“Unfortunately, we never had a really effective strategy around communicating to the public the benefits and the rationale behind health care reform,” said Ezekiel J. Emanuel, a physician and University of Pennsylvania vice provost who was a top White House adviser involved in developing the program. “We never had a spokesperson, and the public never really understood what we were doing.”…

“No one in history has ever been able to communicate successfully about health care, because it is a deeply personal and polarizing issue and people are therefore afraid of the unknown,” said Dan Pfeiffer, the White House communications director. “We need the law to be fully in effect before the known overtakes the unknown.”…

Either way, health care rose to the fore in part through circumstance. The House passed a climate change bill, but it took deal-making and lobbying that alienated some around Mr. Obama. The White House concluded that the Senate could not pass the climate plan with only Democrats, since some from coal states opposed it. Likewise, Mr. Obama lost Republican cooperation on immigration, leaving health care the most plausible initiative.

“It wasn’t a choice so much as, of the three issues, the only one that had a chance was health care,” said a senior administration official who asked not to be named discussing priorities.