WASHINGTON — A global flu pandemic loomed the very day in 2009 that Kathleen Sebelius took command of Washington's massive health care bureaucracy. She had to marshal a response quickly.
A year later, when a drilling rig exploded in the Gulf of Mexico, she had to deal with the medical fallout from the worst oil spill in U.S. history.
But throughout her two years as the secretary of health and human services, her toughest challenge has been to shoulder the defense — and weather the political blows — of the biggest expansion of America's health care system in half a century.
"I cannot overstate the pressure she was under during the health care debate, yet she handled it with aplomb and the facts," said Democratic Sen. Barbara Boxer of California. "She doesn't engage in hyperbole. She's calm. She reflects the no-drama-Obama kind of approach."
A year after the 10-year, $1.1 trillion overhaul passed without a single Republican vote, it remains a deep and divisive fault line in American politics.
Bridging it seems out of the question. Opposition to "Obamacare" is the price of admission to being taken seriously in Republican circles. Sebelius' critics remain implacable.
"I'm not pleased, frankly, with her performance," said Republican Sen. John Cornyn of Texas, who opposed her nomination. "I think the law is unaffordable, and costs will explode far beyond the preliminary estimates."
The secretary is just as pointed when she talks about the plan by Republicans in the House of Representatives to replace Medicare's guaranteed benefit with set payments to individuals, adjusted for inflation, for them to purchase private insurance.
The nonpartisan Congressional Budget Office has said that the plan, offered by Republican Rep. Paul Ryan of Wisconsin and passed by the House, would shift more health care costs onto seniors. By 2030, they could be on the hook for as much as 70 percent. Supporters of the Ryan plan counter that competition for seniors' health care dollars would reduce the cost of private insurance, thus lowering theirs as well.
At a news conference last week, Sebelius said the GOP plan "would destroy this commitment made 46 years ago to the seniors of this country that they won't go bankrupt based on health care costs. ... The federal government pays 70 percent of the costs of health care for the very members of Congress who voted to flip that on seniors. It's a commitment that they haven't taken on themselves, but they're willing to put on the seniors of this country."
The fight over health care rages on, in the conservative-media sphere, on Capitol Hill and in the courts.
More than two dozen states have challenged the health care law. They contend that the individual mandate, which requires people to purchase insurance or pay a fine, is unconstitutional. Lower court rulings have been mixed so far, and the case is likely to end up before the U.S. Supreme Court.
Congressional Republicans and the party's evolving cast of 2012 presidential hopefuls want to repeal the law.
"The rules and regulations are going to be imposed outside of legislative channels, where you hold people accountable," said Robert Moffit, a senior fellow at the Heritage Foundation, a conservative Washington research center, who served at Sebelius' agency during the Ronald Reagan administration. "Americans correctly believe that they have lost a huge amount of freedom."
Convincing doubters that the Democrats' medicine will be good for them has been difficult. But at 63 and a runner for three decades, Sebelius knows something about endurance.
The former Democratic governor of Kansas, who campaigned around the country for President Barack Obama in 2008, is the front-line defender of what could be his most enduring achievement, or his undoing.
Perhaps her own, as well.
"It fulfills an incredibly important legacy to finally have an opportunity to have health care available and affordable for most Americans and all the children and family services I've believed in and worked on all my life," she said during a recent interview. "I can't imagine at this point being anyplace else."
There are times she probably wishes she were. Her exasperation with the attacks and misinformation — who could ever forget "death panels" — can be abundantly clear.
During a recent hearing before the House Education and the Workforce Committee, Rep. Todd Rokita, a Republican freshman from Indiana, kept pressing Sebelius on when she'd get back to him about a mine safety rule on coal dust. Another Indiana Republican had asked her the same question minutes earlier.
"I can't give you a date certain until I know what it is that we're looking for," Sebelius said. "But I can guarantee you: All of us heard the question four or five times."
"She has been an incredibly good soldier," said Jeffrey Levi, the executive director of the Trust for America's Health, a nonpartisan public-health advocacy group. "She's someone who bears all the criticism and answers all those difficult questions, most of which are being posed not because of substance but because of the politics and trying to score political points."
But Sebelius isn't above playing politics herself.
She was asked at the hearing what the Ryan Medicare plan would mean for a cancer patient.
"People will run out of money very quickly, and if you run out of the government voucher and then you run out of your own money, you're really left to scrape together charity care, go without care, die sooner," Sebelius said.
Critics said she'd inflamed the debate.
Sebelius was mildly contrite: "I certainly didn't mean to suggest that passing the budget made people die sooner. I do think that shifting costs — which is, no doubt, what the plan would do — onto seniors may well leave some people in very difficult situations where they go without care that they may need."
Sebelius wants to see health care restructuring through. That depends, of course, on whether Obama is re-elected, and if so, keeps her on.
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