Conflicts in Institutions

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Conflicts in Institutions: President Obama and the Health Care Debate By Kirk Lohbauer A Thesis The Division of Social Sciences New College of Florida In partial fulfillment for the degree Bachelor of Arts Under the sponsor ship of Professor Keith Fitzgerald Sarasota, Florida May 2009

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Abstract In 2009, President Obama undertook the major task of trying to revamp the American health care system. In doing so, President Obama dealt mainly with interest groups, Congress, and the public. An observation of how the President chose to interact with these groups indicate that the presidency in currently in transition with interest groups becoming more important in order for presidents to achieve their goals. This institutional ch ange of increased interest group participation is directly conflicting with President Obama's mantra of change during his campaign, which made it difficult for the President to be completely effective during the healthcare debate. Ironically, Barack Obama who has been hailed for his oratory skills, was suddenly caught without a message, and therefore contributed very little towards being the public face of the health care legislation. After a few missteps, the President was able to compose a message and control the debate at towards the very end. This turnaround certainly helped in making sure that the health care bill became law, but since the President did was not able to reconcile his different roles earlier on in the debate, there were dire consequen ces in the final legislation, and there likely will be consequences felt in the coming 2010 elections. So, while the President was successfully able to pass sweeping health car reform, he did so at a large cost, all of which has yet to be felt. Dr. Kei th Fitzgerald Division of Social Sciences

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1 On March 23, 2010, President Barack Obama signed into law the Patient Protection and Affordable Care Act, a massive health care reform bill that would insure 32 million Americans, create major changes in private i nsurance regulation, and signal a decisive change in the administration of health care in the United States forever (Stolberg, and Pear, "Obama Signs"; Associated Press). This change was in no way inevitable, and the process leading up to the bill's passa ge was rife with moments of seeming certainty of failure and seeming certainty of success. Various political actors such as Senator Max Baucus, Senator Harry Reid, Senator Olympia Snowe, and the American Medical Association all received their time in the spotlight, all indicative of what point in the process the bill was going through. However, the most interesting of the political actors by far is President Obama himself. President Obama's involvement was pivotal in making sure that the health care leg islation became law, but his work in accomplishing this task was far from perfect. When President Obama began his drive for health care reform, he was severely limited by modern institutional challenges, election promises, and historical limitations. It wa s only by deviating from these restraints that he was able to successfully pass a major health care law, and by not overcoming these limitations earlier, there may be consequences of passing his legislation that are as of yet unseen. Before delving into a ny conversation of the health care bill, it is first helpful to understand what roles different actors have in the political arena. Ingram and Schneider have defined in a more general sense how groups are given their political roles via "target population s." A target population is cultural characterizations or popular images of the persons or groups whose behavior and well being are affected by public policy"

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2 (Schneider, and Ingram 334). So, any politically affected group, from bankers to single mothers are defined as a target population, and there are certainly social consequences to their characterization. Ultimately, these target populations are categorized based on two factors, their perceptions and their power (335). A group's power is derived f rom multiple things such as money, the amount of members, and their propensity to act; a group's perception or "construction" is defined by whether the group is perceived in a positive or negative light (335). With these two distinctions, four types of ta rget populations are possible. Advantaged groups are powerful groups with positive constructions, such as veterans and businesses; contenders are powerful groups with negative constructions, such as unions and cultural elites; dependents are weak groups with positive constructions, such as children and the disabled; and deviants are weak groups with negative constructions, such as criminals and illegal immigrants (335 336). The importance of acknowledging these different groups is that variations in thei r power and perception affect the way that they are addressed in the political arena; groups that are capable will extract "benefits" from political action that help them keep their dominant position, while groups that are incapable will be given "burdens" that are intended to punish (Schneider, and Ingram 337). Since advantaged groups have power and a good social standing, it is easy for the general public to see a reason to support them, and it is easy for these groups to articulate these needs (344). T his combination of legitimacy and ability means that advantaged groups often receive more rewards than they should logically be given, though this is accepted as a positive thing do to their privileged status (337). This method is very different from cont ender groups. While they have vast resources to forward their policy goals, their bad public face doesn't allow

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3 them to advertise it in the same way (338). As a result, legislation directed towards them will have clandestine benefits that are difficult f or outsiders to discern (338). Furthermore, politicians will advance bills that claim to punish contender groups, but have little actual effect since the contenders have the ability to make sure no real burdens exist (338). For dependent groups, supporti ve laws are passed that are related to them, but the support is not substantial (338). Since these groups do not have any real power, they are generally unable to get legislation to allocate any benefits for them. So bills pertaining to dependent groups a re often empty gestures (338). Finally, deviant groups will nearly always receive burdens, since their lack of power and positive construction makes them easy targets (339). Similar to the way in which advantaged groups are oversubscribed benefits to a f ault, the negative construction of deviant groups makes it common for politicians to give them an unnecessary amount of burdens (337, 338). The insight provided by Ingram and Schneider provide a theoretical framework that should allow us to explain why di fferent groups have interest in crafting legislation in certain ways, and health care reform can certainly be observed in this way as well. The modern health care industry in America is a major force, and it is comprised of various target populations that are very clearly defined. Insurance companies, doctors, nurses, hospitals, and seniors are just a few of the groups that modern legislators have to contend with whenever health care legislation is proposed, and having so many entrenched interests can mak e the chances of reform very difficult. However, throughout America's history, these groups have not always been so concrete. The American health care system exists as it does today because of the very idiosyncratic events that have

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4 happened in its past, and understanding this history helps to shed some light on why health care reform has unfolded as it has. For much of America's history, the concept of national health insurance is something simply would have been unthinkable, and even distinct, powerfu l target populations in the health care industry did not start to blossom until the 20 th century (Starr 7 8). The current day medical practice is composed of an intricate weave of required schooling, training, licensing, and membership that creates doctor s, but when the United States first came into existence, none of this existed. The reasons for this were not entirely medical, and in fact, much of the reason that an early American medical industry failed to materialize was due to its political history. Starting with the Revolution, Americans had a democratic fervor that extended to the field of medicine (Starr 52). While today the idea of an authoritative collection of doctors seems necessary for scientific advancement, in early America, it was seen as a symbol of aristocratic privilege (52). Samuel Thomson was a major proponent of this philosophy, and his goal through the "Thomsonian Movement" was to keep medicine understandable to the masses; Thomson feared that making medicine overly scientific in i ts methods and semantics would make it inaccessible to the masses, and equally important, that the people who became esteemed as doctors would hold their position not because of their skill, but because of aristocratic entitlement (52). Thomson's sentimen t was in no way uncommon or groundbreaking, since at the time, ones family was expected to be the primary caretaker whenever someone got sick (32). While hospitals might occupy that role today, during the 18 th and 19 th century, they were not seen as facil ities for respectable individuals, and were instead used to care for the poor and those who had no relatives to

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5 aid them (145). Of course, society reflected this belief, and the layman was trained with a mixture of sources including newspapers, almanacs, oral training, and medical guides written specifically in simple terms (32). This enabled home care, and women were often expected to perform these medical functions, keeping herbs in the house that would help with healing (32). William Buchan authored o ne of the most well known of these medical guides, Domestic Medicine and through his books many editions, he tried to give citizens the tools to diagnose and treat illnesses on their own (32 33). In today's society, a tool such as this would be unthinkab le. There are certainly resources for self diagnosis, and a popular medical website, webmd.com, has a symptom checker that allows people to try to discern what is wrong with their bodies. However, even this checker prefaces by saying that this tool does not provide medical advice It [sic] is intended for informational purposes only. It is not a substitute for professional medical advice, diagnosis or treatment" (WebMD). So, checking for symptoms today is more intended as a precursor to a physicians visi t, as opposed to the 18 th and 19 th century when self diagnosis was a precursor to self treatment. While Domestic Medicine did defer to doctors for some rare cases, it still contended that people should be able to deal with most illnesses without the need of a trained physician (33). As long as this democratic vein in medicine existed, it is easy to see why no major group could rise to medical domination. However, a democratic view of medical treatment was not the only thing that held back any real power structure in the medical field, and the fact that the medical community had yet to reach a consensus for proper treatment also hindered the ability of physicians to become the advantaged group that they are today. Different groups existed that challenged the supremacy of what would become the modern physicians, specifically

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6 the botanic practitioners, homeopaths, and other forms of "lay medicine" (47). Botany provided the largest counter movement to the regular medical consensus, and Samuel Thomson spearhe aded this alterative view (51). According to Thomson, cold is the reason for sicknesses, and reintroducing heat is the only way to return to good health. Heat was caused by two things, digestion and perspiration, and so anything that prevented these proc esses were harmful to health (51). Thomson theorized that some blockage was preventing proper digestion, and he would induce vomiting using plants such as Indian tobacco and cayenne pepper in order to remover the blockage (51). Once the digestion process could occur again, heat would again be produced. Thomson was also noted for his use of steam baths, which caused perspiration, therefore bringing back the needed heat (51). Thomson's dichotomous view of medicine didn't just manifest itself in hot and c old, but it underground and aboveground as well; the use of minerals in Thomsonian medicine was heavily discouraged because they were found underground, and this would only hurt a persons condition (51). Instead, Thomson encouraged the use of herbs as hea ling tools since their growth is in the direction of the sun, while criticizing the medical profession for its continued use of minerals (51). The other, albeit less common alternative to regular medicine, was homeopathy (Starr 51). Homeopathy is based o n the "law of similars," which assumes that an illness can be cured by a drug that gives the same effects of the disease (96). Homeopathic medicine is very heavily diluted with water, and the body attacks this drug in order to learn how to fight the disea se itself (96 97). The existence of three competing medical schools of thought certainly made it difficult for any one to claim ultimate power, but it begs the question, why didn't the

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7 regular physicians simply present the data that homeopathy and Thomson ian medicine didn't work? This is answered by the scientific limitations of the time; the ability to prove them wrong simply did not exist (59). Before scientific advancements took place, the different schools of medicine were all seen as legitimate scie ntific interpretations, and any attempt to gain power over another was viewed negatively as a monopolistic power grab (100). Establishing their scientific legitimacy was a major part of why physicians were able to gain favor over competing schools (142). For instance, for most of the 1800's, hospitals were seen as places that were intended for people that were poor, without family, and not likely to get better (145, 151 152). However, with the development and widespread use of antiseptics in the 1890's, doctors were able to work in a cleaner environment, which allowed them to perform surgery in places that were previously unworkable, and it allowed them to do so with a better survival rate (156). When the developments of antiseptics and anesthesia made m ore intricate surgeries possible, it made an opening for doctors to claim "legitimate complexity," which is the concept that medical terminology and exclusivity exists for the purpose of better patient treatment, not for aristocratic favoritism (59). Sudd enly, physicians had the ability to counter the Thomsonian claims that animals are made up of earth, air fire, and water, and the public suddenly had reason to believe them (51). Furthermore, when medical advances became more and more complex, doctors beg an to rely on each other in a hospital setting for facilities and consultation, cementing their relationships. Ultimately, the early limitations upon American doctors came down to three things: democratic sentiments, scientific uncertainty, and a lack of professional cooperation. The post revolutionary fervor made citizens very wary of an aristocratic

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8 class of physicians, and instead, medical care was mainly handled by women in the home. In this arena, where all ideas are given equal weight, questionable medical groups arose, such as homeopaths and botanical doctors, who were seen as equally valid competitors. Without the science to refute their claims, these schools of thought flourished, and even when science was able to make more lucid claims, physici ans still lacked any reason to work together. This perfect storm of conflicts meant that physicians were unable to form an advantaged group, but this would soon change as barriers that held physicians back began to fall. This extensive history is extrem ely important, because it has arrived physicians at the place where they stand today, an advantaged group. The American Medical Association (AMA), the largest physician organization in the United States, boasted 240,000 members in the United States in 200 6, and collected 48 million dollars worth of dues (Peck). While this membership has declined, it still shows that the AMA is certainly a financially viable institution. However, the AMA is more than just financially capable, and as a result of the above history, doctors have had "cultural authority" and a "distinctive base of power" ever since the Progressive Era (Starr 218). That gives them the second critical component of being an advantaged group (Starr 218). People defer to doctors in medical affair s, and they trust their decision making, and this phenomenon traces back to the late 19 th century when people were beginning to accept that doctors were a necessary and respectable. When one considers this perception, it is no surprise that the AMA has be en a major player in nearly all major attempts at health care reform, and the recent reform by President Obama has been no exception (Jonas 174, 182). People trust their doctors and do not like the idea of medical decisions being usurped by

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9 any other enti ty. Since physicians occupy that niche of monetary ability and widespread respect, the fact that they hold influence is not surprising. While doctors do play this very important role in the health care system, they are not the only interests to consider, and they are not even the most important group to consider. Undoubtedly, the most powerful lobby that exists in healthcare today is the insurance industry (Jonas 125 126). However, they occupy a very different position from doctors when it comes to crea ting policy, and this is traced back to the roles laid out by Ingram and Schneider. There is no doubt that insurance companies have power, given that the top three insurance companies earned just over 170 million dollars in revenues in 2008 (CNN). Howeve r, they do not necessarily hold the same elevated status that doctors have. A 2009 CBS poll asked people to give their opinions of health insurance companies, and while 49 percent of people responded with either somewhat or very favorable, 48 percent resp onded with either somewhat unfavorable or very unfavorable, indicating a very torn perception that is not wholly positive (" Health Poll Search" ). A question that asked people how much confidence they have for insurance companies provided even worse result s, with 49 percent of respondents indicating that they had very little or no confidence in insurance companies, and only 17 percent of respondents saying that they had quite a bit or a great deal of confidence (" Health Poll Search" ). Most of the responden t in this poll (33 percent) did indicate some confidence in health insurance companies, but this commitment seems weak compared to the percentage against (" Health Poll Search" ). Given that public opinion of health insurance companies can be described as t epid at best, it is unsurprising that during the recent health care debate, many politicians defended their positions by condemning health insurance companies

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10 (Sack, "Obama Tries"). The opinion of health insurance companies seems even worse when compared to doctors, who were viewed either somewhat or very favorably by 81 percent of respondents in a Kaiser/Harvard/USA Today poll in 2008 (" Health Poll Search" ). Their physical capabilities, coupled with their negative perception makes insurance companies a c ontender group as outlined by Ingram and Schneider's group model. As a contender group, one expects to see that insurance companies are able to gain benefits for themselves as a result of their resources, but they are not able to get benefits that can be advertised to the public, since people do not generally consider them to be deserving of assistance (Schneider, and Ingram 338). Furthermore, politicians will try to punish these groups through actions that are mainly symbolic, since the public desires to see these groups hindered, but politicians do not have the power to significantly counter them (338). Given that doctors occupy the main role of caretaking in health care, and insurance companies occupy the main role of paying for it, it is unsurprising t hat these two groups are such pivotal players when health care reform becomes an issue. Though it would be disingenuous to claim that these are the only two actors. Seniors, pharmaceutical companies, hospitals, and hospices also have a major stake in how health care develops in the United States, so their involvement was certainly felt in the 2008 health care reform. Seniors, like doctors, are also an advantaged group, especially given that they have a major organizing group through the American Associat ion of Retired Persons (AARP), which describes itself as "a nonprofit, nonpartisan membership organization that helps people 50 and over improve the quality of their lives" (AARP). In 2006, the AARP collected one billion dollars in revenue and spent 23 mi llion dollars for

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11 lobbying efforts (Birnbaum). Apart from monetary abilities, the AARP boasts a membership of 40 million members, making it representative of a sizable portion of the American population (AARP). Claiming representation of this group is es pecially important to politicians because of their voting habits. In the 2008 elections, seniors had the greatest voter turnout among any age group, so it would certainly be beneficial to appeal to them (U.S. Census Bureau). Furthermore, assuming that po ll data on Medicare can indicate how deserving seniors are considered to be, it is reasonable to say that people feel that the elderly should be taken care of (" Health Poll Search" ). Beyond this poll data, another reason it is safe to assume that seniors are an advantaged group is that during the recent health care debate, Republicans were unified in the talking point that the Democratic plan was bad because it cut Medicare ("House Republican Leader John Boehner"). One of the key indicators of an advantag ed group is that public officials advertise that they want policies that will explicitly benefit this group. If seniors were not advantaged, then Republicans would not look to emphasize this interest. All of this historical baggage has placed the Unit ed States in a very specific place when health care reform became an issue again in 2008. Since the development of health care in America has been very distinct, its reform reflects this distinction. Simply using a national health insurance model that is currently used in other countries would be entirely impractical since they have developed in a separate way, require different solutions, and have cultures that make some options possible while making others impossible. Therefore, it wasn't proposed that the models of other countries get used, and legislators had to find an American solution.

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12 In 2008, America found itself in one of the greatest recessions in modern history. Beyond this, the country was in the throes of a major presidential election that would determine who would deal with this crisis. The candidates, senators Barack Obama and John McCain, were consumed by the economic crisis, and rightfully so, given that most of the polls released during the election timeframe indicated that most citiz ens considered the economy to be the most important issue for the country by a wide margin (Polling Report, Inc., "Problems and Priorities"). While health care did consistently rank highly as having importance as well, it trailed significantly behind the economy (Polling Report, Inc.). So while it was not the most important topic facing the candidates, both of them still had their positions on health care laid out. Candidate Obama's plan was ultimately very similar to the one that was passed under his pr esidency, though the final legislation did differ in some ways. Candidate Obama's plan included a mandate to obtain health care, but only for children and for larger businesses (KFF, "Candidate Proposals" ). Businesses were required to either offer insura nce to their workers, or pay taxes that would support a public health insurance plan, as well as supporting subsidies for individuals to buy into the public plan (KFF). Additionally, pre existing condition exclusions would become illegal, children could p articipate in their family's insurance until they were 25, and both Medicaid and SCHIP would be expanded (KFF). Senator McCain's proposal was markedly different, lacking any mandate similar to Obama's (KFF, "Candidate Proposals"). Instead, Senator McCain 's proposal was based mainly on encouraging people to buy insurance on their own accord by giving citizens tax breaks, and for those citizens that would be unable to get an insurance plan due to pre existing conditions, states would create their own public plans with federal aid. Other major

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13 aspects of McCain's health care plan included malpractice reform, removing statewide insurance monopolies, and equalizing Medicare Advantage payments (KFF). Obviously, these two plans indicate extremely different ideo logical focuses that would resurface during the eventual Obama presidency. Senators Obama and McCain differed on mandate requirements, malpractice reform, and the extent of federal involvement, all of which are major issues for disagreement. While these disagreements lived on after the elections, the election itself had to have a closing moment, and on November 8, 2008, Senator Barack Obama was elected to become President of the United States of America. That night, though a celebratory night for many, g ave indications of the deep divisions within the electorate. One of the greatest indications being how the crowd reacted to the mention of Barack Obama during Senator McCain's concession speech: a little while ago, I had the honor of calling Senator Bara ck Obama -(boos) -to congratulate him -(boos) -please -to congratulate him on being elected the next president of the country that we both love" (New York Times, McCain's Concession Speech" ). This bitter sentiment would play a key role in the h ealth care debate ahead Before dealing with health care, President Obama first turned his focus to the economic crisis. The President was signed into office on January 20, 2009, and the four quarters of 2008 that that preceded his presidency experienced gross domestic product (GDP) growth of 0.7 percent, 1.5 percent, 2.7 percent, and 5.4 percent (Bureau of Economic Analysis, 6). In order to stop the decline, Congress and the President enacted the American Recovery and Reinvestment Act of 2009. The fi nal bill had a cost of 789 billion dollars, with 507 billion of that intended for government spending, and 282 billion

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14 of that intended for tax rebates (New York Times, Economic Stimulus" ). This move towards direct government spending is a prime example of fiscal policy, which adjusts government spending or taxation levels in order to change some desired aspect of a country such as unemployment, gross domestic product, or inflation (Gordon, 19). Fiscal policy is contrasted with monetary policy, which tri es to achieve the same goals through an adjustment of interest rates and the money supply (19). However, by the time that the stimulus bill passed Congress, the options for monetary policy had already been exhausted with little effect. On December 16, 20 08, the Federal Reserve decreased their target federal funds rate by 0.75 percent to 0 0.25 percent, and on the 17 th the primary discount rate was reduced to 0.5 percent, all done with the intention of making lending more appealing (The Federal Reserve, Open Market Operations" ; The Federal Reserve, Discount Rate" ). Despite this action, banks were still reluctant to loan money, and continued to make their lending rules more restrictive after the Fed's interest rate deductions (Associated Press, Banks Co ntinue" ). So, since changes in the interest rate were unable to spur investment, the government intervened directly through deficit spending. This deficit spending would hopefully stave off the unemployment and GDP decline, as outlined by Keynesian econo mic thought. The process by which an increase in government spending is intended to increase GDP and decrease unemployment is fairly simple. Government spending increases aggregate demand since the government is now purchasing goods and services that wer e not previously being purchased. In order to meet this added demand, businesses hire more workers, reducing unemployment. Ideally, this new employment would spark even more spending, since the newly employed would use their income to make purchases, but this was probably less of an

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15 effect during the Recession, since low consumer confidence made people more likely to save. The only concern that arises from constant deficit spending is the inflationary pressures that it causes. However, given that the re cession reduced demand so drastically below supply, there were strong inflationary pressures to fight against. The data on inflation supports this, since despite the massive federal stimulus, inflation only rose at a rate of 0.2 percent per month (Bureau of Labor Statistics). Meanwhile, GDP after the stimulus was enacted showed signs of promise. In the four quarters of 2009, the change in GDP was 6.4 percent, 0.7 percent, 2.2 percent, and 5.6 percent (Bureau of Economic Analysis, 6). This positive cha nge is surely a validation of the course taken by the administration. While in retrospect it can be said that the stimulus package was a positive step towards helping the economy, the reality of the situation does not always match with public perception Polls from USA Today and Gallup, CNN and Opinion Research, and the Washington Post all indicate that public opinion on the President's handling of the economy had steadily declined since February of 2009, which was when the stimulus bill passed (Polling Report, Inc., President Obama" ). Beyond the perceived failure of the President's stimulus plan, people were beginning to believe more than ever that government was getting too involved in too many things and placing too many regulations on business (New port). These factors would make a very difficult climate for health care reform. The public was seemingly tired of government involvement after seeing a wave of activity that was generally not understood, such as a bailout under President Bush, a stimulu s package under President Obama, and various actions undertaken by the Federal Reserve. In the middle of a crisis where unemployment was

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16 reaching 10 percent, President Obama and the Congress seemed consumed with adding even greater government responsibili ties by addressing health care. This concern was echoed throughout the media, yet Obama's choice to continue on his agenda was in no way surprising. He indicated that the recession would not hamper his domestic agenda as early as Election Day: "Finally, as we monitor and address these immediate economic challenges, we will be moving forward in laying out a set of policies that will grow our middle class and strengthen our economy in the long term. We cannot afford to wait on moving forward on the key prio rities that I identified during the campaign, including clean energy, health care, education and tax relief for middle class families" (New York Times, Obama's Press Conference" ) Even before beginning his tenure as president, Barack Obama was very clear that fixing the economy was a two pronged task that required fixing the immediate problems as well as tackling issues that would prove to harm the economy later on. So, while his presidential hurriedness may have worried citizens, it was certainly in keep ing with his earlier statements. In many ways, the factors that surrounded the modern health care debate were the very same factors that were present when President Clinton tried to reform the health care system during his presidency. Like Obama, Preside nt Clinton was elected following a downturn in the economy, and a major part of the mandate for his victory was both economic recovery and health care reform (Skocpol 173). However, these two expectations soon found themselves directly in conflict, since the poor state of the economy left people with little trust in government, making citizens skeptical that the government could properly tackle an issue as large as health care (174). So, President Clinton was faced with the difficult task of trying to for ge a health care plan that would

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17 not run agitate peoples fears of an increasing deficit and debt, while at the same time trying to propose a massive, national program that could actually solve the problems of the health care crisis. While the historical di fficulties of a recession were certainly problematic for the Presidents health care plan, it was not the only difficulty. As a candidate, Obama ran on a platform of hope and change, and the promise for change was centered around the idea that politics in Washington needs fundamental reform ( "Plan For Change Ad" ). While certainly not an original concept for a presidential candidate, it helped make the future president very popular. This promise included removing the influence of lobbyists, making strong e fforts towards bipartisanship, and keeping a better track of earmarks; each of these aspects became hot button issues during the health care debate ( Politifact.com, "The Obameter" ). Perhaps one of the most important guarantees in President Obama's promise of change was that he would try to achieve the bipartisanship that had been seemingly lost in the previous administration. In this spirit, President Obama did not conceive a major White House health care plan that was solely developed in house; in fact, President Obama seemed devoid of any involvement of developing the health care plan at all (Stolberg, Greater Role on Health Care" ). This approach held two advantages, it avoided the appearance of a dominating Democratic plan, and it did not conjure memo ries of President Clinton's failed Health Security Act, which was completely orchestrated by the President's Task Force on Health Reform, headed up by Hillary Clinton and Ira Magaziner (Skocpol 9, 10, 15). Instead of displaying a strong executive presence President Obama was mainly absent, and the task of forging a bill was

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18 supposed to be a bipartisan Congressional process, and the President spelled out this desire on more than one occasion (Lee; Brandon). This understanding was certainly shown by member s such as Senator Ron Wyden who said "the president is very much aware that to bring about enduring changeyou need bipartisan support," so good faith certainly seemed to be present. While leaving the details to Congress did provide the President with the some benefits, it also generated difficulties that ultimately weakened the chances for health care reform to get passed. One of the most notable problems was that by not crafting one cohesive plan, it prevented the President from having one coherent mess age. By the time of the final passage of the bill, the House and Senate had a total of 14 different health care proposals that had been advanced (KFF, Side by Side" ). Of course, not all of these bills were seriously there for consideration, such as Repr esentative Boehner's bill which was tailored mainly to a state level and focused heavily on medical malpractice reform, neither of which factored heavily into President Obama's stated goals (KFF). However, the sheer existence of over two dozen bills, rega rdless of their likelihood of passage simply made the process more confusing. What was more harmful than the confusion is that having fourteen potential bills meant that could attack concepts from any one of them, while Democrats would have no one particu lar bill to defend (Pear, Democrats Develop Pitch" ). With all of these difficulties, the debate over health care began. While the discussion took some time to truly get started, even from very early on, legislators began drafting reform proposals and in terest groups jockeyed for positions, some even before Barack Obama had even assumed the presidency. One such interest group calling itself

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19 Health Reform Dialogue (HRD) had started meeting since the September before the presidential election (Pear, Divid e Over Overhaul" ). The HRD was headed by Richard J. Umbdenstock, president of the American Hospital Association, and had members from a broad group of interests such as physicians, nurses, employers, unions, and pharmaceuticals (Pear). The main purpose of the HRD was to form a large, respected group that could reach a consensus as to what any new legislation should entail, though early on, it was clear that there would be difficulties in accomplishing this. By March 7, 2009, two union representatives in the group, the Service Employees International Union (SEIU) and the American Federation of State, County and Municipal Employees (AFSME) had left the coalition, reducing the 20 member group to 18 (Pear, "In Divide" ). After this reduction, they continued in their attempts to forge a cohesive plan, and on March 27, 2009, the group released their final report (KFF, Recommendations" ). Interestingly enough, this report said nothing about individual mandates, employer mandates, or a public option, all of whic h are the main points of contention. Given that this was a report that there was participation from so many groups, it is not surprising that these greatly disputed topics were avoided, and as one unidentified participant said, the broad inclusion of grou ps meant that any consensus would end up "reflecting the lowest common denominator" (Pear, Divide Over Overhaul" ). Thus, the final five page statement by HRD focused on more agreeable platitudes such as a "fair and transparent marketplace," "improving h ealth care delivery," and better attempts at "quantifying long term cost savings." (HRD 2, 5). The broad strokes agreement that was outlined by HRD is not surprising given the how many players were involved, but it is also unsurprising given how early on in the

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20 process their memo was released. By March 27 th when HRD released their report, the debate had certainly started, but it had not reached the pitch that it would. By this time however, many of the health care bills that would be reviewed had alread y been introduced. Representative Dingell was the first to introduce legislation when he introduced the National Health Insurance Act (H.R. 15) on January 6, 2009. The goal of H.R. 15 was to create a national health insurance plan that would cover citize ns with incomes above a certain level, and since 1957, Representative Dingell has introduced legislation similar to this bill with no success (KFF, Side by Side" ). In its most recent iteration, the bill was equally unsuccessful, which is unsurprising giv en its very specific and expansive nature. H.R. 15 only created a national health insurance program, but it did not touch on some of the other insurance regulations such as pre existing conditions (KFF). While this particular bill was too narrow in its focus to progress past committees, it was just the first of many bills to emerge from the House and the Senate. By the end of March 2010, when the final reconciliation bill was passed, 14 pieces of legislation had been introduced in the House and Senate for consideration. What is interesting about all of these potential bills is that eight of them had already been introduced before the President made his first major public appearance to discuss health care reform. This is not to say that President Obama was completely silent while a plethora of bills were introduced, since he did outline in a radio address what he would like to see in the final legislation, and also spoke before the American Medical Association about health care (" Office of the Press Secr etary;" CBS News ). However, none of the President's appearances were speeches to the general public until his major press conference on

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21 health care delivered on July 22, 2009. What this meant is that during those first few months, the President provided no real central guidance. This lack of a message was one of the most major mistakes of the President's health care strategy, since it allowed others to control the tone of the debate. Various pundits and politicians surfaced in the time before President Obama made his first address, and said negative, often untruthful statements about the health care bills in Congress, and the opposition was able to make criticisms for months without any significant rebuttal. One of the most prevalent criticisms about a Democratic health care plan that emerged before the Presidents first public appearance was that it would amount to a government takeover of healthcare. This argument posits that President Obama's plan amounts to either a de jure or de facto removal of th e private insurance industry in favor of a national health insurance plan. While President Obama never supported such a plan, he did support a public health insurance option, which his critics said would eventually drive the insurance companies out of bus iness (Pear and Calmes, Public Option" ). Republican Senator Orrin Hatch described the public option as "a Trojan Horse for a single payer system," and this statement generally embodies the tone that Republicans adopted from a very early stage in order to criticize Democratic reform plans ( Pear and Calmes). As early as March 4 th this line of attack existed, as shown by Senator Tom Coburn's remarks that passing the President's plan would eventually end private insurance (Politifact.com, Statements About" ). Since President Obama did not give a national response to this claim until July 22 nd this gave the single payer rumor far too much time to permeate.

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22 While there were criticisms that the President's "Trojan Horse" would deprive private insurance emplo yees of their job in a recession another potent criticism that arose was that since the public option would be so appealing that employers would drop their private plans and move towards the cheaper, public option (Politifact.com, Statements About" ). The shift could mean a major upheaval for people such as different doctors, benefits, and pay requirements. This concern was certainly touched upon by the opposition, which was to some extent justifiable since it was inevitable that the enactment of a public option would cause some people to lose their private insurance, the extent of the problem was certainly exaggerated. The problem with allowing this rumor to persist harks back to the early development of doctors. As doctors gained legitimate complexity, patients gained a very special relationship with their particular, and losing your doctor is seen as a very negative thing because there is a level of trust that is lost ( Starr, 217 ). So, any threat of disrupting that relationship would be viewed very ne gatively by patients. While rumors of losing one's private insurance and personal doctor were somewhat disingenuous, there was certainly some truth to them. This would inevitably happen to some people, but it is not forced upon anyone, and it would not b e an epidemic across the nation. However, one of the last attacks to be fielded towards a Democratic health care plan, the one that seemed to become most the popular, did not have any basis in truth. The last accusation was that Democrats were planning o n requiring seniors to counsel with the government to see how they could die more quickly (Politifact.com, McCaughey Claims" ). The first person to purport this claim was Betsy McCaughey, chairman of the Committee to Reduce Infant Deaths, who said that C ongress would make it mandatory absolutely require that every five years people in Medicare have

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23 a required counseling session that will tell them how to end their life sooner," while on Senator Fred Thompson's radio show on July 16, 2009 (Politifact.c om). The measure that motivated Betsy McCaughey's comment was a provision on advanced care planning services that was in the main health care bill in the House, H.R. 3200. The section in question deals with Medicare reimbursements, and it outlines what t ype of end of life planning the government will pay for. The five year requirement provision is not a requirement for the elderly, but rather an explanation that Medicare will cover end of life counseling once every five years. The legislation states tha t advance care planning consultation' means a consultation between the individual and a practitioner de scribed in paragraph (2) regarding advance care planning, if, subject to paragraph (3), the individual involved has not had such a consultation withi n the last 5 years" (US Congress). So, if the patient has more than one meeting every five years, it is not counted as advanced care planning. This technical detail is a far cry from forcing seniors to get a certain medical procedure. While this assertio n is definitely questionable, Betsy McCaughey's influence was still important, since it was her reading of the legislation that led Sarah Palin to criticize the plan for potentially forcing her child with Down syndrome to be judged before the President's death panels" (Seelye). Sometime after Sarah Palin's remarks, Betsy McCaughey became a major figure, and she even appeared as a guest on a major cable comedy show, the Daily Show with Jon Stewart, in order to defend her claims While on the Daily Show, s he clarified her earlier statements, saying that while patients were not explicitly forced to receive end of life counseling, the new bill would financially punish Medicare doctors that did not engage in the practice (The Daily Show).

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24 What is noteworthy a bout Betsy McCaughey's appearance on the Daily Show is that it represents the type of coverage that president was not achieving. Ms. McCaughey was given a platform to present her ideas where she could reach a wide audience. By July 22, 2009, months after some of these criticisms first appeared, President Obama and the White House began to realize that the major detrimental effects of the rumors from people such as Betsy McCaughey, and they began to worry that they were losing control of the discussion (St olberg and Zeleny). So, the president held a primetime press conference specifically dedicated to health care. Some parts of the press conference focused on combating the rumors, as evidenced by statements from the President such as If you have health i nsurance, the reform we're proposing will provide you with more security and more stabilityIt will keep government out of health care decisions, giving you the option to keep your insurance if you're happy with it ("News Conference"). He also tackled th e claim that health reform will be unaffordable with statements such as health care reform is not going to add to that deficit; it's designed to lower it. That's part of the reason why it's so important to do, and to do now" ("News Conference"). Though ultimately, this news conference, which was the President's first major, official foray into the health care battle didn't seem to achieve what the President needed to do. While the President lightly addressed the false accusations that were made about th e bills that were going through Congress, most of his time was not spent refuting falsehoods. Instead, he spent time outlining the problems with health care, and illustrating what he would like to see in the final package. The problem with this approach is since the President was leaving the details to Congress in hopes of a bipartisan solution, he did not get very specific about what he would like to see in a final bill beyond deficit reduction and

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25 advanced coverage ("News Conference"). At one point, Pr esident Obama acknowledged this uncertainty about what the ultimate package would be when he described the Senate Finance Committee's attempt to create a bill, "I have not yet seen what the Senate Finance Committee is producing. They've got a number of ide as, but we haven't seen a final draft" ("News Conference"). What this press conference evidenced is how the President's campaign promise of bipartisanship hobbled him; he was unable to highlight specific aspects of legislation, and he mainly outlined bro ader goals of deficit reduction and increased coverage, which made the press conference come across almost like a campaign speech. A Democratic aide who said, "the president needs to step in more forcefully and start making some decisions, anonymously cri ticized the lack of substance. Everyone appreciates the fact that Obama has devoted so much time to health carebutwe would like to hear more from the president about what he wants in this bill" (Stolberg and Zeleny). The problem with making this press conference more of a campaign speech is that it did not answer any of the difficult questions that needed to be addressed, and instead focused on issues that even Republicans would agree on. There is certainly consensus that health care reform is importan t, as illustrated by a Pew Poll taken from July 17 th to July 20 th just two days before the President's press conference. This poll, which asked if people thought that health care reform was an important issue, found that 95 percent of respondents conside red health care to be important. Also worth noting is that two separate Gallup/USA Today polls showed that 77 percent of respondents considered it either very or extremely important to be able to keep their current insurance if Congress reforms health car e, and 88 percent of people polled found it either very or extremely

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26 important that they be able to pick their own doctors and hospitals if Congress reforms health care ("Health Poll Search"). What this shows is that the President was misguided in emphasi zing the importance of health care reform, since that is generally accepted, and he should have given more than passing mention to the ability to pick doctors, hospitals, and insurance providers, sine this is what people are concerned about. Since the opp osition was criticizing him on this point, and the public felt strongly about it, the President should have made these concerns the focus of the press conference. However, in the President's defense, a Fox News/Opinion Dynamics poll indicated that 60 perc ent of respondents did not think that it was possible to have health care reform without raising taxes, so it is understandable that the President focused on deficit reduction as much as he did ("Health Poll Search"). It is still true however that other i ssues needed much more attention than the President provided, but since he was attempting to leave the details to a bipartisan Congress, he could not address these issues. So this campaign promise essentially left him with no real message. Ultimately, on e of the biggest failures of the President's health care press conference had nothing at all to do with health care. While the press conference was geared towards health care, and the President opened with a large introduction about health care reform, it was still a general press conference. As a general press conference, other topics were eventually discusses, as is to be expected. While this did not have to be an issue, it became one, since one of the other topics ended up overshadowing the President' s discussion on health care. The very last question at the press conference asked the President how he felt about the recent arrest of Henry Louis Gates. Henry Louis Gates, a distinguished Harvard professor, was arrested by Cambridge police on

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27 July 16, 2 009 while trying to break into his own house (Goodnough). A neighbor, who did not know the professor, saw what she thought was an attempted break in and called the police (Goodnough). After arriving at the scene, Sergeant James Crowley arrested Professor Gates for disorderly conduct, which Sergeant Crowley attributes to Professor Gates being "uncooperative," on account of his yelling and other actions. Professor Gates disagreed, and felt that he was a victim of racial profiling (Goodnough). The case sud denly became a national issue when it was asked about at the press conference and the President responded by saying that "the Cambridge police acted stupidly" ("News Conference"). This response would go on to dominate the news for the next few days. A go od barometer for how people responded to the speech is to look at what they chose to look up later on. Fortunately, Google keeps extensive data on the daily search trends, and in the days after President Obama's speech, searches for the terms "health care reform" and "henry gates" experienced a sizable jump ("Google"). However, the term "henry gates" was searched more than three times as much. Of course, Google search history does not provide a scientific conclus ion, but it reasonable to assume that it p rovides a useful picture, since in 2006, 73 percent of Americans used the Internet, and Google is the most popular search engine in the world (Madden; "New York Times," "Times Topics"). However, perhaps more telling than the search habits on Google is the fact that President Obama ended up holding a "beer summit" with Professor Gates, Sergeant Crawley, and Vice President Biden eight days after the speech (Cooper, and Goodnough). The New York Times described the fervor over the Gates case during these eigh t days as "nonstop news coverage," while President Obama expressed annoyance and described himself as "fascinated with the fascination" (Cooper, and Goodnough). However, the

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28 beer summit seemed to achieve its intended goal of quelling the obsession, and se arches for Henry Gates declined significantly after the meeting. On August 1st, health care reform overtook Henry Gates as the more popular search term for the first time in eight days, and it would stay that way ("Google"). Still, this fiasco is evidenc e that the President made a major mistake by entering the health care debate with an open forum press conference that gave ample opportunity for distraction. What makes the President's failure to properly open up the health care dialogue all the more dama ging is the fact that he is the most capable person to articulate what should be done. The act of "going public," where the president appeals to the public for a specific goal, is a tool of the modern executive branch that takes advantage of the unique st atus of the president in order to gain public attention and support, which allows the president to pressure Congress to achieve his goals Kernell, and Jacobson 283 285). Members of Congress do not have this same appeal, so having the central figure of the President can be pivotal for steering legislation. This is especially the case when it comes to President Obama and the current Congress. In late July, soon before President Obama made his address, the President had an approval rating of 56 percent (Jon es). While this is not as high as it had been, it was much higher than Congress' approval rating, which was in the low 30's at the time (Newport). The approval of House Speaker Nancy Pelosi is also worth looking at, since most of the debate was focused o n the House of Representatives in July. So, if Obama was not the face of leadership in health care reform, she would be the next logical step. In late July, the Speaker was viewed unfavorably by 48 percent of Americans (Saad). While it seems that this p oint in time was a crucial point for the President to come forward with guidance that would dispel

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29 falsehoods, this did not happen. The President's press conference achieved none of the goals that it should have achieved because he did not have a solidifie d agenda to promote, and as a result he ended up suggesting that health care is in fact important, and it must be deficit neutral. Neither of these statements were hotly contested before the press conference, so it did not add any real pressure on Congres s. However, even if the President had given a very poignant speech that advanced his goals perfectly, the press conference setting made it easy for the trivial, tangential issue of Professor Gates became the main talking point for the rest of the month. While the President's first major public appearance did have these major flaws, the President has more roles to fulfill than simply being a cheerleader for major issues. It was in these other areas where the President was truly effective. Another very i mportant role that the President must play is that of the negotiator. The President negotiates with members of Congress to forward legislation, and using the bully pulpit is often done when these negotiations fail (Kernell, and Jacobson 284 285). However a modern development of the presidency is that negotiating is now not only done with Congress, but with interest groups as well. As Crenson and Ginsberg outline in their book, Downsizing Democracy political elites are finding less use for mobilizing vo ters to action, and are instead turning to less participatory interest group activities such as lobbying and litigation in order to achieve their goals more effectively (Crenson, and Ginsberg 3, 108, 154). As interest groups become more prevalent, they be gin to occupy a role of "pseudo representation," where one particular group purports to speak for a large swath of the population in order to achieve goals for that group (169). This habit can be dangerous for litigious interest groups, since they are not constantly accountable to a

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30 large base of supporters, but is less of a problem for lobbying groups since they are dependent upon some degree of mobilization (169). Evidence of this trend can certainly be seen in the President's actions during the health care debate, since President Obama was often negotiating with drug company representatives, insurance company representatives, and other stakeholders in order to reach agreements as to what the final bill should be (Kirkpatrick "Active Role"). It is impor tant that President Obama did excel in his role as a negotiator, because without that talent, it is likely that a bill may not have successfully gone through Congress. The reason that this aspect is so important relates back to the theory of group power f orwarded by Ingram and Schneider. Since the medical industry is composed of so many advantaged groups that are viewed as deserving of benefits, such as seniors, doctors, and hospitals, it would be hard to advance a health care bill without the support of these groups. As interest groups become more prominent in the political scene, this becomes all the more true. Looking back to the Clinton health care debacle, this was one of the issues surrounding its ultimate failure. While all of the major interest groups supported the concept of health care legislation, individual groups did not want reform plans that would cost them something (Skocpol 142). Since all of the various players in the industry all had different concerns, almost every regulatory mechani sm under the Clinton plan faced criticism (143). The final result was that important health care groups all endorsed the idea of reform, and while some did not specifically berate the President's plan, they all made various policy criticisms that created a sense of concern about all of the major aspects of President Clinton's plan (143). The negative atmosphere that these interest groups created is best encapsulated by the still famous Harry and Louise' ads. These ads, run by the Health Insurance

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31 Associ ation of America, forwarded the idea that the President's legislation would result in a loss of control to bureaucrats and higher medical costs (137 138). So, with united opposition from a slew of interest groups as well as all of the Republicans, any cha nce of a final compromise became impossible, resulting in collapse of the Health Security proposal (157 158). While Clinton seemed to face near universal opposition from interest groups from 1993 to 1994, President Obama was in a very different situation. Early on in his presidency, on May 11, 2009, President Obama got four major industries in health care, physicians, hospitals, insurers, and pharmaceutical companies to agree to a voluntary cost reduction of two trillion dollars over the next ten years (Pe ar, "Obama Push"). While this guarantee was not necessarily reflected in legislation, it was indicative of the model that President Obama was going to follow throughout the rest of the debate; interested parties would be able to negotiate through the Whit e House in order to help achieve their goals in the final piece of legislation, but they would have to be willing to make some concessions (Pear, "Obama Push"). This is not to say that President Obama faced no difficulty because of his negotiation comprom ises; each particular group had its own qualms, one of the biggest being the President's support of the public option, which insurance industry representatives, the American Medical Association, and drug industry representatives opposed (Kirkpatrick, "Whit e House Deal"). The public option was not the only contentious issue by far, pharmaceutical lobbyists opposed proposals for government studies of treatment efficiency, and the American Hospital Association opposed setting a minimum level of required chari ty care that would be necessary in order to allow hospitals to be considered tax exempt (Kirkpatrick, "Protect Profits"; Pear,

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32 Charity Care"). Though despite these problems, many of the groups tended to support the president since there was hope that the unsavory parts of the legislation could be removed later ( Kirkpatrick, "Active Role"). What is significant about this is that not only did they offer their support, but they offered their support from very early on in the legislative process (Herszenhorn, and Stolberg, "Hidden Costs"). In the early stages of the debate, it seemed as if the President was constantly announcing support from some new group. This started with the voluntary two trillion dollar cost savings from multiple groups in early May, and this was soon followed in June by a guarantee by the drug industry that they would reduce costs by 80 billion dollars as long as the drug industry would be spared of any further losses when the bill was being crafted (Kirkpatrick, "White House Deal"). Fi nally, in early July, various hospital lobbies agreed to cost reductions amounting to 150 billion dollars over the next decade (Herszenhorn, and Stolberg, "Hidden Costs"). Beyond these assurances of costs savings, the President was also able to gain fairl y consistent support from two of the most important advantaged groups in the entire debate, the AMA and the AARP. This meant that Obama was somewhat able to avoid the pitfalls that President Clinton fell into, where early criticism from a variety of healt h groups resulted in early mistrust from the polity, making progress difficult from the outset. Unfortunately, President Obama was not vocal enough when addressing other critics, so some of that mistrust still existed. However, this mistrust did not aris e from health care interest groups, as was the case in 1993 and 1994. The difference between President Clinton and Obama's experience with interest groups was depicted perfectly in a series of ads that aired during the 2009 debate in support of reform. I n these ads, a couple discusses the

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33 difficulties of health insurance in 2009 and end by exclaiming, we can get the job done this time" (Gorman). This couple would be very familiar to anyone who studied history of health care, since they were the same act ors that played Harry and Louise in 1993, reprising their roles in 2009 to promote a very different message, that health care reform should now pass (Gorman). The new Harry and Louise ads were partially sponsored by the Pharmaceuticals Research and Manufa cturers of America, a major pharmaceuticals trade group, and it is telling about the differences from 1993 to 2009. While President Clinton had to fight Harry and Louise, President Obama was able to negotiate. As a result, Harry and Louise were on his si de. What is particularly interesting about President Obama's actions in the beginning of the health care debate is that they seem to defy one of the major developments of the modern presidency. In The Rhetorical Presidency political scientist Jeffrey Tul is posits that the use of the bully pulpit has become much more common, and is generally expected from presidents today (4). President Woodrow Wilson was one of the first presidents to adopt this change, and he believed that it was his role to understand and mold public opinion so that the president can claim to be the true voice of America (Tulis 128 129). This view of the president is heavily contrasted with earlier 19 th century conceptions of the Presidency, which was very disconnected from the people for fear of demagoguery; this is most clearly evidenced by President Lincoln, who did not think it was "proper" to hold policy discussions during public speeches (Tulis 27, 80). Presidents, as Tulis explains, "have a duty constantly to defend themselves p ublicly, to promote policy initiatives nationwide, and to inspirit the population," and it is this trend towards bombastic rhetoric that makes the President's strategy on health care seem so

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34 counterintuitive (4). In a way, the President seemed to reverse the trend that is explained in The Rhetorical Presidency because his first inclination for achieving his legislative goal was not to use persuasive rhetoric in order to coral public opinion. Instead, President Obama immersed himself in deliberations with stakeholders, only making a speech in late July when it became apparent that it was necessary. What this may indicate is that the presidency is again evolving into something beyond what was described by Tulis, and this does seem to be the case. An explor ation of President Obama and healthcare shows two major differences from what we would expect of a modern president. First, the President was more geared towards negotiation as opposed to rhetorical statements. Second, the subject of the negotiation has changed. When Tulis describes how presidents use direct appeals to the people, he describes it as a way to "go over the heads" of Congress and avoid negotiating with them (4). However, with the health care debate, when the President did not use direct ap peals, he did not fall back onto negotiations with the legislature. As described above, he instead negotiates with interest groups. While interest groups got some mention in Tulis' book (138), they were not a major focus. Now however, interest groups ar e a major part of the political landscape, and the health care debate seems to indicate that the institution of the presidency is changing to accommodate them. Instead of invigorating the people in order to affect change in the opinions of Congressmen, th e President decided that it would be more efficient to deal directly with the affected interests. It appears that since the President's reason for interest group mediation was to make sure that a bill passed through Congress, the end goal is still the sam e, and that end goal is to manipulate Congress towards a particular end. A pessimistic view of this

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35 presidential development might be to say that interest groups are usurping the role that the people played in the modern presidency, since the people are n o longer required in order to influence Congress. Though it is probably more likely that interest groups are not usurping, but they are simply adding another tool that the President can use. There is certainly no question that interest groups would be an effective way to exert control, since interest groups have various options at their disposal to pressure Congress to act a certain way (Kernell, and Jacobson 525). Of course, they can exert the same pressures on the executive branch, so the President can not simply manipulate interest groups any way that he desires, in the same way that the President cannot manipulate citizens in that way. However, since the President is a lone, recognizable figure, he seems the most capable of brokering interests in a wa y that individual Congressmen cannot. As a result, we can see that the presidency is evolving beyond the ""new way" described by Tulis into something that accommodates the growing influence of interest groups. A new stage in the modern presidency is deve loping where rhetoric may not be the most important tool that the President uses to influence Congress. Instead, the President must contend with the growing importance of interest groups in American politics. While the two main functions of the President had previously been negotiation with Congress and popular appeal, a new function has been added. Now, a President must negotiate with Congress, negotiate with interest groups, and use popular appeals in order to pass legislation. Since interest groups ar e becoming more important in the American political landscape, the target populations that are described by Ingram and Schneider become all the more important. According to Ingram and Schneider, politicians try to give the most benefits to advanced (both powerful and positively constructed) groups since people feel

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36 these groups are deserving (337). Given that interest groups are more commonly becoming the spokespeople for different target populations, it would be expected that if the presidency were evolv ing to include interest groups as well, then the President would vie for and advertise the benefits bestowed upon advantaged interest groups. As can be seen with the AMA and the AARP, this was certainly the case. Senator Chris Dodd spoke about the AMA su pporting the Senate bill by stating that "o f all the organizations and individuals that have supported this bill, I rate this one as the most important" (Pear, and Herszenhorn, "Democrats Face"). The President obviously held similar sentiments, since supp ort of the AMA was mentioned during his first press conference, and the President made an unplanned statement a press briefing with Press Secretary Robert Gibbs in order to announce that the AMA and the AARP supported the House health care legislation ("Ob ama: "This is No Small Endorsement""). Obama described the AARP's support as "no small endorsement' and described the AMA's backing by saying "the doctors of America know what needs to be fixed about our health care system" ("Obama: "This is No Small Endo rsement""). While the AMA and the AARP provide clear examples of the evolving presidency, they are not the only example. Contender (powerful but negatively constructed) groups are also present in the health care industry, most notably through the existenc e of health insurance companies. Ingram and Schneider predict that these groups will be negotiated with in secret while chastised in public (338). The health care debate provides a perfect example of this, since Obama's dealing with insurance companies w as done mainly through secret discussions that were not as clearly advertised ( Kirkpatrick "Active Role"). Though, while these negotiations were occurring, the President was

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37 simultaneously criticizing the insurance industry for their questionable practice s, as he did during the same press conference where he lauded the AARP and AMA endorsements ( "Obama: "This is No Small Endorsement""). Soon though, these criticisms would get him in trouble, since the insurance companies became uneasy with their portrayal (Abelson). This new evolution of the presidency as interest group negotiator was shown to be very important in the 2009 health care debate. Obama took this role to be the most important, and it was successful in that it prevented him from facing major op position from too many interest groups. By the time that the President made his first press conference on health care, the only real major group that seemed to be campaigning against health reform was the Chamber of Commerce (Sack, "Seize the Moment"). W hile the Chamber of Commerce is a significant lobby to have opposing one's plan, it is not nearly as significant as having opposition from the entire medical sector. And so, with this seeming support, progress towards a final bill continued. Just a week before Obama's press conference, the House unveiled the America's Affordable Choice Act, which was planned to be its final legislation. This bill created a government insurance option, and would require all citizens that are financially capable to purchas e some form of insurance (Pear, and Herszenhorn, "House Health Plan"). Cost control measures stemmed mainly from various taxes such as one for larger employers that did not offer insurance to their workers, one for individuals that could not afford to pur chase insurance, and an income tax on families that make above 500,000 dollars which would subsidize lower income citizens (Pear, and Herszenhorn, "House Health Plan"). Of these taxes, the one on larger business owners would provide the most revenue, whic h partially

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38 explains the opposition from the Chamber of Commerce. While the House of Representatives was crafting their version, the Senate was also going to work on creating their bill. By this point in mid July, the only Senate bill to have gained any t raction was the Affordable Health Choices Act (KFF, "Side By Side"). Three other potential bills were also present in the Senate, but did not move through their committees. However, the Affordable Health Choices Act did start moving, and on July 15 th it was passed by the Committee on Health, Education, Labor and Pensions without any Republican supporters (Pear, and Herszenhorn, "Partisan Divide"). This bill was the companion to the one working its way through the House, and as such, it was very similar in its broad outlines of individual and employer mandates, taxation, and a public option (KFF, "Side By Side"). While differences did exist between the bills in each chamber, this is to be expected ("How the Health Bills Compare"). Two days after the Sen ate H.E.L.P. Committee passed their bill; the House moved their version through two committees, the Committee on Ways and Means, and the Committee on Education and Labor ("THOMAS"). While these actions ostensibly indicated that the President was quickly a chieving his goals, in reality, many legislators were becoming uneasy with the fast paced progress of the legislation before them (Pear, and Herszenhorn, "Democrats Wary"). The cracks in consensus were certainly not difficult to see, since all the of the committee votes on the health care bill did not receive any Republican votes, and the two House committees had Democratic members vote against the measure (Pear, and Herszenhorn). Many of the concerns came from fiscally conservative Democrats that were wo rried about the costs of the legislation, especially since the Director of the Congressional Budget Office said that the major bills before both chambers would not

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39 actually reduce the growing costs of health care (Pear, and Herszenhorn). As these concerns mounted, Obama then gave his major health care press conference that failed to address the major issues, as described above. Following this speech, Congress' summer recess was fast approaching, and this would mark the beginning of a very negative saga fo r the President's health care attempts. Before the recess began, there was some positive development in that the House legislation would successfully pass through another committee, the House Committee on Energy and Commerce (Pear, and Herszenhorn, "Clear s Hurdle"). Though even this victory was very contentious, since the bill was passed by a vote of 31 to 28 with five Democrats voting against the measure. Over the summer, the apprehension that motivated those no votes would explode into a fervor that ha d not yet been seen, further dampening the President's goals. In early August 2009, Congress began their recess for the 111 th session and members went home to their districts. For many congressmen, this recess would result in town hall meetings where furi ous constituents expressed their problems with the government's possible involvement in the health care industry. Some congressmen faced particularly harsh attacks, such as when a constituent said to Senator Alren Specter that "one day, God's going to sta nd before you, and he's going to judge you and the rest of your damn cronies up on the Hill" ("Health Care Debate"). The negative energy from the August recess was fueled by a variety of legitimate fears, such as the poor review from the Congressional Bud get Office, and illegitimate fears, such as mandatory end of life counseling and the end of private insurance. However, protesters did not just have very clear complaints, they also had an amazing tenacity for their cause. Part of this tenacity was cause d by capable organization, such as from the conservative opposition

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40 organization FreedomWorks (Kirkpatrick, "Drug Firms"). Freedomworks, along with other conservative associations such as Americans for Prosperity, focused heavily on making their supporter s aware of upcoming appearances, and encouraging them to voice their opposition (Herszenhorn, and Stolberg, "Health Plan"). Interestingly, one of the chairman of FreedomWorks is former House Republican Dick Armey, who was against President Clinton's plan in 1993 ((Kirkpatrick, "Drug Firms"). With the discussion heating up again in a way that would not be helpful to the final legislation, the President again set out to allay the fears that were being expressed (Rutenberg, Calmes). Through a series of publ ic appearances, the President tried to drive home the message that the new legislation would not be a government takeover and that citizens could keep their private plans (Rutenberg, Calmes). However, in many ways, the president lacked the clear, cohesive attack that his opponents possessed. To conservative opponents, there was a vivid enemy in government control and socialism, but due to Obama's role as a negotiator, no clear enemy existed that could make it easier to pass the health care bill. The most obvious opportunity for villianization would most certainly be the insurance companies, since the public's ambivalent view of them makes them the easiest group to criticize in the medical industry, and this criticism certainly did occur. While speaking t o reporters in late July, House Speaker Nancy Pelosi launched one of the most hostile attacks against insurance companies when she referred to them by stating: "It's almost immoral what they are doing, of course they've been immoral all along in how they h ave treated the people that they insurethey are the villains. They have been part of the problem in a major way. They are doing everything in their power to stop a public option from happening" (Cowan). Though this line of attack is the most intuitive, i t is not one that the President was easily

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41 able to follow, since he was trying to broker agreements with the insurance industry at the time (Stolberg, "Obama Says"). The president did adopt critical rhetoric to some extent over the recess when he complain ed about the profit margins of the insurance industry and vaguely stated that "in some cases what we've seen is also funding in opposition by some other insurance companies to any kind of reform proposals," but Obama would never reach the level of criticis m that Speaker Pelosi adopted (Abelson; Stolberg). However, even with these slight criticisms, the chief lobbyist for America's Health Insurance Plans (AHIP), which had been the main insurance industry contact with the Obama administration, expressed frus tration with the tone that the debate had adopted (Abelson). The President found himself unable to truly take a stand against insurance companies because of his need for their cooperation, while at the same time, the rhetoric from Congress continued to be confrontational. Speaker Pelosi would go on to make more statements, saying that the "glory days" were over for insurance companies, which almost seems to equate insurance industries with the robber barons of early America. In response to the town hall meetings, she also went on to co write an editorial piece with Representative Steny Hoyer in USA Today where the pair wrote that passing the health care bill would finally shift the priorities in medicine from insurance company profits to proper patient ca re (Pelosi, and Hoyer). At this time late July and August, President Obama and Speaker Pelosi were the two politicians that received the most coverage from the New York Times regarding health care, and they were sending two different messages. This con flict during the ugly August recess is simply another illustration of how President Obama was trapped by the evolving institutional role of the presidency.

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42 Interestingly, this trap is very similar to one that President Woodrow Wilson faced when he was try ing to create the League of Nations. After World War I had ended, President Wilson was trying to pass the Treaty of Versailles, part of which included provisions to create a League of Nations (Tulis 147 148). Originally, the treaty was crafted without an y input from the Senate, and the Senate then took issue with some of the League of Nations provisions when it became necessary for them to ratify. While compromise with the Senate was necessary to pass the bill, the President refused to adjust the Treaty in any way, causing it to fail (148). After this failed ratification, the Senate again tried to craft recommendations that the President could agree to and the Senate could ratify, but President Wilson still refused to make any changes, which caused the U nited States to be excluded from the League of Nations (148). Jeffrey Tulis argues that Wilson's failure in getting the United States to join the League of Nations did not come from an irrational refusal to compromise with the Senate, but was actually the result of Wilson being caught between two conflicting interpretations of the role of the presidency (158). According to Tulis, Wilson's two tasks were to convince senators to vote for the Treaty and to convince the polity that their senators should vote for the treaty; unfortunately for Wilson, the actions required for each of these goals were incompatible (158). The modern constitutional view of the presidency required that Wilson speak to the people in a way that distanced him from the Senate, and the language used to persuade the Senate versus the language used to persuade the polity completely contradicted itself (159 161). As a result of his differing rhetorical styles, Wilson's message could not be trusted, causing him to lose full support of the p eople (161). Without this support, Wilson could not effectively pressure Congress to bow to his wishes, and he did not succeed (161).

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43 As President Obama saw the need to defend his health care plan in August, similar difficulties emerged, but they emerged in a different context of the presidency. As coverage of town hall meetings harmed public perception, President Obama came out to speak on the benefits of his plan ( Rutenberg, and Calmes ). The ultimate goal of his public appeal, as with any public appea l, was affect how congressmen vote by affecting how their constituents felt. Enlisting more supporters in Congress was important at the time, since many Democrats were beginning to question the financial viability of a public plan and pull away from it (P ear, and Herszenhorn, "Democrats Wary"). However, just as Wilson was torn between the rhetorical needs of the Senate and the rhetorical needs of the public, Obama also found himself torn. In order to convince the public, the President needed a villain th at could be countered against the evil specter of government intervention. The best villain would be the insurance industry, but this conflicted directly with his rhetorical needs with the insurance industry. When President Obama began making even slight ly negative caricatures of the industry, AHIP immediately made their anger public. This was a crucial time for the insurance industry since the public option, a plan that they did not support, was working its way through Congress. Groups like AHIP only h eld back their fierce opposition because of their negotiations with the President. Once the President started making criticisms, this agreement seemed less stable. Since Obama was caught between the rhetorical needs of the polity and the interest groups, he ultimately lost his ability to effectively control Congress. Without clear approval from the public, hesitant Democrats had no reason to support the President, and since the President could not get clear approval from the insurance industry, Congress had no pressure from these groups either. Meanwhile, while the President was silent on these

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44 issues, figures such as Nancy Pelosi did make the grand negative statements about the insurance industry, which left the Democrats with an uncoordinated message t hat was different depending on the speaker. This difficult institutional balance that the President had to engage in did not just cause him to lose a vivid enemy, it also caused him to lose any specific desires within the legislation. The biggest illustr ation of the President's indecisiveness in regards to policy specifics is shown through his handling of the public option. During his campaign, Barack Obama was supportive of a public option, and it was one of the main pillars of his health care platform (KFF, "Candidate Proposals"). Once Barack Obama assumed the presidency, the public option was still something that he fought for, but he did hint that it may not be essential. In a June speech to the AMA, the President described the necessity of reshapin g health care by saying that these reforms need to take place regardless of whether there's a public option or not" (CBS News). Even though the President indicated a willingness to compromise during the speech, at the same time, he also extolled the bene fits should a public option be included (CBS News). The President's main defense of the public plan would be to "keep the insurance companies honest," and he made the advantages of this benefit clear (CBS News). So at this early stage, the President gave his full support for a public plan, even if it was not totally essential. The fact that these comments were directed towards the AMA makes them even more telling, since the AMA had officially spoken against the idea of government insurance just a few day s before the president's speech (Pear, "Doctors' Group"). However, this message of measured support did not stay consistent, and on July 17, 2009, President Obama released a weekly address where he stated that the final bill

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45 he received would have to inclu de a public option. According to the President, that's why any plan I sign must include an insurance exchangeincluding a public option to increase competition and keep insurance companies honest, and choose what's best for your family" ("Office of the P ress Secretary"). This "keeping them honest" mentality was an argument that the President had advanced for some time, and it indicated that the President considered the public option to be a very important part of his legislative agenda (Stolberg, and Pea r, "Obama Takes"). This seemed to be a comfortable place for the President, because even though the AMA did not want a public option, they still wrote a letter of support for H.R. 3200, which included a public option ("AMA"). While they did lend support for the bill, their official statement outlined the aspects of the bill that the AMA found desirable, and the public option was not included in this list ("AMA"). The AMA was not the only group that seemed to adopt this approach of tacit approval in spite of the public option. In early August, as the House bill was being approved in committees, The Pharmaceutical Research and Manufacturers of America (PhRMA), a trade group that opposed the public option, said that they did not plan to fight it because the y were protected through other measures that were discussed with the White House (Kirkpatrick, "White House Deal"). Though soon after this, the President changed his tone again by suggesting that the public option could be replaced by government financing of nonprofit medical cooperatives, which are customer owned medical cooperatives that were intended to compete against insurers in the same way that credit unions compete against banks (Pear, and Harris). After the President's alternative was announced, there was not much support for the plan since other groups did not see the benefit of it (Pear, and Harris). Insurance lobbyists still viewed co ops as a

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46 competition similar to a public option, liberal Democrats were attached to the public option, modera te Democrats had concern about the effectiveness of co ops, and prominent Republicans said that the co op idea was simply another government intrusion (Pear, and Harris). With his changing opinion on the public plan, the President again seemed caught in b etween institutional needs with no clear option that would satisfy all of the groups. Beyond the tumult and the strained messages from the President, the summer of the August recess was a very important time for another reason. Starting on June 17 th Sena tor Max Baucus and five other members of his Senate Finance Committee began to gather in order to form a bipartisan health bill (Herszenhorn, and Pear, "Health Policy"). This group, made up moderate Senators Chuck Grassley, Olympia Snowe, Michael Enzi, an d Jeff Bingaman, Kent Conrad, and Max Baucus, seemed to discard the idea of a public option immediately (Herszenhorn, and Pear). Senator Baucus, who led the committee, explained that this was because no bill with a public option would get any Republican v otes, and more importantly, a public option bill could not even get all of the Democratic votes that would be required in order to even bring the bill up for debate (Herszenhorn, and Pear, "Democrats Address"). Senator Baucus' reasoning about the impossib ility of bipartisanship with a public option seemed reasonable, especially given that Senator Grassley described it as a "kind of litmus test" for whether or not Republicans would lend their support (Pear, and Hardwood). So while the public option was dis carded, this bipartisan group spent months wrestling over issues where there potentially could be agreement such as insurance cooperatives, where taxation will occur, and whether the insurance would be mandatory (Herszenhorn, and Pear, "Health Policy"). G iven the

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47 President's stated desire for broad bipartisanship, Senator Baucus' "gang of six" suddenly assumed a very important status, since it was assumed that the production of their talks would result in the only broadly accepted bill, and it would theref ore be the only bill that could pass with the bipartisan acceptance that the President had been vying for (Herszenhorn, and Pear). What this meant is that until the Finance Committee came out with their agreement, other actions in the legislature essentia lly stopped while waiting for this plan that was expected to be a game changer (Herszenhorn, and Pear). While the gang of six was in the middle of their discussions, the President found himself in a similar position as he had been just a month ago. As t he August recess was coming to a close, many of the sentiments from the angry town hall meetings still existed, and the President had yet to find a clear voice with which to attack his opposition. Despite the fact that the Finance Committee was intended t o craft a bipartisan solution, they would not reach a conclusion for some time, and in the meantime, various rumors persisted about President Obama's health care plan. For instance, Representative John Boehner falsely claimed that abortions would be feder ally subsidized, Sarah Palin made the infamous claim that "death panels" will be created that judge your eligibility based on how productive you are in society, and Rush Limbaugh stated that circumcisions would become mandatory (Politifact.com, "Statements About"). Even Senator Grassley, who was supposed to be part of a bipartisan solution, made a comment to his constituents that they had "every right to fear" that the government would "pull the plug on grandma" (Montopoll). The President was faced with t he same difficulties a month ago when he gave his health care press conference; concerned that he was losing control of the debate, the president gave a speech to rally people towards his cause. At the end of August,

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48 President Obama was under fire for sim ilar things, his plan for a public option seemed to be slipping away, and there was a need to reclaim the debate. So, as Congress reconvened in early September, the President gave a speech before a joint session of Congress, and it focused entirely on the health care issue. This speech seemed to be much more capable than his previous press conference, mainly because he had more specific legislation that he could discuss. However, there were still hints of confusion, as evidenced by Representative Louie G ohmert, who held up a sign throughout the night that read "What Bill?" (Friedl). Perhaps the most important takeaway from Obama's address to the joint congress was the fact that bipartisanship seemed to be a near impossible goal. Representative Gohmert's signs ended up being one of the more civil expressions of disagreement for the night, and the most prominent show of partisan bickering coming from Representative Joe Wilson, who s creamed "you lie!" in response to the President saying that illegal immigran ts would not be able to receive care under his new plan (Hulse). While this alone indicates the difficulty in compromise, the response afterwards showed even more how grim the possibilities for a middle ground were. While Representative Wilson did apolog ize for his comment, voters had a very divided view of his remarks (Smith). Soon after the address to Congress, Rep. Wilson had raised over a million dollars in campaign contributions following a promotion by the conservative website, The Drudge Report (S mith). Representative Wilson's opponent also soon raised a million dollars from the affair, which highlights the dichotomous views of the remark (Smith). On top of these two Representative's actions, Representative John Shimkus, a Republican from Illinoi s, walked out before the speech had even finished (Greiner).

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49 These instances during the President's speech point to a greater problem that stem from his promise of change during the campaign. One of the aspects of change that the President intended to br ing with his election was a spirit of bipartisanship, and this goal ending up hampering his abilities to pass his legislation (Curl, and Dinan). The election promise was certainly carried over into the President's actions, and even some Republican congres smen would acknowledge this. Senator Grassley recounted an example of this bipartisanship in a conversation that he had with the President regarding the public option: "I [Senator Grassley] said, Yeah, it's [the public option's] a problem,' and he [Presi dent Obama] said something along the lines of, If I get 85 percent of what I want with a bipartisan vote, or 100 percent with 51 votes, all Democrat, I'd rather have it be bipartisan.' So, the President certainly wanted bipartisanship, and he was willi ng to make the sacrifices in order to achieve it. He ultimately did sacrifice the public plan, which is indicative of this compromising spirit. However, the problem with the President's goal of cooperation is that the Republicans never seemed intent on c ompromising on the legislation, and even if they had wanted to, they placed themselves in a position where compromise had become impossible. From a very early stage, the Republicans adopted an uncompromising rhetorical style that was intended to portray t he President and his health care attempts as harmful for the country (Calmes). Even conservative columnist David Frum would later criticize the Republicans for their strategy, which he described as no negotiations, no compromise, nothing. We were going f or all the marbles" (Frum). Part of this was the result of the President's successful election, where the coattails effect earned him some congressmen that would normally be Republicans, and as a result, he was left with a Republican Party that was compos ed

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50 mainly of party loyalists (Calmes). These loyalists viewed all of the Congressional proposals very negatively, and they used the language to match this sentiment. When the Senate was preparing to vote for their health bill, which did not include publi c insurance, Minority Leader Mitch McConnell described the bill as a "legislative train wreck of historic proportions" (Herszenhorn, and Hulse). Meanwhile, when the House of Representatives was about to pass their version of the health bill, Minority Lead er John Boehner called the bill, which did include a public option, the greatest threat to freedom that I have seen in the 19 years I've been in Washington" (Hulse, and Herszenhorn). Criticisms were also directed towards the President himself, such as Se nator John Kyl's response the September joint session of Congress: 'I must say I've never heard a more partisan speech by a president in that House chamber, and I've listened to five presidents now" (Stolberg, and Zeleny). Language like this leaves little room for mediation, and it makes it understandable why the August town hall meetings reached such an emotional state. The enemy in health care reform was not only a policy disagreement; it was the destruction of democracy. While these comments seem exag gerated on their own, they seem even more hyperbolic when contrasted with comments from Senator Olympia Snowe, the Republican that had some of the most contact with President Obama due to her involvement in the gang of six. In an interview with the New Yo rk Times, the Senator was asked if she agreed with her colleagues that viewed the President as a big government Democrat that could is some cases be described as socialist. The Senator responded by saying: "No, you know, it's interesting I don't. In fact I almost sense the opposite. He's been very realistic in his views on health care, understanding the implications he understands that there are

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51 fundamental differences and disparate views and how controversial they can be I've gotten an impression that h e would probably do less than more" ("Interview with Olympia Snowe"). When asked if the President was a moderate, she described him as "more moderate than liberal," and this certainly goes against the partisan portrayal that her Republican colleagues had b een giving ("Interview with Olympia Snowe"). Based on the President's emphasis on negotiation and malleability, it is difficult to see how he could be described as partisan or socialist, yet these attacks were common. However, once his opponents gave him this characterization, he was immediately branded as someone that could not be worked with. To compromise with a socialist would be tantamount to helping destroy the country. This dilemma was not lost on the President, and during his speech to the Repub lican Caucus, he brought up the fact that Republicans had boxed themselves in to make it completely impossible to work together ("In Obama's Words"). At first, the President tried to reconcile this difference by changing his definition of bipartisanship t o the inclusion of Republican amendments, but he would not solve his bipartisanship crisis until late in the debate (Pear, and Baker). Regardless of the seeming impossibility, the President made a promise for bipartisanship, and on September 16, 2009, Sena tor Baucus unveiled his proposal that was intended to solve the partisan problem, but during its announcement it did not have any Republican support (Pear, and Herszenhorn, "Baucus Offers"). The proposal that Senator Baucus put forward had a variety of di fferences from that bill that had been going through the House, the most notable being that there was no public option, opting instead to use nonprofit cooperatives (Pear, and Herszenhorn). Other major differences include the smaller and more selective su bsidies for lower income citizens, an excise tax on more expensive insurance plans, and taxes on large businesses that do not provide

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52 health care for their employees (Pear, and Herszenhorn). Ultimately, this bill still had to be passed by the Senate Finan ce Committee, and after failed committee attempts to amend the bill to include a public option, the bill passed through Finance Committee nearly a month after its announcement with only one Republican vote, Senator Olympia Snowe (Pear, and Herszenhorn, "Re publican's Vote"). While this was not the major consensus bill that some hoped it would be, the Senate Finance Committee bill did get one Republican vote, which was more encouraging than anything else thus far. Oddly enough, despite the three months of co mpromise work with Republicans and constant contact with the President, the work done in the Senate Finance Committee would be undone almost immediately. On October 26, 2009, just two weeks after the Senate Finance Committee passed their bill, Majority Le ader Harry Reid introduced a public option to the Senate version of the bill (Pear, and Herszenhorn, "Public Option"). The public option in the Senate legislation was toned down from the version in the House of Representatives in a variety of ways, the mo st notable being that it included an opt out provision that would allow states to not offer the public option if they chose to (Pear, and Herszenhorn). The Senate version also differs in that it negotiates payment structures with different medical provide rs (while the House bill was attached to Medicare payment rates) and includes the government cooperatives that the Finance Committee produced (Pear, and Herszenhorn). While the announcement showed that the Senate was progressing with its legislation, ma ny difficulties still remained. By endorsing the public option, Senator Reid alienated Republicans and conservative Democrats, and since 60 votes would be needed for any debate to occur, Senator Reid would need the support of his entire caucus. When the public option was announced however, Democratic Senators

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53 Mary Landrieu, Ben Nelson, and independent Senator Joe Lieberman indicated that they would not vote for the public option idea (Pear, and Herszenhorn, "Senate Leader"). With a more concrete plan emer ging from the Senate, the House of Representatives began working on their version again, which had not moved since the beginning of the August Recess. Just three days after Senator Reid revealed his proposal, the House released their new bill as well (Pea r, and Herszenhorn, "Buoyant Democrats"). The bill was essentially a combination of the bills that had been approved before the recess, but they were revamped as a new plan in order to give the impression of renewal and change, in order to separate the Ho use bill from the angry sentiments that persisted over the summertime (Katie). Through the use of a public option, this bill would insure 36 million people and reduce the deficit by 104 billion dollars over the next 10 years. (Pear, and Herszenhorn, "Buo yant Democrats"). The Republican response highlighted the difficulties of bipartisanship, since Republicans as described the fiscal responsibility as accounting tricks (Pear, and Herszenhorn). On November 3 rd 2009, just a few days after the announcement of the House bill, House Republicans announced their own version, an amendment to the main House bill, as a symbolic gesture to express their discontent (Pear, and Herszenhorn, "G.O.P. Counters"). Unlike the Democratic bill, the Republicans did not includ e any individual or employer mandates for coverage (KFF, "Side by Side"). Instead, states are incentivized to make sure that coverage is provided through a variety of measures. For one, a "reinsurance program" would be created whereby the states pay for insurance claims beyond some given amount, and states would also be required to create high risk pools for those that cannot get coverage elsewhere (KFF). States would be given federal

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54 funds to help them establish these pools, and states that reduce per c apita premiums and the number of uninsured residents would receive even further financial benefits (KFF). The Republican bill was also different from the Democrat's plan in that it did not include subsidies for lower income citizens, it would not add any new taxes, would not outlaw the use of preexisting conditions (though it did outlaw annual and lifetime insurance claims), and it set new limits for awards given in medial malpractice cases (KFF). Even though this had no chance of passage, it does show th at the differences between Republican and Democrat interpretations of reform are staggering. None of the major aspects of the Democrat's legislation were present in the opposition's bill, not even the ban on preexisting conditions, which Republicans had s upported (Pear, and Herszenhorn, "G.O.P. Counters"). It highlights the fundamental differences that the parties have in deciding how to address issues, and lends further evidence to the idea that compromise was never possible, and the President's hopes fo r bipartisanship only resulted in losing time and losing the tone of the debate. Oddly enough, while the Republican alternative did promote a radically different view of government, it did not actually attempt to solve the problems in the health care indus try. In the CBO's analysis of the Republican amendment, they discovered that only 3 million more Americans would receive coverage under their bill and it would only reduce premiums for a majority of Americans by zero to three percent (Congressional Budget Office, 3, 5). The relative ineffectiveness in attracting customers and lowering premiums is unsurprising given the nature of the health care industry. The problem with the health care industry is that it experiences the free rider problem. For the un insured there are various options when it comes to paying for medical care; one can one can pay

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55 for their services out of pocket, go to public health centers for free treatment, or go to a doctor and receive care at no cost (Graig, 16 17). This last optio n, going to a doctor at no charge, is ultimately paid for, but those with health insurance shoulder the burden, and higher premiums arise as a result (17). What makes the premiums even more costly is that when the poor do obtain medical care, they tend to be sicker than the average patient (Karsten, 130). The reason that poor and uninsured are usually sicker when they look for medical care is that they do not have a regular physician due to their lack of insurance, so they wait longer and the first doctor they go to see is in an emergency room (Jonas, 79). This act creates a host of inefficiencies that ultimately results in higher premiums. First, being sicker, the uninsured require more expensive treatments than might not have been necessary if they had gotten care sooner. Secondly, it fills emergency rooms with patients that likely should not be there (80). Emergency rooms are always accepting three types of patients, nonurgent patients that are not in need of emergency services, urgent patients that need medical care soon though not necessarily immediately, and emergent patients that need care instantly in order to avoid any further damage (80). When the uninsured go to emergency rooms for problems that are not entirely serious, they increase the num ber of nonurgent patients that the emergency doctors must tend to, clogging the system with patients that should be visiting primary care physicians instead (80). The only way to avoid this problem is to ensure that more people have access to primary care thereby reducing overall medical costs and efficiency, thereby lowering premiums. Since the Republican plan insured so few people, it is unsurprising that the effect on premiums was minimal. The other major omission from the Republican plan was that it did not ban the use

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56 of preexisting conditions to deny coverage to a citizen. The use of preexisting conditions is an understandable practice for insurance companies because it is trying to address the free rider problem. If those with preexisting conditi ons could not be excluded from coverage, then no one would have a motivation to buy insurance before becoming sick, since anyone could simply buy insurance when they get sick without the fear of being turned away. The existence of preexisting condition ex clusions gives citizens an incentive to buy insurance when healthy so that they can be covered if they do suddenly require major medical treatment. While there is this benefit to insurance companies, the existence of preexisting condition exclusions simpl y creates negative externalities for society as a whole. This is because while the insurance company can shed itself of the cost of coverage by excluding a person, that person must eventually get coverage. So, it creates a pool of uninsured people with a need for medical treatment. Since the uninsured often end up waiting longer to see a doctor, and seeking care in emergency rooms, they raise the overall costs of health care. So while preexisting conditions serve a useful, necessary function to a firm, they shift costs to the greater society while also exacerbating those costs. Despite this problem, it was ultimately impossible for the Republican bill to ban preexisting conditions because of the free rider problem that would be associated with it. The only way to eliminate the ban on preexisting conditions and make sure that people still pay for insurance is mandate that they purchase it. However, Republicans frowned upon the mandate, and therefore preexisting conditions could not be removed, even thou gh Republicans did support their removal. The essence behind the Republican plan seemed to be that a free market system is the best way to deal with the health care crisis. The problem with this assumption is that

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57 health insurance operates in no way like a free market. Free markets operate on a range of assumptions that must be met if they are to work properly. The first assumption of a free market is consumer sovereignty, meaning that consumers, through their actions, are the ones that influence what is produced while firms adjust to this demand (Case, and Fair, 40). The second assumption is that individuals are able to enter into the market and sell their products freely (40). The third assumption is that output is allocated in a decentralized manner, and the fourth assumption is that prices are the tools that are used gauge an items value (41). When it comes to the health care market, nearly all of these items are violated. Health care is a very particular market due to the limited knowledge and con trol that the consumer ultimately has. Consumer sovereignty cannot truly exist because customers for the most part do not know what they are purchasing. Ever since doctors gained the status of legitimate complexity, we defer our medical decisions to them This being the case, it is questionable that costs would very often factor into the medical decisions of the insured. Instead, we are more concerned with what our doctors recommend as the best treatment. Second, American insurance companies are far from free entry. A study by the American Medical Association found that consumers generally have very few insurance providers to choose from, resulting in near monopoly markets ("U.S. News & World Report" ). According the AMA's study, in 24 states, two in surers have control of at least 70 percent of the market, which indicates a lack of free competition. While output allocation is still decentralized, the fourth assumption of prices being the tool used to determine demand may not hold true. Most insured Americans, 61.4 percent in 1997, receive their insurance through their employers, and as such, they are not directly familiar with the pricing of the insurance that they are getting

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58 (Graig, 15). Since most consumers are personally removed from the act of purchasing insurance, it cannot be said that they are using their purchasing power to gauge an item's value. Instead, they are locked into particular health plans based on whatever an employer offers. While it might be argued that employers help determi ne these prices based on the health care plans that they choose to purchase, this argument is weakened by the near oligopolistic nature of the health insurance industry. Despite the theoretical problems underlying the proposal, the Republican bill did sti ll slightly raise the insured, and it did slightly decrease premiums, so the Republicans introduced it as their viable alternative. And so, just days later when the House bill continued its debate on the floor, the Republican amendment was voted down ("THO MAS," "H.AMDT.510"). Later that same day, the House voted on its health care resolution, passing by a vote of 220 to 215 (Hulse, and Pear). During this time, we saw glimpses of the President's negotiation skills again, as he traveled to the House on the day of the vote to hold private meetings with representatives that had yet to commit themselves to the legislation (Hulse, and Pear). Ultimately, these meetings were productive in achieving the bills final passage, as the President is specifically credite d with ensuring the vote of Representative Michaud. While the passage was not easy, especially due to a last minute battle over federal abortion funding in the bill, it was finally passed, leaving the Senate with the responsibility to move their health pr oposals forward in order to achieve a final law (Herszenhorn, and Calmes). 11 days after the completion of House bill, Senator Reid announced his plan, H.R. 3590, and delved into more specifics about the taxation that hadn't been discussed when

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59 he announc ed his support for a public option bill in late October (Pear, and Herszenhorn, "Senate Says"). Since the inclusion of a public option essentially ended any plans for Republican support, Senator Reid was left with the difficult task of making sure that al l of 60 senators that are part of the Democratic Caucus would vote with the bill. While the Democrats seemingly possessed a filibuster proof number of legislators, a few of these were very clear about their opposition to the public option. Despite the th ree senators that were opposed, Senator Reid was able to get the caucus to agree to begin the debate on the Senate floor, and over the next month, the conservative Democrats would propose amendments that would be necessary in order to win their final suppo rt (Pear, and Herszenhorn, "Senate Votes"). Senator Reid's precarious task of corralling 60 votes around the controversial issues seems impossible when one looks at the stated desires of the different Democratic Senators. Senator Blanche Lincoln was expr essly against a public option and referred to it as a "terrible idea" while Senator Lynn Woolsley described it as "very difficult" for her to consider voting for a bill without a public option, or at least a Medicare buy in (Herszenhorn, and Pear, "Senate Votes"; Stolberg, and Pear, "Obama Health"). The month of December was dedicated to finding how to reconcile these differences, and the strategy that Senator Reid followed indicated that he hoped to depend on the reliability of liberal Democrats, surrende ring some of their goals in order to appeal to the conservative Democrats that had been far less accommodating throughout the whole process. This strategy was displayed very early on, since one of the first aspects of the Senate legislation that was disca rded during negotiations was the public plan, which critics did not consider financially viable (Pear, and Herszenhorn, "Reid Says"). In order to appease

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60 liberal Democrats who favored the public option, the public plan was replaced with a Medicare extensi on whereby citizens from ages 55 to 64 could participate in Medicare for a fee, and the government would help to subsidize their premiums (Pear, and Herszenhorn). Soon after this concession, Senator Joe Lieberman announced that he was opposed to the Medic are extension and he would not vote for the legislation as long as this provision was included (Herszenhorn, and Kirkpatrick). Since all 60 votes were a necessity, the Senate leadership soon acquiesced to Lieberman's desires, much to the consternation of the liberal wing (Herszenhorn, and Kirkpatrick). The removal of the Medicare provision almost proved to be a last straw for liberal groups, who started to publicly opposing the bill once it was dropped (Stolberg, "Liberal Revolt"). Howard Dean, a respect ed Democrat on the issue of health care, began stating that the Senate should start over, unions considered holding back on supporting the bill, liberal journalists began questioning the advantages of passage, and liberal Senators began openly commenting a bout the uncertainty of how they would vote (Stolberg, "Liberal Revolt"). Representative Anthony Weiner expressed his frustration with the situation by saying that some of us have compromised our compromised compromise. We need the president to stand up for the values our party shares" (Stolberg). While indications of a liberal opposition were starting to sprout, the White House acted quickly to quell the dissent, and the liberal Democrats chose to vote for the legislation with the hopes of restoring the public option and Medicare provisions when the House and Senate bills were reconciled (Stolberg, "Liberal Revolt"). Furthermore, the conservative wing of the party was clinched after various bargains such as forgoing the public option, removing the exten ded Medicare, and including extra funds for the

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61 states of Nebraska and Vermont in order to achieve the votes of their senators (Herszenhorn, and Hulse, "Democrats Clinch"). Majority Leader Harry Reid justified the extra funds by saying that "a number of s tates are treated differently from other states. That's what this legislation is all about, compromise" (Herszenhorn, and Hulse). Abortion also became a major point of contention towards the end of debate, and though a conclusion was reached, it did not s atisfy groups with a wide range of views on abortion such as Planned Parenthood and the United States Conference of Catholic Bishops (Pear, "Negotiating 60)". With all the votes in place, the Democratic Caucus was able to work its way through all of the p rocedural blocks from the Republicans, and on Christmas Eve, the Senate passed the Patient Protection and Affordable Care Act (KFF, "Side by Side"). With the lack of a public option, a different taxation scheme, different Medicaid eligibility, as well as other variations, it was clear that the two bills would have to go through major revisions before finally approaching the President's desk (KFF). With these two major health bills now requiring homogenization, the process got under way to craft the fina l bill. Instead of going to a conference committee, which is the normal path for disparate bills from the House and Senate, informal negotiations were held that included President Obama as an integral part; this was a drastic change from the Senate negotia tions where he was largely uninvolved (Pear, and Stolberg, "Obama and Lawmakers"). Fortunately for the President, these talks did yield some fruit, since an agreement was reached on taxing more expensive insurance plans, which were opposed by unions that feared that their members would be greatly affected (Herszenhorn, "Democratic Leaders").

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62 While the talks were beginning to look promising, a surprise candidate from Massachusetts would soon render them irrelevant for some time. On January 19, 2010, Repub lican Scott Brown went on to beat Democratic candidate Martha Coakley in a special election race for the seat formerly held by Senator Ted Kennedy (Cooper). Just a month ago, Coakley was considered to be the sure victor given Massachusetts' largely Democr atic makeup, but a poor campaign coupled with general unease in the country ultimately resulted in her loss (Cooper). Brown, who appealed to the growing distrust in government, ran his campaign on the promise of preventing major government programs such a s the Presidents' health care and environmental policy goals (Cooper). Brown's election would make him the 41 st Republican Senator, meaning that Democrats would lose their ability to stop a unified filibuster from Republicans. So, with Senator Brown's el ection, the health care legislation that seemed so certain was suddenly thrown into complete doubt. Initially, the White House reacted to Senator Brown's victory by showing a new willingness to compromise with Republicans and accept a bill that would be f ar less ambitious than his intended agenda ( Stolberg, and Herszenhorn, "Obama Weighs" ). This strategy was ultimately not adopted, and interestingly enough, the President instead followed a plan that gave him a clear voice in the health care debate for the very first time. So while the election of Scott Brown initially inspired fear by those who wanted sweeping reform, it eventually caused the President to find a successful strategy that he should have been following since he began the push for health care legislation. After the election of Scott Brown, the Democrats seemed understandably stunned. The months of planning with a definite end was suddenly halted by this major game

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63 change, and the Democratic leadership immediately moved onto other topics unti l they composed a plan. Soon after the election, Harry Reid was asked about health care and responded by saying "we're not on health care now, we've talked a lot about it in the past...There is no rush" (Herszenhorn, and Pear, "Democrats Put"). The Presi dent also changed topics, and at his first State of the Union address, where he had originally hoped to expound upon the great progress in the negotiations, the President instead found himself mainly discussing the economy, and health care was only brought up half an hour into the address (Pear, and Herszenhorn, "Health Care"). While this lull could have meant the permanent stalling of the health care bill, the President quickly jumped into action to revitalize his health plan. He became the point man in a way that had not previously been seen, since the debate had previously been focused around the actions in the House and Senate that Obama remained aloof from. However, on January 29, 2010, the President made his first major appearance on health care sin ce the election of Scott Brown. In an unprecedented appearance, President Obama was a guest at the House Republican Retreat, and partook in a lengthy question and answer session where he directly address the criticisms of Republican congressmen (Baker, an d Hulse). This appearance was a fantastic first step into his new public face, because the "into the lion's den" ambience of the whole affair garnered it widespread coverage, and given the President's talented oratory, he was able to parry with the Republ icans in a way that clearly expressed his goals for bipartisanship and health care solutions. It is difficult to say how much effect this particular event had on the tenor of the rest of the health care discussion, but this event was the starting point wh en the President finally began to reconcile the institutional conflicts that the role of the modern president demands.

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64 Soon after this meeting, three major events would occur that would continue the President's trend of overcoming his previous institution al difficulties. First, Anthem Blue Cross in California, which is owned by WellPoint, Inc., sent out a notification to its customers that their insurance premiums would be raised (Pear, "Health Executive"). The average escalation of premiums was about 2 5 percent, but some faced premium increases up to 39 percent (Pear, "Health Executive"). This increase seemed like an exorbitant amount of money to most The White House and Congress, and soon, the CEO of WellPoint was testifying before the House Energy an d Commerce Committee in order to justify her firm's decision (Pear). Customers being charged with the increase were also asked to speak before Congress, and they unsurprisingly came to support the President's health care reform (Pear). Soon, under intens e denunciation, WellPoint agreed to delay their rate increases for two months until they were properly reviewed, but the White House continued to criticize this as a reason for why reform was essential (Sack, "Insurer Delays"). According to the White Hous e, new reform was needed to ensure that the people were protected from such increases forever, not just for two months (Sack). Thanks to these well timed rate hikes, the President was again using the insurance company as villains to illustrate the need fo r reform. Soon after this, the President published his own outline for health care legislation for the first time in his Presidency. This 11 page proposal was essentially a compromise between the version that had passed between the House and the Senate, with some of the vexing topics removed such as the special deal with Nebraska and the excessive abortion restrictions ("White House," "President's Proposal"). This proposal finally gave the President his own plan to defend,

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65 unlike in previous statements s uch as his first press conference, when he was just generally advocating reform. Now, the President, the House, and the Senate stood firmly behind similar legislation, and while there were some differences in the plans, they all followed the same general outline. The third major event that caused a major turn around in the course of health care after Scott Brown's election was the bipartisan health summit that was held after the President's plan was released. Before this summit, when speaking to the Repu blican caucus, the President was criticized by Congressman Chaffetz for not living up to his mantra of change: You stood up before the American people multiple times and said you would broadcast the health care debates on C SPAN, you didn't...You said you weren't going to allow lobbyists in the senior most positions within your administration, and yet you did...And when you said in the House of Representatives that you were going to tackle earmarks -in fact, you didn't want to have any earmarks in any of your bills -I jumped up out of my seat and applauded you. But it didn't happen ("White House," "Remarks"). When the President responded to these claims, he took some blame for not doing as he promised, but still maintained that he was doing more than a ny previous president before him ("White House," "Remarks"). In reality, it was impossible for the President to live up to the standards that he set during his candidacy. The promises that he made on the campaign trail conflicted directly with the respon sibilities of the modern president. The promise to air everything on C SPAN was not plausible because so much of the progress from the health care debate came from the President's closed door negotiations with interest groups. While this was antithetical to his campaign goals of openness, not having these talks would only have caused more opposition to the bill, likely resulting in its

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66 failure as in 1993. The removal of earmarks would have posed a similar dilemma. Had the President followed through on a ll of his campaign promises, he would have been unable to achieve anything. The President ran his campaign against the very duties of interest group negotiation, while at the same time, interest group negotiation was becoming pivotal. So, his turnaround comes as no real surprise. Since the President did have to give in on some of his campaign promises, this left him open to attacks such as the one from Representative Chaffetz. The Representative was certainly not the only one to feel this way, as shown by a Kaiser Family Foundation poll that showed that 73 percent of Americans felt that the healthcare debate was evidence that the policymaking process is broken (KFF, "Public Opinion March"). Another poll taken in the February after Scott Brown's election showed that 59 percent of Americans thought that the delays in the health care bill were about Republicans and Democrats playing political games, and not about the issues (KFF, "Public Opinion February"). The health summit allowed the President to knock down these criticisms by addressing them directly on television. By holding this summit, the President could say that he was achieving every single one of his campaign promises. It was bipartisan, it was displayed on television, it was free of lobbyists, and the President's plan lacked earmarks that were in the Senate legislation. By the end of the summit however, it was clear that the chances for any bipartisan compromise were nonexistent (Stolberg, and Pear, "President Urges"). Two New York Times write rs cleverly described the extent of the disagreement by pointing out that, "If there was any question about how deeply divided Republicans and Democrats are about how to reshape the American health care system, consider that they spent the first few hours of President Obama's much anticipated health care forum on Thursday arguing over whether they were in fact

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67 deeply divided" (Stolberg, and Pear, "President Urges"). Republicans at the summit drove home the point that they could not vote for the bill, and t he only option was to start over (Stolberg, and Pear "President Urges"). This was exactly what the President needed because it gave him the justification to go ahead and push through his legislation, now that it was confirmed that any semblance of biparti sanship was unattainable. After this summit, the gears for passage of the health care bill were truly set into motion. A week after it took place, the President held a press conference urging an "up or down vote" on the bills in Congress (Stolberg, and P ear, "Obama Calls"). The President was referring to reconciliation, the process by which debate on a budget bill can be limited to 20 hours with the approval of a majority (Herszenhorn, "Budget Reconciliation"). The plan that Democrats decided to follow was for the House to approve the Senate health care measure with the understanding that the Senate would use reconciliation to pass a corrections bill afterward that would address the concerns that House members had with the Senate version (Pear, and Hersz enhorn, "Pelosi Predicts"). With new direction from the President, Congress got to work putting the votes together, and on March 12 th ; Nancy Pelosi suggested that the House would pass the bill within 10 days (Pear, and Herszenhorn). Given the gravity of the situation, Obama postpones a trip to Indonesia in order to help persuade Democrats to vote for the bill (Pear, and Herszenhorn). While the President was making his appeals for votes, the Congressional Budget Office released a report that gave the bill a favorable rating, putting even more pressure on the Democrats that had yet to commit to the bill (Herszenhorn, and Pear). After intense negotiations with the President and Congressional leaders over the next few days, the House of Representatives was f inally able to clench enough votes to pass the

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68 Senate's Patient Protection and Affordable Care Act by a vote of 219 to 212 (Pear, and Herszenhorn, "Obama Hails"). Just a few days afterwards, the House and the Senate would pass a reconciliation bill that i ncluded the changed that House Democrats bargained for, and with the signing of this legislation, the great health care debate drew to a close (Herszenhorn, and Pear, "Final Votes"). By the end of the debate, it was clear to see that the President was ver y pleased with the final outcome of the bill. Upon the House passage, President Obama commented by saying we proved that we are still a people capable of doing big things" (Pear, and Herszenhorn, ("Obama Hails"). Joe Biden was also satisfied, as he expr essed during the signing ceremony when he said to Obama, "Mr. President, this is a big fucking deal" (Herszenhorn, "At White"). Their jubilation was understandable, since they had just achieved a goal that multiple presidents had failed to achieve since T eddy Roosevelt, a universal health care system in the United States (Jonas, 173). Teddy Roosevelt, Franklin Roosevelt, Harry Truman, and Bill Clinton all made some attempt at providing universal care, but were ultimately met with defeat (174 177, 187). S o, the question that remains is that given President Obama's early mistakes and failed rhetorical entrances, how was he able to pass his reform? Perhaps the most important factor in the President's success was his ability to adapt to the new institutional requirement of the presidency, where negotiating with interest groups is pivotal. From the very beginning, he was able to enlist support from a variety of medical players that made his task easier than others have had to face in the past. So, while he n ever really developed a clear message until the end of the debate, he was able to stave off the most harmful opposition, which allowed the House and Senate to negotiate in a better environment.

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69 It is worth noting however that the President did make a majo r mistake in not being more vocal with a clear message from the very beginning. Obviously, making this mistake did not cost him his health care agenda, but failing to be a commanding figure did have other consequences. For one, losing the debate may have cost him aspects of the final bill that he would have preferred. As noted above, the public option was one of the President's campaign goals, but by letting others define what the public option would entail, it ended up becoming too politically difficult Furthermore, since the fight for passing the bill was very dirty, people became disenchanted with the process, and lost even more faith in their government. Had the President been a central, positive figure, he may have been able to fight that cynicism The lingering resentment that people have towards the political process could likely result in Democrats losing their seats in Congress during the 2010 election, and even the loss of Senator Kennedy's seat to Senator Brown was partly caused by people's negative feelings towards the health care debate. Had the President addressed this earlier, it may have been possible that Senator Brown would not have won because he could not have capitalized on those bitter feelings. So, the President's rhetorical fai lings did cost him, and some of the costs from this will likely still be felt in the 2010 elections. While the negotiator role that the President adopted was certainly crucial, and it was enough to pass the reform, it did not pass reform in the best way p ossible. Towards the end of the debate, we saw some of the best appearances from the President, notably with the bipartisan summit and the speech for the Republican House members. It is my opinion that had he done these actions from the very beginning, t he resulting health care bill would have been more in line with the

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70 Presidents original plan. Had the President held a bipartisan summit at the very beginning of the debate, it would have become clear that bipartisanship was not possible, which would have freed the President of many of his burdens. Ideally, the President could have held three initial summits, one for Republicans, one for Democrats, and one that was bipartisan. This would have allowed for a message to be crafted early from both parties, w ith the intention of meeting in the middle at the bipartisan summit. However, once the bipartisan summit showed insuperable conflicts, the Democrats could have legitimately pushed forward without attempting any more bipartisanship from the very beginning. Though in the end, the President did get a health care bill, so the most major intention was accomplished, even it if will be at the cost of Democratic seats in Congress. This survey of the health care overhaul effort tells a very turbulent story about how modern institutions interact with each other. In particular, the office of the President seems to have gone through a major shift where interest groups are now on par with Congressmen and citizens as institutions to deal with. By tackling health care in the United States, the President had to face this institutional challenge, in combination with the historical challenge of the recession, and his own election promises which conflicted directly with the expectations of the modern president. At first, Barack Obama seemed only able to handle one of these challenges by excelling in his role as a negotiator while his other responsibilities floundered. However, by the end of the debate, the President was finally able to craft a message and use it to pass a comprehensive health care reform law.

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"The Obameter: Tracking Obama's Campaign Promises." Politifact.com St. Petersburg Times, Web. 7 Apr 2010. "Open Market Operations." B oard of Governors of the Federal Reserve System The Federal Reserve, 26 Jan 2010. Web. 15 Apr 2010. . Pear, Robert, and Gardiner Harris. "Alternate Plan as Health Option Muddies Debate." New York Times Aug ust 17, 2009: Web. 6 Apr 2010. Pear, Robert, and David Herszenhorn. "Buoyant Democrats Unveil Health Care Legislation." New York Times 29 Oct 2009. Web. 5 Apr 2010. Pear, Robert, and David Herszenhorn. "Democrats Face Challenge in Merging Health Bills." Ne w York Times 21 Dec 2009. Web. 7 Apr 2010. Pear, Robert, and David Herszenhorn. "Democrats Grow Wary as Health Bill Advances ." New York Times 17 Jul 2009. Web. 2 Apr 2010. Pear, Robert. "Democrats To Develop Pitch to Sell Health Plan." The New York Times 14 May 2009. Web. 6 APR 2010 Pear, Robert, and Peter Baker. "Experts Dispute Some Points in Health Talk ." New York Times 22 Jul 2009. Web. 5 Apr 2010. Pear, Robert, and David Herszenhorn. "G.O.P. Counters With a Health Plan of Its Own." New York Times 3 Nov 2009. Web. 6 Apr 2010. Pear, Robert, and David Herszenhorn. "Health Bill Clears Hurdle and Hints at Consensus." New York Times 31 Jul 2009. Web. 2 Apr

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