If anyone could make or break President Barack Obama's health care agenda, it might be Karen Ignagni.
The Democratic former union official and firefighter's daughter is also the unlikely face of the powerful health insurance industry as its top Washington lobbyist.
Ignagni is such a formidable advocate that when she went head to head with industry-bashing filmmaker Michael Moore on the Oprah Winfrey show, she emerged not only unscathed, but with Moore seconding some of her points.
Now, with the prospect of a congressional health care overhaul looming, Ignagni's role is more important than ever. It's a moment she's long prepared for.
Ignagni and her board at America's Health Insurance Plans foresaw three years ago that 2009 could be a year that health care would top the agenda, and they decided to craft a plan.
Fleshing out their proposal
For months, Ignagni has been fleshing out their proposal bit by bit at congressional hearings, ensuring maximum attention.
The plan would achieve Obama's goal of universal health coverage through a regulated insurance market. Insurers would agree to significant concessions such as not charging more to people with pre-existing conditions. In return, they want to quash a government-run insurance plan that Obama supports, but that Ignagni fears would put private insurers out of business.
Although Congress may not embrace all her proposals, Ignagni can claim notable success in positioning her industry as an ally of health care change, not its enemy. That's a 180-degree turnaround from where the industry was during the health care wars of the Clinton years.
Not only are health insurers at the table, they're sometimes driving the debate, as with the White House announcement this month that the health industry would cut its own costs by $2 trillion to further Obama's cause. Ignagni was a key architect.
"She's gifted at anticipating what issues are likely to be," said George Halvorson, chairman of the Kaiser Foundation Health Plan and AHIP's immediate past board chairman. He credited Ignagni with orchestrating the board's preparation for the health care debate.
"The fact that we sat down and wrestled with all of the issues on underwriting and so forth was genius on her part," Halvorson said.
But as publicly constructive as the insurance industry's role has been so far, a giant question mark remains: What will Ignagni do if Congress does produce a bill she doesn't like? Will her group try to kill it, resurrecting "Harry and Louise"-style attack ads that proved so devastating during the Clinton years? That could doom Obama's health care goals.
Liberals fear the wrecking ball
Liberals fear AHIP is already preparing the wrecking ball. Ignagni refuses to say how they'll respond to an unfavorable bill.
"We're how many weeks away from seeing whatever is proposed? So no responsible person could answer a question like that," Ignagni, 55, said in an interview.
"The people who are working on this issue, even in areas where we have differences, are very thoughtful, have the right objectives, and we have a long history of working with them," she added. "So we're going to give them the courtesy of thoughtfully responding to what they propose."
Ignagni didn't work for the insurance group that produced the "Harry and Louise" commercials. Indeed the man most responsible for them, Chip Kahn, who's now at the Federation of American Hospitals, went up against Ignagni when their two insurance lobbies merged in 2003, and she beat him out for her current job. Kahn declined to comment for this story.
"Whatever AHIP pays her, it's not enough. She's unbelievably effective," said Princeton economist Uwe Reinhardt. "It's just amazing what she's achieved for them against all odds."
Ignagni's total compensation, according to AHIP's most recent filing from 2007, was $1.58 million, which includes $700,000 in base salary, $370,000 in deferred compensation and a bonus. Ignagni won't say how many hours a week she works. The number's so high it's embarrassing, she said.
Private insurance plans
Among successes cited by Reinhardt and others is helping persuade the Bush administration to develop private insurance plans within Medicare that are producing unexpectedly high payments for private insurers.
When Congress was considering expanding a children's health insurance program in 2007 by taking money from the private Medicare Advantage plans, Ignagni worked successfully to stop it.
Those private plans are being targeted again by Obama, who wants to squeeze them to pay for his health care agenda. Ignagni's industry group is organizing older people to defend the plans.
A front group called the Coalition for Medicare Choices has a Web site inviting older people to share their stories about Medicare Advantage. The fine print gives AHIP the right to use that information however it wants.
Ignagni's job isn't easy. AHIP's board consists of chief executives of top insurers and Ignagni has to bring them to consensus in order to make her moves. People who work with her say she does it by listening hard and being well-informed, respectful and prepared.
"She's always on her game and knows her substance," said Tom Scully, a former Medicare administrator. "Health insurance CEOs come and go, but Karen has been a constant."