Late one summer afternoon, I met my brother Rahm—then the White House chief of staff—in his West Wing office. We chatted, and then he asked in his usual staccato, “What else is going on, Zeke?”

“I’m also working on the medical malpractice proposal I told you about,” I began.

He immediately cut me off: “Shut the f— up! We are not doing malpractice. Period. Every time the AMA comes in here, they don’t talk about malpractice.” Their first, second and third priority, he said, was the formula used by Medicare to determine doctors’ pay. “We don’t need to do malpractice for the doctors, and I am not alienating the president’s base for nothing,” he barked. “Stop it.”

Rahm’s reaction told me everything that I needed to know about the politics of the issue. Democrats would accept malpractice reform under two circumstances: if they needed it to keep the AMA’s support for the bill, or if they needed it to attract Republican support. Neither was true. In backroom negotiations, the AMA was solely focused on securing higher physician payments—not on malpractice. And not a single Republican in Congress would even negotiate.

The president had already aggravated liberals by forgoing a “public option.” He’d offended unions by limiting the tax exclusion. He wasn’t going to antagonize trial lawyers, another core Democratic constituency, for no gain.