Obama feared a “one-term presidency” after passing the health care law

By the time his ambitious health care legislation was introduced and chopped up and cursed and left for dead and revived and compromised and passed and finally signed into law, the entire process had taken its toll on President Barack Obama.

Passing the Affordable Care Act would be his signature legislative achievement, but it propelled Republicans to a landslide midterm election victory and control of the House of Representatives. And Mr. Obama thought he might be the next to pay the price at the ballot box. “This will be a one-term presidency,” he told an aide in late 2010.

He turned out to be wrong, but the fatalism Obama expressed privately that day reflected the dire consequences of one of Washington’s most consequential legislative battles in modern times. A new series of oral histories released Fridayon the eve of its 14th anniversary on Saturday, documents the behind-the-scenes struggle to transform the nation’s health care system to cover tens of millions of Americans without insurance.

The interviews with key players in the drama were conducted by Incite, a social science research institute at Columbia University, and were made public as the second phase of a yearslong effort to document the eventful times under the country’s 44th president. The transcripts, posted online Friday, include recollections from 26 members of the White House staff, his Cabinet and Congress, as well as activists, advocacy group figures and a handful of Americans who made their voices heard, but not the former president himself or, for example, what matters, his Republican opponents.

The oral histories chronicle Obama’s journey from an uninformed candidate embarrassed by the banalities he uttered during his campaign to a beleaguered president who gambled his political future on all-or-nothing legislative mismanagement. They also paint a portrait of Mr. Obama as a steadfast, hyper-disciplined but not particularly warm policy man who searched the Brookings Institution website for ideas and had to overcome his own political mistakes.

The story of the Affordable Care Act, in a sense, began at a candidate forum on health care in 2007, when Obama faced off against Senators Hillary Clinton, John Edwards and Joseph R. Biden Jr., among others. for the Democratic presidential nomination. “Senator Obama was terrible,” recalls Neera Tanden, who worked for Clinton at the time. ‘He was faint. He had no experience with this issue, so he kept talking about, “This is why we need to come together.”

Obama knew he had done a bad job, and it made him take the issue more seriously, she said. “I honestly think if he hadn’t been kicked in the ass, he wouldn’t have put together such a detailed plan,” Ms. Tanden said.

After Mrs. Clinton lost and Mrs. Tanden joined the Obama campaign in 2008, she said, “A lot of his advisers said, ‘We should just drop this health care thing.’ He said very clearly, “I’ll do health care when I’m president. You have to figure out how we succeed in the campaign to build a mandate, but I will.’”

Upon taking office in January 2009, Obama tackled a challenge that had irked presidents of both parties, most recently Bill Clinton, whose first term nearly collapsed after he himself failed to pass sweeping health care legislation. Mr. Obama’s advisers were determined to learn from the mistakes of the past.

By developing their own plan publicly and involving major players with stakes in the issue, such as insurance companies and congressional leaders, the Obama administration hoped to build support rather than simply adopt a secretly crafted plan to Congress, as the Clintons had done in the 1990s.

“The Clinton administration was focused inward on the perfect policy — and I was part of that, so I don’t want to sound ‘alien’ about it,” says Nancy-Ann DeParle, a Clinton administration veteran turned director of the Clinton administration. Obama’s Office for Health Reform in the White House. “The Obama administration was the opposite. It focused much more on stakeholders and people and made Congress do the work of debating policy and passing a bill.”

But Mr. Obama made his own misjudgments. Ms. Tanden, who became a senior adviser at the Department of Health and Human Services and admired Mr. Obama’s determination to make sweeping reforms, said his team nevertheless spent “an inordinate amount of time” on smaller issues rather than systemic issues and that she didn’t. initially expected abortion to become a “big problem.”

Ezekiel J. Emanuel, a special adviser on health care who also appreciated that Mr. Obama “never wavered,” said the White House should have sent members of Congress home for their summer recess in 2009 with a slide deck to describe the plan components. “We didn’t do our job, and I think that was a big mistake,” recalled Dr. Emanuel himself. “They needed better tools to explain it to people.”

Peter R. Orszag, the director of the Office of Management and Budget, got a taste of the plan’s misunderstandings and distortions while vacationing in Maine that summer, where he saw signs in front of stores falsely warning of “death panels.” that would supposedly arise through the legislation.

“That was probably the first time it really hit me,” he said, “just seeing board after board after board about things that — you can see why people might think that’s where it would go.”

Hopes for Republican support then virtually evaporated, leaving Obama only able to work with the Democrats. He was deeply involved in negotiating. Kathleen Sebelius, then secretary of Health and Human Services, recalled a key meeting in January 2010 to reconcile different versions of the plan. “The president led these negotiations from start to finish,” she said. “He was the chief negotiator.”

It would eventually pass, but not without painful concessions and legislative machinations. Mrs. Sebelius talked about the champagne party on the Truman Balcony in the White House the night it passed. Mr. Biden, then vice president, told her: “This is the most important thing the president will do for the international community.”

She asked what he meant. “The world will now know when this young president says, ‘I will do something,’ he will do it,” Mr. Biden responded.

Yet Mr. Obama did not know how much time he would have to do anything else. Ms. DeParle was the aide who recalled Obama musing about just one term as he tried to persuade her to stay in the White House after health care.

“That’s fine with me,” he said of a possible four-year presidency, “as long as we can do the things that I think are important.” But Ms. DeParle found his comment “very surprising” and thought to herself, “Gosh, this is my fault.”

Mrs. DeParle made some of the most personal observations of the ascetic president. She said, among other things, that he refused to eat in public and only ate at his regular times every day. When he ate with his staff, you “eat with him in silence” while he read or prepared for his next event. And his meal was almost always the same: salmon or dry chicken breast, brown rice and broccoli.

“Trust me,” she said. “That was it.” His only nod to taste? “Add lemon juice, or some lemon.” And never dessert. “To him, eating is like putting a coin in the meter,” she said. He wouldn’t even eat cake even though he said he liked cake. “He has no weaknesses that I can see,” she said.

Ms. DeParle found him a mystery and only came to understand Mr. Obama when she accompanied him to his home state of Hawaii. “The waves come in and go out,” she said. “He has a calm demeanor, which is the same for me. He doesn’t worry about anything. And the fact that he was in a place that was as close to Tokyo as it was to New York – he has an international point of view,” she added. “He sees the world differently than many American presidents.”

It turned out that he obviously had two terms for that. And the Affordable Care Act, for all its birth pangs and flaws and Republican efforts to repeal it, remains the law of the land.