President Obama signs the Affordable Care Act in the East Room of the White… (J. Scott Applewhite, Associated…)
WASHINGTON — President Obama had reason to be hopeful in July 2009, as he met one afternoon in the Oval Office with Maine Sen. Olympia J. Snowe.
The new president was trying to sustain his ambitious initiative to overhaul the nation's healthcare system. He needed Snowe, a centrist Republican, to make the effort bipartisan. Now, she was telling Obama what he wanted to hear: She would be with him.
That would precipitate a months-long scramble as the president and his team shaped the legislation to meet Snowe's concerns. White House aides worked through a 10-point memo that Snowe's office emailed through her favored intermediary — budget director Peter Orszag. (Orszag had dated a Greek shipping heiress; Snowe is active in Greek American circles.) On Capitol Hill, Democratic staffers on the Senate Finance Committee sent nearly every paragraph of legislative language to Snowe for review.
In the end, Obama got his bill, the most sweeping domestic legislation since the 1965 creation of Medicare. But he couldn't win over Snowe or any other Republican.
As the president seeks reelection, the Affordable Care Act, passed in 2010, stands as a historic achievement, ending a decades-long quest by Democrats — and some Republicans — to guarantee healthcare to all Americans.
At the same time, Obama's inability to bring the parties together represents a signature failure. The president, who promised to break Washington's partisan stalemate, would sign the most consequential legislation in modern history passed by only one party.
Obama's struggle to expand health coverage was equally a testament to the challenge of forging compromise while one party was growing increasingly hostile to the federal government, fueled by the tea party movement that would unseat a series of centrist GOP lawmakers.
The president repeatedly sought Republican participation. He solicited input from individual GOP lawmakers. He rejected bedrock Democratic positions that would alienate Republicans. He even surrendered authority for crafting the law to Congress, a highly unusual move for a new president.
But Obama ran up against a GOP opposed to the very idea that Washington should do something as big as guarantee health coverage. Republican congressional leaders would say that Obama's plan amounted to a government takeover of American healthcare that would increase costs and swamp the federal budget.
Senior Republicans were unified and stalwart. Several health industry officials said they were told explicitly by GOP leaders not to work with the president.
"The Republican Party has changed," said Dan Nickelson, a former lobbyist for the prestigious Cleveland Clinic who worked on healthcare issues in Washington for four decades. "Almost right from the get-go, their tone was so negative. I don't know if there was ever a real chance for bipartisan cooperation."
That left Obama with few options. "He had to rely on an old-fashioned strategy — to go where the votes were," said former Democratic Senate Majority Leader Tom Daschle, a close advisor who helped craft Obama's healthcare strategy.
When fully implemented, the law will for the first time ensure all Americans can get health coverage, even if they have preexisting medical conditions.
Obama and his Democratic allies designed it to allow most Americans to keep the health coverage they get through work. That makes the law's impact largely invisible to many consumers, though a host of new regulations have put a substantial burden on employers, insurers and medical providers.
At the same time, millions of people have already seen small benefits. Adult children can now stay on their parents' health plans until age 26. Seniors are getting discounts on prescription drugs. And all Americans with insurance get check-ups and other preventive care without a co-payment.
Starting in 2014, insurers will be forbidden from denying coverage. Americans who don't get health benefits through an employer will be able to shop on new Internet-based markets, or exchanges, for an insurance plan that meets government-mandated standards.
Low- and moderate-income Americans will get subsidies to help them buy insurance. And the poorest Americans will gain access to the government Medicaid program, except in states that reject the Medicaid expansion.
In total, the law is expected to cover about 30 million more Americans over the next decade.
It also includes potentially transformative initiatives backed by many experts to protect consumers from poor-quality medical care. The government will penalize hospitals where patients get infections and other dangerous conditions, and reward doctors who intensely manage their patients' care.
"These reforms are already beginning to have an impact," said Dr. Mark McClellan, who oversaw the Medicare and Medicaid programs under President George W. Bush.