“Taking giant steps in health policy takes a certain number of characteristics,” Shalala told an audience of 800 health care executives and policy experts in March at the University of Miami, where she formerly served as president. “Over the years we have learned what the elements have to be to do that. We have learned through the failures.”

Here are the lessons Shalala learned about major health policy legislation:

• The president must have passion for pushing the bill through to completion. Presidents need to be prepared to use up a lot of political capital along the way. President Obama overruled the naysayers in his own White House because of the searing memory of his mother arguing with her health insurance company as she lay dying of cancer.
• Move fast. Time is not on your side. “Presidents lose power every day. The height of their power is the beginning of the administration. In the Clinton Administration, we delayed. Clinton was distracted by other things.”
• You must have a plan. President Obama had the advantage of being cornered during the 2008 primary season by Hillary Clinton, who released her own health reform plan. He was forced to think about his plan during the campaign.
  • Presidents must stay out of the weeds. Just keep trumpeting the big themes. “Carter loved the details. Clinton loved to get into the weeds.” It didn’t help them any.
  • You won’t get anywhere without congressional buy-in. “Just sending them up a bill was unsuccessful for any president.”
  • You must win the support of the stakeholders. “Every unsuccessful effort has been stopped by stakeholders: the American Medical Association, the hospitals, or the pharmaceutical industry.” In political science, she said, “we talk about negative coalitions. Every stakeholder decides there is something they don’t like. You have to put a positive coalition together. Lyndon Johnson tricked the AMA into supporting Medicare. Everybody knows the Obama story: with pharma, the nurses, the insurance companies, he learned from the previous experiences and lined up the stakeholders.”
  • Don’t mix the coverage issue with the cost issue. The successful reformers have not made holding the line on medical costs a major goal. “The politics of coverage is very different from bending the cost curve. The stakeholders line up in different ways. I have always thought the politics of coverage is much easier than the politics of cost control. If what they are talking about is pulling money out of the system, that is very different from putting a trillion dollars into the system and expanding the coverage.”
  • Finally: “You have to explain and explain and explain. You cannot let those in opposition capture the moment and capture the opposition. In the Clinton administration, the “Harry and Louise” ads killed us, even though they were only shown in Washington, DC. . . . Hillary made the mistake of talking about them; then they were all over network TV. We lost control of the story.”
    

    Shalala made these remarks in the context of a public one-on-one dialogue with Kathleen Sebelius, who was Obama’s HHS secretary during and after passage of the only successful major health reform since the 1960s. Toward the end, she said to Sebelius: “No one ever gets their legislation perfect. What would you have done differently?” Sebelius ticked off a list of regrets: They should have reduced administrative paperwork, Congress should have funded the insurance risk corridors, HHS needed more outreach and education money, Medicaid should have been expanded to every state.

    For Democrats, the political costs of passing this comprehensive legislation have been steep. Largely because of united Republican opposition to their reform law, they first lost control of the House of Representatives, then the Senate. They lost control of many houses in state legislatures, 10 governor’s offices, and finally, the White House.

    Speaking of regrets, I asked them in the question period, “Was what you gained worth the enormously consequential price you paid?”

    Shalala cut me off: “We got 20 million people covered with health insurance,” she said. A huge wave of applause rewarded her statement.

    For Shalala, that’s the bottom line. Everything else is secondary.