WASHINGTON - Campaigning for president, Barack Obama said repeatedly that any overhaul of the health care system should be negotiated publicly and televised for all to see. Throughout this year's negotiations, however, the big deals have been struck in secret.
With tax increases and limits on what's covered among the possible ways of offsetting perhaps $1 trillion over a decade in expenses, neither the administration nor Congress is willing to give up its right to do the most sensitive talking in private, as it's always been done.
"It's unrealistic to think every aspect of the negotiations is going to be public," said Senate Assistant Majority Leader Richard Durbin, D-Ill.
White House Press Secretary Robert Gibbs, traveling with Obama in L'Aquila, Italy, said Thursday that "this president has demonstrated more transparency than any president." He said that Obama had participated in multiple town-hall meetings with doctors, nurses and providers to discuss revamping health care.
"I don't think the president intimated that every decision putting together a health care bill would be on public TV," Gibbs said.
The notion of televising negotiations behind a health care revamp was so central to Obama's campaign promises of change and openness, however, that it became part of his stump speech as he traveled the country in 2007 and 2008.
He'd describe how televised deliberations would take place around a big table, with seats filled by doctors, nurses, insurers and other interested parties. As president, he'd joke, he'd get the biggest chair.
"Not negotiating behind closed doors, but bringing all parties together and broadcasting those negotiations on C-SPAN," Obama explained in a Democratic debate in Los Angeles in January 2008, in language similar to many of his campaign stops.
However, the two biggest deals so far - industry agreements to cut drug and hospital costs - were reached in secret.
"They were private, yes," said Senate Finance Committee Chairman Max Baucus, D-Mont., a key participant in the process.
C-SPAN, the cable public-policy network, did carry a White House Forum on Health Reform in early March in which the president spoke and participants fanned into working groups.
That was a kickoff event, however, not a negotiation. C-SPAN spokesman John Cardarelli said that beyond that, "There hasn't been a collaborative effort of coordination of coverage of 'special events.' " The decisions about what to air are made independently on a case-by-case basis, he said.
The Senate Health, Education, Labor and Pensions Committee's bill-writing sessions, which began about three weeks ago, have been open, and various committees and subcommittees have had dozens of public hearings.
The private sessions continue, however.
Four Senate Republicans met for an hour and a half Wednesday to discuss health care with Senate Majority Leader Harry Reid, D-Nev. Separately, Sens. Olympia Snowe, R-Maine, and John Kerry, D-Mass., have been in intense discussions. White House Chief of Staff Rahm Emanuel and Office of Health Reform director Nancy-Ann DeParle are in constant, private contact with key players.
The House of Representatives could vote on a plan before the August recess. The Senate is poised for a longer debate. Assuming they pass differing plans, any final product would emerge from a conference committee, whose negotiations typically offer even less public scrutiny.
Lawmakers, health care interests and public policy experts acknowledge that Obama's campaign vision hasn't exactly come to pass.
"Sometimes for people to say what's really on their mind, it helps to do it outside the public eye," said Senate Finance Committee member Thomas Carper, D-Del. "Could the process be more transparent? I suppose it could be."
The health care negotiations are "no different from any other negotiation over the years when deals are struck quietly," said Sen. Judd Gregg of New Hampshire, the top Republican on the Senate Budget Committee and a member of the health committee.
Some experts said that Obama's decision, once in office, to ask Congress to write the legislation rather than repeat the Clinton administration's failed approach in 1993 of writing its own bill and delivering it to Capitol Hill meant that the president was relinquishing control of how public the process would be.
They said that despite all the private talks involved in this year's effort, it was still far more open than others had been, including the Clinton plan.
"I think it's been as open as it can be given the way things work around here," said William A. Galston, a former policy adviser to President Bill Clinton who's now affiliated with the center-left Brookings Institution, a research center.
In contrast, Galston said, the Clinton health care task force was "a systematically insulated process. We had hundreds of participants on the inside, but it was not a process that was designed to be open to public scrutiny during the actual drafting. What's happened now is significantly more public."
Last month, Baucus and the pharmaceutical industry announced on a Saturday afternoon that they'd reached a deal to cut drug costs for elderly people. The White House gave the talks "its blessing," said Ken Johnson, a senior vice president at the Pharmaceutical Research and Manufacturers of America. "The average person doesn't understand our business model."
Vice President Joe Biden formally announced another deal Wednesday, in which leading hospital groups would accept $155 billion in cuts to government programs. Biden and the hospital executives who flanked him declined to take questions from reporters.
One participant who agreed to talk later, Sister Carol Keehan, the president and CEO of the Catholic Health Association of the United States, said that her group had been in "constant conversation" with policymakers, which had "accelerated in the last month."
In May, two Senate committees, Finance and Commerce, held three days of closed-door meetings to discuss health care legislation. One of the meetings lasted eight hours, and participants said that no agreement was reached on the biggest controversy, a public-insurance option.
Committee members said this week that none of these deals or meetings violated the spirit of transparency.
In a twist, the post-campaign version of Obama's grass-roots group, Organizing for America, now controlled by the Democratic National Committee, sent an e-mail this week to supporters asking them to call their lawmakers and urge them to back Obama's concept of health care restructuring.
"The behind-the-scenes committee negotiations aren't front page news," the e-mail said, but warned that "as we speak, key committees in Congress are weighing options and making final decisions about how to tackle health care reform. This could be one of the last opportunities to shape the legislation before it's written."
(Steven Thomma contributed to this report from L'Aquila, Italy.)