The Road to Health-Care Reform: Five Milestones

The days after Republican Scott Brown's Senate victory were tense for supporters of the health-care legislation, many of whom anxiously awaited a mass defection from conservative Democrats that they feared could come at any moment. The Atlantic's Marc Ambinder summed up those fears in January, offering a bleak outlook for passing a bill: "Good luck with that!" he wrote. Other media outlets, meanwhile, appeared eager for signs of the reform's collapse. The Drudge Report posted a blaring headline on Jan. 21 linking to Speaker Nancy Pelosi's comments that the House could not pass the Senate bill: "THE DAY HEALTH CARE DIED." How did Democrats get from such a low point to Sunday night's historic health-care vote?

1. Finance Bills Distract Attention

Pelosi's remarks were widely misinterpreted in the press, a trend that would continue throughout the next two months as reporters jumped on any sign of movement on health care. Her claim that she lacked the votes to pass the Senate bill was no different than what House Democrats had said before Brown won in Massachusetts—they needed changes before they could vote on health care. Already there were indications that Democrats had a path to just such an outcome: a two-track process in which the House passed the Senate bill accompanied by an additional fix through the budget reconciliation process.

But to get to that point, Democrats first needed to avoid a panic from rank-and-file members who voted for the House bill, even a small number of whom could all but doom the legislation by reversing their position. Health-care reform supporters like Rep. Barney Frank (D-MA) preemptively surrendered, saying reform was finished without Republican support. But as the hours and days went by, no such panic occurred, and Frank quickly conceded he "perhaps overreacted." President Obama, criticized by many observers for not quickly reassuring Democrats that the bill could still pass, helped relieve the pressure on wavering Democrats by announcing a new financial-reform package, which quickly changed the subject in the press away from "health-care death watch." And the decision by the Supreme Court to overturn campaign-finance laws, although a major blow to Democrats, also proved a boon for the health-care bill, pushing the issue even further out of the spotlight.

"The shock of Brown's victory produced an overreaction in the immediate days afterward, and I think a lot of people soon realized it was an overreaction," said Paul Starr, who served as an adviser to President Clinton during the 1993 health-care push.

While Obama offered less than reassuring words, including vague talk of a possible scaled-down health-care bill, a number of key players announced within 24 hours of Brown's victory that they were open to the eventual reconciliation strategy, including organized labor and Sen. Kent Conrad, chairman of the budget committee. Behind the scenes, Pelosi insisted that only comprehensive reform would do and that Democrats could not turn away from their pledges on health care, according to Politico. With luck and skill, Democrats had survived the most dangerous period of Obama's presidency.

2. The Insurance Industry Hikes Rates

After pronouncing health-care reform dead on Jan. 21, The Drudge Report and some other news outlets largely ignored any suggestions that it might be revived over the next three weeks, even as Pelosi, Reid, and Obama laid the groundwork for the coming final push with increasingly confident rhetoric.

After initially leaving health care for Congress to work out, Obama launched his own reform effort on Feb. 7 after a strong State of the Union address two weeks before, bringing health care back into the spotlight by scheduling a bipartisan summit to discuss the issue. Obama's move was, by all accounts, crucial to passing the bill. But as luck would have it, the day after the summit announcement brought Democrats an added gift at just the right time: Anthem Blue Cross announced a 39 percent hike in insurance premiums for its customers. The White House quickly pounced on the news as proof reform was urgently needed. Families USA Executive Director Ron Pollack, whose organization is a leading advocate of reform, described the event as crucial.

"The announced premium increases of 39 percent in California and even larger in some states helped galvanize support not just on Capitol Hill, but among constituents across the country," Pollack said. "That rate increase helped spur the conviction we needed to get this done and move it forward quickly."

3. The GOP Holds Up Unemployment Benefits

Obama's bipartisan summit was somewhat anti-climactic, proving to be more civil and policy-oriented than expected. But a series of events in the Senate helped turn public attention to Republican obstructionism when Democrats needed it most. Sen. Evan Bayh (D-IN), considered one of the most conservative lawmakers in his party, announced his retirement, prompting criticism from some Democrats that he was abandoning a safe seat and jeopardizing their majority. In declaring his intention to leave, however, Bayh unleashed an unexpected assault on the GOP's endless filibusters and procedural roadblocks, citing a vote on a proposed deficit-reduction panel he supported in which previous Republican supporters switched their stated position at the last minute to hand Obama a legislative defeat. Lending support to his argument that the Senate was broken were two high-profile acts of obstruction: first, a blanket hold by Sen. Richard Shelby (R-AL) on Obama's nominees for federal positions over a Defense earmark, and then a one-man filibuster of unemployment benefits by Sen. Jim Bunning (R-KY).

4. Obama Energizes the Base

While the conservative grassroots proved energized and effective in its opposition to health-care reform in 2009, the Democratic base had been far more disappointing to supporters of the legislation. Much grassroots energy had been expended on internal disputes over whether the bill would include a public option, and shortly before the Brown election, some leading activists on the left, including Daily Kos' Markos Moulitsas Zuniga, former presidential candidate Howard Dean, and blogger Jane Hamsher, even openly advocated scrapping the current Democratic legislation and starting over.

But with Obama now putting his presidency on the line, the situation turned around rapidly. MoveOn.org took a vote of its members and found that 83 percent backed the president's proposal. The group began raising money for primary challengers against Democrats who opposed reform, quickly putting together more than $1 million. Moulitsas backed away from his previous attacks and went on the air to threaten progressives who voted against the bill from the left with primaries as well. The AFL-CIO and SEIU, despite their opposition to a tax included in the Senate bill on high-end health benefits, began to throw their weight around, putting heavy pressure on wavering House Democrats to toe the party line.

Obama had said in his speeches he was motivated not by politics, but by the importance of reform, and his fiery rhetoric helped rally and unite the base.

"Any poll will tell you it's not smart politics [to pass the bill]," said Joe Trippi, a Democratic strategist who argues heath-care reform will hurt Democrats in midterm elections. "I truly believe the administration believes this is what's in the best interest for the country. If they didn't believe it, they wouldn't put so many Democrats at risk."

Despite warnings of political damage, Democrats' renewed enthusiasm could be seen in some polls as well, with a small but measurable uptick in overall support for health-care reform that White House pollster Joel Benenson eagerly touted to show Obama's hands-on approach was working.

5. Democratic Holdouts Line Up Behind the Bill

With passage of the health-care bill increasingly viewed as inevitable by Democrats and Republicans alike, the scene at conservative rallies began to resemble the final weeks of the 2008 presidential election, when attendees at McCain and Palin events shouted "terrorist!" and turned their anger on reporters in attendance. For conservatives, many of whom were sure reform was defeated with Brown's election, it was a maddening shock to the system. Enraged protesters reportedly screamed racial and anti-gay slurs at Rep. Barney Frank (D-MA), who is gay, and Rep. John Lewis (D-GA), an icon of the civil-rights movement. An office of Rep. Louise Slaughter, whose proposed "deem and pass" procedure for enacting the Senate health bill was frequently attacked by conservatives before being abandoned by Democrats, was vandalized with a brick thrown through its window. But despite the last-minute protests, Democrats in swing districts targeted by conservative activists and GOP officials surprisingly broke in favor of health-care reform, even several who had previously voted against the House bill. Just as in November 2008, everything began to fall in place at once for the Democrats as holdouts on the left, right, and center lined up behind the bill with the last pro-life opponents, led by Rep. Bart Stupak (D-MI), finally clinching the bill's passage after cutting a deal with the White House. Only eight weeks after Brown's election, the bill was on the verge of becoming the law of the land.

Benjamin Sarlin is Washington correspondent for The Daily Beast. He previously covered New York City politics for The New York Sun and has worked for talkingpointsmemo.com.