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One of the most 

his campaign promise to take immediate action on health care. Reform was not only good

public policy that would help millions of Americans, it also was inextricably tied to reducing the deficit.

I shared Bill’s profound concerns about the economy and the fiscal irresponsibility of

the prior twelve years, under the Reagan and Bush Administrations. Recent deficit projections by the Bush Administration camouflaged the real deficit by underestimating the

effects of a stagnant economy, the impact of health care costs and federal spending on the

savings and loan bailout. These costs had helped swell the projected deficit to $387 billion over four years―considerably higher than the estimate the departing Bush White

House had released. But beyond budgetary concerns, I believed health care reform could

relieve the anguish of working people throughout our wealthy country. As the wife of a

Governor and now a President, I didn’t have to worry about my family’s access to health

care. And I didn’t think anyone else should have to, either.

My experiences serving on the board of Arkansas Children’s Hospital and chairing a

state task force on rural health care introduced me to problems embedded in our health

care system, including the tricky politics of reform and the financial quandaries faced by

families who were too “rich” to qualify for Medicaid but too “poor” to pay for their own

care. Traveling around Arkansas in the 1980s, and then around the United States during the

presidential campaign, I met Americans who reinforced my belief that we had to fix what

was wrong with the system. Bill’s commitment to reform represented our greatest hope of

guaranteeing millions of hardworking men and women the health care they deserved.

Bill, Ira, Carol and I walked out of the Oval Office, past the bust of Abraham Lincoln

by Augustus Saint-Gaudens and across the narrow hall to the Roosevelt Room, where a

crowd of cabinet secretaries, senior White House staff and journalists was waiting for

what the official schedule listed as a “task force meeting.”

Stepping into the Roosevelt Room is stepping back into American history. You are

surrounded by banners from every U.S. military campaign and flags from each division

of the U.S. Armed Forces, portraits of Theodore and Franklin Roosevelt and the Nobel

Peace Prize medal that Theodore Roosevelt won in 1906 for mediating a settlement of the

Russo-Japanese War. During our time in the White House, I added a small bronze bust of

Eleanor Roosevelt so that her contributions as a “Roosevelt” would also be acknowledged in the room named for her uncle and husband.

In this historic room, Bill declared that his administration would present a health care

reform plan to Congress within one hundred days―a plan that “would take strong action

to control health care costs in America and to begin to provide for the health care needs

of all Americans.”

Then he announced that I would chair a newly formed President’s Task Force on National Health Care Reform, which would include the Secretaries of Health and Human

Services, Treasury, Defense, Commerce and Labor, as well as the Directors of Veterans

Affairs and of the Office of Management and Budget and senior White House staff. Bill

explained that I would work with Ira, the cabinet and others to build on what he had

sketched out in the campaign and in his inaugural address. “We’re going to have to make

some tough choices in order to control health care costs ... and to provide health care for

all,” he said. “I am grateful that Hillary has agreed to chair the task force, and not only

because it means she’ll be sharing some of the heat I expect to generate.”

Heat came from all directions. The announcement was a surprise inside the White

House and federal agencies. A few on Bill’s staff had assumed I would be named domestic policy adviser (which Bill and I had never discussed). Others thought I would work on

education or children’s health, largely because of my past experiences on these issues.

Maybe we should have told more staff members, but sensitive internal information was

already flowing out of the White House, and Bill wanted to break the story himself and

answer the first questions raised.

Many White House aides thought it was a great idea. Several of Bill’s key lieutenants

heartily endorsed the idea, including Robert Rubin, Chairman of the National Economic

Council and later Secretary of the Treasury. One of my favorite people in the administration, Bob is fabulously smart and successful, yet thoroughly self-effacing. He later joked

about his extraordinary political acumen: He didn’t think my appointment would generate

such intense political fallout. I was surprised by the reaction, too.

Some of our friends gave us lighthearted warnings about what lay ahead. “What did

you do to make your husband so mad at you?” Mario Cuomo, then Governor of New

York, asked me during a White House visit.

“What do you mean?”

“Well,” Mario replied, “he’d have to be awfully upset about something to put you in

charge of such a thankless task.”

I heard the warnings, but I didn’t fully realize the magnitude of what we were undertaking. My work in Arkansas running the rural health care task force and the Arkansas

Education Standards Commit tee didn’t rival the scale of health care reform. But both efforts were considered successful and made me excited and hopeful as I took on this new

challenge. The biggest problem seemed to be the deadline that Bill announced. He had

won the election in a three-way race with less than a majority of the popular vote―43

percent―and he couldn’t afford to lose whatever political momentum he had at the beginning of the new administration. James Carville, our friend, adviser and one of the most

brilliant tactical minds in American politics, had given Bill this warning: “The more time

we allow for the defenders of the status quo to organize, the more they will be able to

marshal opposition to your plan, and the better their chances of killing it.”

Democrats in Congress were also urging us to move quickly. A few days after Bill’s

announcement, House Majority Leader Dick Gephardt asked to meet with me. He was

known on Capitol Hill for his Midwestern roots and sensibilities, as well as his command

of budget issues. His compassion for people in need reflected his upbringing, and his

commitment to health care reform was heightened by his son’s bout with cancer years

earlier. Through position and experience, Gephardt would be a leading voice in any

health care deliberations in the House. On February 3, Gephardt and his top health care

aide came to my West Wing office to discuss strategy. For the next hour, we listened as

Gephardt outlined his concerns about health care reform. It was an intense meeting.

One of Gephardt’s chief worries was that we would be unable to unify Democrats,

who were seldom united under the best of circumstances. Health care reform widened existing divisions. I thought of the old Will Rogers joke:

“Are you a member of any organized political party?”

“No, I’m a Democrat.”

I knew of the potential divisiveness but hoped that a Democratic Congress would rally

around a Democratic President to show what the party could accomplish for America.

Democratic members had already begun to outline their own models for reform in order to influence the President’s plans. Some proposed a “single payer” approach, modeled on the European and Canadian health care systems, which would replace the current

employer-based system. The federal government, through tax payments, would become

the sole financier-or single payer-of most medical care. A few favored a gradual expansion of Medicare that would eventually cover all uninsured Americans, starting first with

those aged fifty-five to sixty-five.

Bill and other Democrats rejected the single-payer and Medicare models, preferring a

quasi-private system called “managed competition” that relied on private market forces to

drive down costs through competition. The government would have a smaller role, including setting standards for benefit packages and helping to organize purchasing cooperatives. The cooperatives were groups of individuals and businesses forged for the purpose of purchasing insurance. Together, they could bargain with insurance companies for

better benefits and prices and use their leverage to assure high-quality care. The best

model was the Federal Employees Health Benefit Plan, which covered nine million federal employees and offered an array of insurance options to its members. Prices and quality were monitored by the plan’s administrators.

Under managed competition, hospitals and doctors would no longer bear the expense

of treating patients who weren’t covered because everyone would be insured through

Medicare, Medicaid, the veterans and military health care plans or one of the purchasing

groups.

Perhaps most important, the system would allow patients to choose their own doctors,

a non-negotiable item in Bill’s view.

Given the multitude of approaches to health care reform, feelings in Congress ran

deep, Gephardt told us. Just a week earlier, he had held a health care meeting in his

House office in which two members of Congress disagreed so violently that they nearly

came to blows. Gephardt was emphatic that our best hope for passage was to attach

health care reform to a budget bill known as the Budget Reconciliation Act, which Congress usually voted on in late spring. “Reconciliation” combines a variety of congressional budget and tax decisions into one bill that can be approved or disapproved by a

simple majority vote in the Senate without the threat of a filibuster, a delaying tactic often

used to kill controversial legislation, which requires sixty votes to break. Many budget

items, particularly those relating to tax policy, are so complicated that debate can endlessly tie up proceedings in the full House and Senate. Reconciliation is a procedural tool

designed to move controversial tax and spending bills through Congress. Gephardt was

suggesting that it be used in an unprecedented way: to legislate a major transformation in

American social policy.

Gephardt was sure that Republicans in the Senate would filibuster any health care

package we put forward. He also knew that the Senate Democrats would have trouble mustering sixty votes to stop it, given that Democrats held only a fifty-six to forty-four advantage. Gephardt’s strategy, therefore, was to circumvent a filibuster by putting health care

reform into the budget reconciliation package. A simple majority would be required to

pass the bill, and Vice President Gore could cast the tiebreaking fifty-first vote, if needed.

Ira and I knew that Bill’s economic team inside the White House would likely reject a

budget reconciliation strategy that included health care because it could complicate the

administration’s efforts on the deficit reduction and economic plan. We broke up our

meeting, and I took Gephardt straight to the Oval Office to make his case directly to Bill.

Bill was convinced by Gephardt’s argument and asked Ira and me to explore the idea

with the Senate leadership.

Armed with Gephardt’s suggestions and Bill’s encouragement, Ira and I trooped up to

Capitol Hill the following day to meet with Majority Leader George Mitchell in his office

in the Capitol. This was the first of hundreds of visits I made to members of Congress

over the course of health care reform. Mitchell’s soft-spoken demeanor belied his toughminded leadership of the Senate Democrats. I respected his opinion, and he agreed with

Gephardt. Health care would be impossible to pass unless it was part of reconciliation.

Mitchell was also nervous about the Senate Finance Committee, which would otherwise

have jurisdiction over many aspects of health care legislation. He was particularly worried that committee Chairman Daniel Patrick Moynihan of New York, a veteran Democrat and a skeptic about health care reform, would react badly to the plan. Moynihan was

an intellectual giant and an academic by training―he had taught sociology at Harvard

before running for the Senate―as well as an expert on poverty and family issues. He had

wanted the President and Congress to take up welfare reform first. He wasn’t happy when

Bill announced his one-hundred-day target for health care legislation―and he let everyone know it.

At first I found his position frustrating, but I began to understand. Bill and I shared

Senator Moynihan’s commitment to welfare reform, but Bill and his economic team believed that the government would never get control of the federal budget deficit unless

health care costs went down. They had concluded that health care reform was essential to

his economic policy and that welfare could wait. Senator Moynihan anticipated how hard

it would be to get health care through his committee. He knew he was going to be responsible for shepherding Bill’s economic stimulus package through the Finance Committee

and onto the Senate floor. That in itself would require extraordinary political skill and

leverage. Some Republicans were already publicizing plans to vote against it, no matter

what it contained. And some Democrats might need convincing, particularly if the package involved a tax increase.

We left Mitchell’s office with a clearer sense of what needed to be done, particularly

on reconciliation. Now we had to convince the economic team―notably Leon Panetta,

Director of the Office of Management and Budget―that including health care reform in

reconciliation would serve the overall economic strategy the President was pursuing, not

divert attention from the deficit reduction plan. Bill only had so much political capital to

work with, and he had to use it to get the deficit down, one of his central campaign promises. The thinking in some quarters of the West Wing was that Bill’s focus on health care

would divert Americans from his economic message and muddy the political waters.

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