After­ward, we posed for a pho­to op, each of us hold­ing a beer, and as we made forced ban­ter for the cam­eras, I couldn’t help but reflect on how quick­ly the ideals and agen­das could get swal­lowed up by the soap opera of pol­i­tics, as described in Chap­ter 16.

As sum­mer turned to fall, I found myself reg­u­lar­ly engag­ing in a sim­i­lar bal­anc­ing act—trying to keep the Amer­i­can peo­ple focused on long-term goals while man­ag­ing the dai­ly the­ater of Wash­ing­ton, the cable news cycles, and the relent­less tor­rent of crit­i­cism that con­sti­tut­ed my new nor­mal. Despite the dis­trac­tions, we con­tin­ued to push for­ward on health­care reform. In Sep­tem­ber, I addressed a joint ses­sion of Con­gress, hop­ing to regain the ini­tia­tive. I offered a detailed defense of the leg­is­la­tion, spelling out the ben­e­fits for the insured, the unin­sured, and seniors; the ways we’d reduce health­care costs; and the mech­a­nisms for pay­ing for reform—all with­out adding a dime to the deficit. I called out the most egre­gious myths being ped­dled by oppo­nents of reform, includ­ing the absurd charge that we planned to set up “death pan­els” to decide which seniors lived or died. I acknowl­edged hon­est dif­fer­ences of opin­ion between Democ­rats and Repub­li­cans but crit­i­cized those who were spread­ing out­right lies in the ser­vice of par­ti­san gain.

The speech was well received, pro­vid­ing our efforts with a much-need­ed boost. More impor­tant­ly, it marked the begin­ning of a more aggres­sive stretch of work on health­care, with every part of our admin­is­tra­tion and our con­gres­sion­al allies mov­ing full-bore to get leg­is­la­tion passed. On the leg­isla­tive front, the biggest chal­lenge remained the Sen­ate Finance Com­mit­tee, chaired by Max Bau­cus. Despite his best efforts, Bau­cus had failed to per­suade a sin­gle Repub­li­can on the com­mit­tee to sup­port a watered-down ver­sion of our plan. Nev­er­the­less, with the help of his Demo­c­ra­t­ic col­leagues, he man­aged to shep­herd a bill out of com­mit­tee by the slimmest of mar­gins.

Over in the House, Nan­cy Pelosi mar­shaled her troops with equal deter­mi­na­tion, con­sol­i­dat­ing var­i­ous com­mit­tee bills into a sin­gle piece of leg­is­la­tion that she maneu­vered through to pas­sage despite fierce Repub­li­can oppo­si­tion, as well as skit­tish­ness from some in her own cau­cus over abor­tion cov­er­age and the pub­lic option—a gov­ern­ment-run insur­ance plan pro­posed as a way to keep pri­vate insur­ers hon­est.

In Novem­ber, with vice pres­i­den­tial encour­age­ment, Har­ry Reid man­aged to cajole, whee­dle, and horse-trade his way to get­ting every last Demo­c­ra­t­ic senator—and two independents—to sup­port bring­ing our ver­sion of health­care reform to the Sen­ate floor. It was a her­culean feat, giv­en the ide­o­log­i­cal breadth of the Demo­c­ra­t­ic cau­cus and the unyield­ing oppo­si­tion from the oth­er side, but it set the stage for the chamber’s first seri­ous debate on health­care reform in near­ly two decades.

Still, for all our leg­isla­tive maneu­ver­ing, what I remem­ber most from that peri­od were the sto­ries that kept pour­ing into the White House: let­ters from Amer­i­ca, voic­es that served as a con­stant reminder of what was at stake. There was the young woman with breast can­cer whose insur­ance com­pa­ny had can­celed her pol­i­cy when she got sick, on the pre­text that she hadn’t report­ed a case of acne on her ini­tial appli­ca­tion. The mid­dle-aged man who couldn’t get cov­er­age because he’d once had back surgery for a her­ni­at­ed disk. The par­ents strug­gling to pay for their son’s insulin. These sto­ries, more than any­thing, kept me going, a coun­ter­bal­ance to the cyn­i­cism and dem­a­goguery and some­times soul-crush­ing com­plex­i­ty of try­ing to bring about change in Wash­ing­ton.

As the year wound down, I found a moment one evening to walk alone through the emp­ty halls of the West Wing, reflect­ing on the jour­ney thus far. I thought about my cam­paign promis­es, the expec­ta­tions of those who had vot­ed for me, and the skep­ti­cism of those who hadn’t. I con­sid­ered the eco­nom­ic cri­sis we faced upon assum­ing office, the deci­sions we had made that had pulled us back from the brink but left many Amer­i­cans still hurt­ing. I thought about the wars in Iraq and Afghanistan, the efforts to close Guan­tanamo, the chal­lenges of cli­mate change, and the ongo­ing scourge of ter­ror­ism. I thought about the lessons of that sum­mer: the furor over my com­ments on the arrest of Hen­ry Louis Gates Jr., the orches­trat­ed pan­ic over “death pan­els,” the bal­anc­ing act between ide­al­ism and prag­ma­tism.

Stand­ing there in the qui­et, I felt the weight of the pres­i­den­cy, the relent­less pres­sure of con­stant deci­sions, the knowl­edge that every action tak­en or not tak­en had real con­se­quences for real peo­ple. Yet despite the weight, or per­haps because of it, I felt a res­olute sense of pur­pose. The fight for health­care reform, like every bat­tle we engaged in, was not just polit­i­cal; it was a moral imper­a­tive, a tes­ta­ment to our belief that in Amer­i­ca, no one should have to choose between med­i­cine and mort­gage pay­ments, that no one should be one ill­ness away from finan­cial ruin, that in the wealth­i­est nation on earth, health­care should be a right, not a priv­i­lege.

As I returned to the Oval Office, I knew the road ahead would be ardu­ous. But I also knew we had come too far to turn back. Our resolve had only hard­ened, for­ti­fied by every sto­ry of strug­gle and hope and per­se­ver­ance. And so, with a renewed sense of deter­mi­na­tion, we pressed on, into the bat­tles that lay ahead, know­ing that the cause was just and the time was now.