She had to leave Left Coast behind

In the final hours before the House approved the most sweeping healthcare legislation in 40 years, Speaker Nancy Pelosi demonstrated that she had the one indispensable quality required to produce a Democratic victory: a split personality.

Pelosi is a San Francisco liberal who launched a series of fruitless efforts to cut off funding for the Iraq war after becoming speaker nearly three years ago. But long before making her home on the Left Coast, Pelosi was the attentive daughter of an old-school East Coast politician who made whatever deals it took to win. That upbringing proved crucial in the healthcare marathon.

In the fight to get the legislation through the House, Pelosi’s impulse to tilt at windmills disappeared and her pragmatic heritage came to the fore. That’s what enabled Pelosi to build a majority, one compromise at a time, including the pivotal deal with antiabortion Democrats.

The math illustrated the challenge: Democrats hold 258 House seats. But 49 of them are in districts won by Republican John McCain in last year’s presidential election. With 218 votes needed for passage, tinkering with the bill to gain one vote could cost another.

Without the luxury of GOP support, it became clear that the only way to hold Democratic conservatives was to compromise on two issues close to liberals’ hearts.

One was abortion. The other was the government-run insurance plan known as the public option.

Pelosi’s readiness to compromise despite deep personal beliefs was mirrored in her liberal colleagues, who in the end swallowed hard and chose political pragmatism over ideological principle.

With the national spotlight squarely on the House, Pelosi and other Democratic leaders came up against antiabortion members of their own party, who vowed to kill the healthcare bill unless the leadership accepted their uncompromising version of a ban on using federal funds for abortion.

Earlier, Democrats -- who had included what they considered a strict ban in their original proposals -- thought they could work out a modest compromise. But when that effort failed, Pelosi gave way.

She summoned antiabortion Democrats to her ornate Capitol office. She conferred with the U.S. Conference of Catholic Bishops to be sure the new restrictions were acceptable. She even consulted by telephone with a cardinal in Rome.

Then, Pelosi convened the most wrenching meeting of all: to inform the Pro-Choice Caucus, her longtime liberal colleagues, of the deal she had struck.

Pausing only to order in cheeseburgers all around, she revealed that she would allow a floor vote on restrictions that many liberals believed went beyond present law -- which applies mostly to Medicaid recipients and to workers who receive health benefits through the federal government.

The healthcare amendment would, in effect, ban abortion coverage by all insurance plans purchased with taxpayer dollars -- affecting millions more people. As in current law, the amendment includes exceptions for rape, incest or threats to the woman’s life.

Because the amendment would draw substantial support from conservative Democrats, plus near-unanimous support from Republicans, allowing a floor vote was tantamount to guaranteeing that the tougher rules would be part of the final House bill.

Liberals would have to vote for it or lose everything.

The trade-off capsulated Pelosi’s leadership style -- “kid gloves and a hidden stiletto,” one member called it.

The abortion amendment was approved. And for the whole bill -- the most sweeping healthcare legislation since the creation of Medicare in 1965 -- Pelosi got crucial votes from antiabortion Democrats.

In the weeks preceding the landmark vote Saturday, Pelosi ruled her ideologically divided caucus not as a San Francisco liberal but as the daughter of Thomas D’Alesandro Jr., mayor of Baltimore from 1947 to 1959 and before that, a member of Congress.

D’Alesandro oversaw his formidable political machine from his home -- under the eyes of his children. (Pelosi’s brother, Thomas L.J. D’Alesandro III, later served as mayor himself.)

Pelosi, a polarizing figure since her historic election as speaker, has dismal approval ratings nationwide and has been a perennial target for Republicans, who scorned the trillion-dollar healthcare overhaul effort as socialized “PelosiCare” -- at least, when they weren’t calling it “ObamaCare.” But the 69-year-old speaker assumed a role behind closed doors that seemed to come as easily as her on-camera appearances often seemed awkward.

“She counts from the bottom, then she counts from the top. She could lay out any bill like a deck of cards,” said Rep. Louise M. Slaughter (D-N.Y.), an abortion rights advocate, who applauded Pelosi’s performance despite the abortion concession, which she predicted would drive poor women “to the back alley.”

The roots of Pelosi’s conundrum lie in 2006, during the political campaign in which Democrats gained the House majority and made Pelosi speaker. The outcome hinged on recruiting Democratic candidates who could win in red states -- that is, conservatives. Pelosi was one of the architects of that strategy.

But it produced a diverse Democratic majority. The healthcare bill had to appease the party’s progressive base without alienating its conservatives or costing them their seats -- and, potentially, depriving Democrats of their majority.

The public option too had the potential to threaten party conservatives. Liberals insisted on it as a counterweight to insurance companies, but conservative Democrats recoiled. As pressure against it intensified, freshman Rep. Frank M. Kratovil Jr. was hanged in effigy outside his Maryland office.

Eventually, the option was tweaked to make it more palatable to moderates: Rather than paying doctors the Medicare rate plus 5%, the secretary of Health and Human Services would negotiate rates with providers.

Day after day, Pelosi could be seen talking in members’ ears as they gathered on the floor. Any Democrat who wanted a meeting with her got it. In one day alone last week, she called 50 members of her caucus.

“Apparently, she doesn’t sleep or eat,” Slaughter said.

Even Pelosi, who runs on a reservoir of inexhaustible energy, acknowledged that she was wired. “You’ll have to excuse me today, because I had a half a cup of coffee,” she told colleagues at one meeting.

Looking for the magic 218 votes, House leaders assessed the margin of error. There wasn’t any.

On Thursday, Pelosi marched two California holdouts off the House floor and into her private office. There, Democratic Reps. Dennis Cardoza of Atwater and Jim Costa of Fresno got a commitment to address their Central Valley water needs.

Meanwhile, Pelosi swore in a pair of Democrats elected just days earlier -- John Garamendi of California and Bill Owens of New York.

Two more “yeas.”

Earlier, she persuaded Rep. Robert Wexler of Florida to delay leaving Congress for a job with a Washington think tank.

Another “yes” vote.

Not all the issues were small or parochial. To help pay for their plan, Democrats were imposing a surtax on affluent Americans. Rep. Gerald E. Connolly, a Democrat, worried about how his prosperous northern Virginia district would react.

When Connolly first raised the issue, he said, senior Democrats responded, “Vote any way you want; who cares?”

He drafted a letter to Pelosi and gathered signatures from colleagues who shared his worry.

She scaled back the tax.

She even donned an oversize football jersey with “Mean Machine 1” on the front last month and stood in the rain, cheering at a charity football game between members of Congress and Capitol police. Her sights were set on Redskins quarterback turned North Carolina congressman Heath Shuler, an undecided Democrat.

“On something like this, she’s a laser beam,” said Steve Elmendorf, who served as chief of staff under House Democratic Leader Dick Gephardt. “If she has to go to a football game, if she has to fly somewhere, she’s going to do what it takes to win.”

It’s “a mixture of charm and a little bit of intimidation,” said Rep. James P. Moran (D-Va.). “And she never forgets.”

No one was happy with every particular of the final bill. But at a midnight news conference after passage, House Democrats had what most of them thought really mattered: a bill.

Pelosi, her red dress bright against a sea of dark suits, fairly beamed.

“Oh, what a night,” she said.

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faye.fiore@latimes.com

richard.simon@latimes.com

Janet Hook in the Washington bureau contributed to this report.