Last fall, David Blumenthal and James Morone published a timely history of the presidential handling of health reform from Franklin Roosevelt onward, called The Heart of Power (see my review in Health Affairs). At the end of the book, they offered eight rules for presidential management of health reform distilled from the experience of the past eleven presidents. Below are their eight rules, and this analyst’s assessment of how President Obama did.

 1) Passion. “The first key to success is a president who cares deeply.” Obama committed a staggering amount of his political capital to enacting health reform. He personally kept the issue at the top of his presidential agenda, despite the concerns of both his economic and political advisors. You could feel how important this issue was to him; he bet his presidency on it. On Passion, Obama rates an A+.

2) Speed. “The day after the presidential election, the savvy health policy analyst will slip his or her president-elect a message: ‘Hurry up — you’re running out of time.’ The window of opportunity always slams shut quickly.”

Obama entered the White House with his health reform team in place and moving at a dead run, only to lose its captain, Tom Daschle, less than two weeks after inauguration to ethics problems. The decision to let Daschle go cost the Obama team nearly three crucial months (which were consumed with stopping a financial panic). Health reform also took a lengthy summer pause as Finance Committee Chairman Max Baucus attempted unsuccessfully to craft a bipartisan Senate proposal. Then a succession of congressional recesses and processing the disastrous by-election in Massachusetts introduced further delays.

The longer the process stretched out, the more vulnerable it was to such events as the Scott Brown election, which almost killed health reform. With the caveat that the president’s congressional dancing partner was fully codependent, on Speed, the president gets a C+.

3) Bring a Plan with You. Blumenthal and Morone stressed the importance of “coming into office with a legislative proposal in hand.” While Obama did not enter office with such a proposal, his health czar designee, Daschle, did—a well-written, thoughtful road map to reform in his book Critical.

When Daschle went under the bus, so did the script, and the virtually invisible White House hand in the subsequent process made it appear as if Congress was setting priorities. The resulting House bill HR3200 pushed the process to the left and alienated a lot of Democratic moderates. Only in September, when the process was languishing from a summer of tea party activism, did the president declare his “plan.” The reality was that, post-Daschle, the president’s “plan” was negotiation with congressional power brokers. By not throwing down the gauntlet, as the Clintons did, he did not trap his congressional partners. But he paid a price in public perception that he was not in charge. On Bringing a Plan, Obama gets a B-.

 4) Hush the Economists. Blumenthal and Morone believed that “expanding health coverage requires presidents who are able and willing to overrule their economic advisors.” This Obama did, clearly and effectively. He overruled economic advisors who questioned the fiscal capacity of the government to finance health reform in the face of mounting federal deficits. His deficit hawk, OMB’s Director Peter Orszag, buried his concerns about the deficit and played a strategic role in shaping the health provisions of the stimulus package (comparative effectiveness and health information technology), as well as in resurrecting an Independent Medicare Commission and in insisting on a Cadillac health plans tax in the Senate bill. After initial problems with deficit forecasts on HR 3200 from the Congressional Budget Office (whose gloomy estimates fatally damaged the Clinton reform proposals), Obama’s staff was able successfully to surmount multiple reviews without setting off deficit alarms.

It didn’t sell with the public, though. Only 23 percent of his own party surveyed in March by the Kaiser Family Foundation believed this package would not increase the deficit.

On Hushing the Economists, for better or worse, Obama gets an A.

5) Go Public. “There is one job only the president can do: create popular momentum for reform.” Here Obama waxed and waned. His persuasive September address to Congress on health reform helped restore the momentum to the process that had been lost during the summer, and the covering fire he provided in the last month of the health reform debate dramatically increased support among the Democratic base for a bill that disappointed many of them (due to the lack of a public option, the abortion and immigration restrictions, etc). The president’s dramatic push saved health reform, making up for lengthy and inexplicable periods during the summer, fall, and winter where the White House seemingly went dark on this issue and permitted the opposition to define the debate. Obama showed a formidable capacity to persuade. For Going Public, the president earned a B+.

6) Manage Congress. “The successful president must be nimble at making our convoluted legislative machinery work.” Here, Obama brilliantly anticipated the legislative dance of health reform by installing a powerful congressional leader as his chief of staff, and recruiting heavily from the Ways and Means and Senate Finance Committees to staff his congressional liaison office. Despite this, congressional relations were challenging, particularly with ineffectual Senate leadership and an ideological House Speaker who early on ran roughshod over the moderates in her caucus. Nevertheless, Rahm Emanuel delivered on this nightmare challenge and made it possible for his president to make it to the signing ceremony. On Managing Congress, Obama earned an A-.

7) Forget the PSROs. According to Blumenthal and Morone, the president who poses as a policy wonk is heading for trouble. Obama displayed a mastery of the arcana of health reform at his congressional health care summit that put even the Clintons to shame. He clearly understood and articulated the key issues without wallowing in jargon or minutiae. He delegated detail management to a capable White House policy staff, headed by Nancy-Ann DeParle. Obama did not appear to get bogged down in the details, nor did he lose sight of the main objectives of reform. On Forgetting the PSRO’s, the president gets an A.

8) Learn How to Lose. Blumenthal and Morone suggest that the odds are that health reform fails, and how one frames the loss may determine whether a president can achieve partial gains on health reform issues later in his term if he does not get the main prize. Obama had several opportunities to walk away. He could have walked away in the weeks immediately after taking office, credibly claiming that the nation’s economic emergency required postponing a coverage expansion—but he didn’t. And after briefly flirting with scaling back his agenda after the Scott Brown debacle, he declined to cut his losses and pressed ahead to ultimate victory. On health reform, the president refused to lose, so on Learning How to Lose, he rates an F, which will not count in his final grade.

A Final Grade. Overall, it’s the outcome that matters, and Obama got to a signing ceremony on March 22 with a bill that accomplished most of his cherished health reform aims, for which Blumenthal and Morone will undoubtedly award him an A. The hard work is just beginning, however.

Obama faces serious challenges in implementing this legislation. The reported selection of Don Berwick as the new CMS Administrator, (a position not filled on a permanent basis since Mark McClellan resigned in September 2006!) is a good start, but a prodigious amount of regulatory wordsmithery remains. The president will also have to protect the funding for coverage expansions from the inevitable deficit reduction challenges he and Congress will face when the economy actually recovers.

Nevertheless, Obama put a structure in place to close an unconscionable gap in health coverage for Americans and has written a triumphal concluding chapter of the second edition of The Heart of Power.