"In the end, the economic team never had a chance: The president had already made up his mind, according to a White House official who spoke on the condition of anonymity in order to be candid. Obama wanted his health policy team - led by Nancy-Ann DeParle, director of the White House Office of Health Reform - to be in charge of the law's arduous implementation. Since the day the bill became law, the official said, the president believed that "if you were to design a person in the lab to implement health care, it would be Nancy-Ann."

They were running the biggest start-up in the world, and they didn't have anyone who had run a start-up, or even run a business," said David Cutler, a Harvard professor and health adviser to Obama's 2008 campaign, who was not the individual who provided the memo to The Washington Post but confirmed he was the author. "It's very hard to think of a situation where the people best at getting legislation passed are best at implementing it. They are a different set of skills."