stop Obama on this,” one Republican senator told a group of right-wing organizers, “it will be his Waterloo. It will break him.” Opponents seized on a provision—proposed by a Republican—that would fund optional end-of-life counseling sessions for seniors, and twisted it into a sinister plot to euthanize the elderly via “death panels.”

Then, at the end of August, Senator Ted Kennedy died after a long illness. Kennedy had called universal health care “the cause of my life.” Before he became too sick to serve in the Senate, he had worked to lay the groundwork for health care reform. His death was a major psychic blow to the reeling Democrats.

To give them a boost, Obama scheduled a prime-time address in the House chamber. In his speech, Obama read from a letter Kennedy had written before his death. Health care, he had written, was “above all, a moral issue.” As Obama made an impassioned case for urgency, Democratic lawmakers’ hearts stirred—here was that old Barack Obama magic that they’d missed in all the haggling over public options and cost curves. Obama confronted the myths about the bill, promising that it contained no death panels, would not pay for abortion coverage and would not cover illegal immigrants.

Suddenly the president was interrupted by a shout from the audience: “You lie!” It was Joe Wilson, a Republican congressman from South Carolina. To Pelosi, the tableau was a perfect illustration: the eloquent African American president, his lofty ideals crashing headlong into the irrational anger of a white southerner who preferred his emotions to the facts. (After the speech, Wilson’s cell phone rang. It was his wife. Who, she wanted to know, was “that nut” who had shouted at the president?)

Right-wing talk radio hailed Wilson as a hero.

And then there were the bishops. Pelosi’s Catholic faith was real and devout, a core part of her identity since childhood. But her politics didn’t always track with the Church. Pelosi took the hairsplitting position that she supported women’s right to make the decision for themselves even though she personally believed abortion to be wrong. “A woman,” as she put it, “has free will given to her by God.” It was a stance that put her at odds with her own family back in Baltimore. Early in her career, as she prepared to give a floor speech in favor of reproductive rights, she confided to a colleague that she hoped her mother wouldn’t see it.

Pelosi’s clashes with the Church became bitter and public as she rose in prominence. On the eve of her swearing-in as Speaker in 2007, protesters gathered as she attended Mass at her alma mater, the service was closed to the public to prevent chaos, and Pelosi sneaked in and out through a back door. Some archbishops said she should be denied Communion, and she feared she might be refused the sacrament. For a time, she attended a different church in San Francisco every Sunday to avoid being singled out. When she traveled to the Vatican in February 2009 and met Pope Benedict, he lectured her sharply on abortion and euthanasia, then put out a public statement boasting about having done so.

And so, when the Church’s position on abortion became the final sticking point in the House’s 2009 health care talks, it was personal for Pelosi. She tried everything she could to get around the bishops’ opposition. She put language in the bill banning abortion funding. She personally phoned a cardinal she knew in Rome. She won over groups of nuns. But none of it was enough. The bishops sent a bulletin to every American parish calling for the bill to be defeated if they didn’t get their amendment. They printed leaflets that showed a pregnant woman with the words “Abortion is not health care, because killing is not healing.” They sent a phalanx of bishops to the Capitol to lobby. The archbishop of Boston personally pressed Obama on the issue as they shook hands at Kennedy’s funeral.

Pelosi had tried every trick she knew in order to collect the votes she needed. She promised two California members that she’d take up their water issues. She persuaded a liberal congressman who was planning to retire to stay until health care was finished. She got a former president of the University of Notre Dame to lean on a moderate Democrat from Indiana. She attended the annual football game between members of Congress and Capitol Police, wearing a jersey that read, “MEAN MACHINE 1,” and cheering for Heath Shuler, the Redskins quarterback turned congressman, who was undecided on the bill. She added a provision for transplant patients, a tax on medical devices and a tax break for paper companies, each giveaway picking off a vote or two. At one point she was so exhausted she drank half a cup of coffee on purpose—a fearful situation for her staff, who knew that the slightest bit of caffeine would increase her usual level of intensity to a frightening degree.

And still, with the bishops opposed, she didn’t have the votes.

And so, on that Friday, after a long day of negotiations, she summoned her liberal female colleagues in and laid out the situation. As the therapy session wore on, she ordered cheeseburgers for everyone and continued to listen. It was 11 p.m. by the time the women stormed out of the meeting, furious at the reality Pelosi had forced them to acknowledge: the bill wasn’t happening without the bishops’ amendment, and they weren’t going to let the bill go down after they’d come this far. She knew it, and they knew it. She sat with them until they realized there was no other way.

Louise Slaughter was so angry that she refused to attend the late-night meeting of the committee she chaired. She holed up in her office with two other pro-choice women. They watched on C-SPAN as their committee approved the bill. The next day, by a vote of 220–215, health care reform passed the House.

The Senate finally began hearings in mid-September, and in October the bill was approved by the Finance Committee. Senate leaders had given up on getting Republican support, but they needed the votes of every single Democrat, including moderates from the South. The public option was dropped. Pelosi worried that the bill might be too weak to be effective. But at last, on Christmas Eve, the Senate bill passed.

The House and Senate had passed different bills, and now they needed to hammer out a compromise. In January, Obama presided over three days of contentious negotiations between House and Senate Democrats. The House bill’s price tag was over a trillion dollars, while the Senate’s cost eight hundred billion, and Obama wanted them to meet in the middle. On the second night, they took a dinner break, and Obama asked them to come back afterward with what they were willing to give. The senators ordered pizza, combed through the bill and came back with seventy billion dollars in concessions.

Then it was the House’s turn. “The House,” Pelosi announced, “will give you nothing.”

Talks continued, and with prodding from Obama, the gap was reduced to just twenty billion dollars—pocket change in budget terms. Obama proposed a way to close the gap, and Representative Henry Waxman, one of Pelosi’s lieutenants, piped up. “You’ve put forward a number that seems reasonable,” he said. “I can’t speak for the House, but it seems like something we can work toward.”

Pelosi shot out a hand to cut him off. “Henry is right about two things,” she said. “One, you’ve put forward a number. And two, Henry doesn’t speak for the House.”

To the other negotiators, Pelosi seemed unreasonably stubborn. Obama grew weary of what he viewed as childish bickering. “Stop this bullshit,” the president said. “I’m going upstairs and going to bed.” Pelosi and the others began gathering their things to leave. But Emanuel stopped them. It was nearing midnight, but he would not let them leave until he’d gotten them to come together on a number. So, at last, in the wee hours of the morning, Pelosi relented.

The negotiations were nearly finished when a thunderbolt struck. On January 19, Massachusetts held a special election to fill Kennedy’s Senate seat. And despite the beloved Kennedy legacy, despite the fact that it was one of the most liberal states in the country, Massachusetts elected a Republican named Scott Brown.

It was a body blow to the Democrats’ health care hopes, made crueler by the irony of its being Kennedy’s seat. Without 60 votes in the Senate, with the Republicans unified in opposition, it didn’t matter what compromise the House and Senate agreed to, because the Senate wouldn’t pass it.

Health care reform was over. “It’s dead,” Barney Frank told reporters. Other Democrats voiced similar views on cable TV. Emanuel and Axelrod advocated a smaller piece of legislation that would expand health care for low-income children. The president seemed to be wavering. In an interview the day after Brown’s win, he said he would support a bill that could pass quickly even if it contained only “the core elements” of reform.

Pelosi told the White House to rein in Emanuel and get him to stop pestering her members about his “eensy weensy bill.” At a meeting in the Oval Office, Pelosi confronted the subject directly. “Mr. President, I know there are some on your staff who want to take the namby-pamby approach,” she said. “That’s unacceptable.” Obama took her side. They were going to go for it.

If the House passed the bill the Senate had already passed, Obama could sign it into law. Pelosi had previously declared the Senate bill “a nonstarter.” She had barely gotten the House bill over the line, with its delicate balance of liberal and conservative concessions. If that had been a Herculean feat, to get the House to pass the Senate bill seemed downright impossible. Pelosi estimated she had no more than 180 members who would vote to pass the Senate bill at the outset, meaning she needed about 40 more.

At one of Pelosi’s press conferences, reporters asked how she planned to proceed. “You go through the gate,” she said. “If the gate’s closed, you go over the fence. If the fence is too high, we’ll pole-vault in. If that doesn’t work, we’ll parachute in. But we’re going to get health care reform passed for the American people.”

At the first meeting of the House Democratic caucus after the Massachusetts election, Pelosi just listened. The meeting went on for hours, as member after member lamented the demise of the legislation they’d worked so hard on. All that effort, the tearful negotiations with the bishops, their two-thousand-page behemoth of a bill to give health insurance to more than thirty million people—all for nothing. Members filed out of the room convinced that it was over.

At the next caucus meeting, Pelosi got up to speak. Here, she said, is how we’re going to pass health care reform.

The White House had a plan. A procedural maneuver called “reconciliation” would allow budget-related aspects of health care legislation to go through the Senate with just 50 votes. So, the White House proposed, the House could pass the Senate bill it loathed, and then, under reconciliation, both houses could pass a companion bill with a set of budgetary tweaks. The Senate bill was more conservative than the House bill, with no public option and a smaller price tag. Its prohibition on abortion funding was weaker than the House’s. It was left to Pelosi to convince her caucus to pass the Senate bill combined with the reconciliation “sidecar.”

The health care bill was unpopular, and members from swing districts worried they’d lose their seats over it. But the damage was likely already done—they could be attacked for trying and failing, or they could be attacked for trying and succeeding. Pelosi told colleagues she believed health care reform was an accomplishment so monumental it would be worth losing the majority over. The point of power, to her, couldn’t be just to hold on to it—it had to be to achieve things that would benefit people.

Pelosi began another furious round of vote-wrangling. To get the pro-lifers, the White House promised an executive order that would restrict abortion funds as sharply as the House bill had. To get the conservative Blue Dog Democrats, Pelosi and Senate Majority Leader Harry Reid worked out funding compromises in the reconciliation bill. To bring along wavering liberals, Pelosi and Obama played on their consciences, reminding them of the moral significance of a bill that, while imperfect, would make health care accessible to an estimated thirty-one million Americans. Pelosi demanded that Reid get every Democratic senator to sign a letter promising to vote for the reconciliation bill, so that her members wouldn’t get hung out to dry yet again.

On March 12, Pelosi sent a memo to her caucus. “We have to just rip the Band-Aid off and have a vote,” she wrote. Pelosi worked the members relentlessly. At one point, after presenting her with a list of more than sixty members who needed a phone call, John Lawrence, her chief of staff, expected she’d divvy up the list among the leadership team. “Give me the list,” she told him, and proceeded to call each of them herself.

The talks went down to the wire yet again. On the eve of the vote, a group of moderates walked out of a midnight negotiating session over reimbursements. But on March 21, with the bill on the floor, Pelosi rose to make her closing speech. The members who voted for this bill, she said, would go down in history: “We will be joining those who established Social Security, Medicare, and now, tonight, health care for all Americans.”

The vote was called, and as the tally crept upward, Democrats on the floor of the House began chanting, “Yes, we can!” After the bill passed, 219– 212, with no Republican votes, the floor exploded in cheering and hugging.

Many of the books and articles subsequently written about the Patient Protection and Affordable Care Act would emphasize the president’s achievement—which of course it was—and the protracted drama in the Senate, more than Pelosi’s work in the House. Senate leaders always think their job is harder because they have to get to 60 votes, while House partisans argue that the House, with its hundreds of personalities and layers of overlapping interests and blocs, is infinitely more complex. But it’s impossible to say whether the Senate struggled because Reid’s job was inherently harder than Pelosi’s or because Pelosi was better at the job of getting controversial legislation through the chamber her party controlled.

To Pelosi’s allies, the Senate was like the misbehaving child who gets all the attention, and is praised lavishly for minor progress, while the gifted, well-behaved sibling has to meet higher expectations. Because she made it look easy, people assumed it was. She compared herself to the swan that seems to glide regally across the water, but actually is paddling its big, black, ungraceful webbed feet furiously underneath.

At a caucus meeting, a liberal congressman, Steve Cohen, passed out buttons that read, “PelosiCare: I was there.”

Excerpted from PELOSI, by Molly Ball. Published by Henry Holt and Company May 5th 2020. Copyright © 2020 by Molly Ball. All rights reserved.