The big difference here is that Obama wanted above all to leave the health insurance oligarchs in power.

Fall 2009 Democrats take the lead; war with the insurance industry; more deals are cut

Two days before the Senate is to vote on the Finance Committee's bill, America's Health Insurance Plans releases a report (PDF) alleging that health care premiums would increase sharply under the bill. "But the importance of that report and its issuance was not really the substance of the report so much as the decision by the industry to put it out there," explains Washington Post reporter Ceci Connolly. "It was the clearest signal in this long drama that the insurance industry was not going to be on board with any sort of health care reform."

On Oct. 13, the health care bill passes the Senate Finance Committee with the support of only one Republican, Sen. Olympia Snowe of Maine. Following the bill's passage, Senate Majority Leader Harry Reid (D-Nev.) takes back control of the bill -- talk of a public option is back on the table and the individual mandates that the insurance industry had fought for are watered down.

And the following Saturday, the president takes on the insurance industry in his weekly Internet address: "They're flooding Capitol Hill with lobbyists and campaign contributions, and they're funding studies designed to mislead the American people," he says. "It's all smoke and mirrors. It's bogus."

But Karen Ignani and her allies fight back by funneling millions of dollars into a tough ad campaign against the legislation sponsored by the Chamber of Commerce.
And the insurance industry's arguments hold sway with a number of key senators. The White House and the Democratic leadership begin cutting deals; they kill the public option, pleasing Sen. Joe Lieberman and others; they lower proposed taxes for medical device makers to win Sen. Evan Bayh's (D-Ind.) support.

The last holdout is Sen. Ben Nelson (D-Neb.), a former insurance industry executive. He agrees to support the bill if he can get a $100 million deal in which the costs of expanding Medicaid in Nebraska would be covered by U.S. taxpayers. Sen. Nelson denies there was a quid pro quo for his vote, saying instead he was opening the door for all states to receive similar Medicaid compensations. But Washington and the media see it differently; the deal becomes known as the "Cornhusker Kickback."

This theme had been reiterated all day: Obama is all about the art of the possible within the system. "This is a classic conflict within the left: Are you a revolutionary or are you a reformist?" Obama said. "I am less concerned with the labels that are placed on me in terms of what kind of leader I am, and I am more interested in results.... I think within the institutional structures we have, we can significantly improve the life chances of ordinary Americans." I asked him to give me some specific examples of what he meant. Is a proposal to convert America's healthcare system to one in which the government is the single payer for all services revolutionary or reformist? "Anything that Canada does can't be entirely revolutionary--it's Canada," Obama joked. "When I drive through Toronto, it doesn't look like a bunch of Maoists." Even so, Obama said that although he "would not shy away from a debate about single-payer," right now he is "not convinced that it is the best way to achieve universal healthcare."

Obama has a remarkable ability to convince you that his positions are motivated purely by principles, not tactical considerations. This skill is so subtle and impressive, it resembles Luke Skywalker's mastery of the Force. It's a powerful tool for a Democratic Party that often emanates calculation rather than conviction. "I don't think in ideological terms. I never have," Obama said, continuing on the healthcare theme. "Everybody who supports single-payer healthcare says, 'Look at all this money we would be saving from insurance and paperwork.' That represents 1 million, 2 million, 3 million jobs of people who are working at Blue Cross Blue Shield or Kaiser or other places. What are we doing with them? Where are we employing them?"

Shifting back to how he sees himself in the Senate, Obama seemed to amend his previous statement about what kind of leadership progressives can expect from him. "I am agnostic in terms of the models that solve these problems," he said. "If the only way to solve a problem is structural, institutional change, then I will be for structural, institutional change. If I think we can achieve those same goals within the existing institutions, then I am going to try to do that, because I think it's going to be easier to do and less disruptive and less costly and less painful.... I think everybody in this country should have basic healthcare. And what I'm trying to figure out is how to get from here to there." He went on to tell me about his support for other structural changes such as public financing of elections, forcing broadcasters to offer free airtime for candidates, adding strong labor protections to trade pacts and major efforts to create a more just tax system.