TOPEKA, Kan. — In Kansas, Gov. Kathleen Sebelius is known as a Democrat who can deal with Republicans, a necessity in a state where the opposition party dominates both houses of the Legislature.
But on matters of health policy, which she will oversee if she is confirmed as President Obama’s secretary of health and human services, Ms. Sebelius’s efforts to forge bipartisan consensus have rarely succeeded. She recently observed that the greatest frustration of her six years in office had been her inability to persuade lawmakers to raise tobacco taxes for a modest expansion of government health coverage.
Now, with the backing of a Democratic Congress, Ms. Sebelius will have a chance to achieve in Washington what she failed to accomplish in Topeka, and then some. When he announces her nomination on Monday, Mr. Obama will effectively make her the point person for what may become the largest expansion of taxpayer-subsidized health insurance in more than four decades.
Ms. Sebelius, 60, would start the job in midstream. Last week, while she was battling with the Legislature over its desire to allow a pair of coal-fired power plants in western Kansas, Mr. Obama began his effort to revamp American health care by telling Congress that change “will not wait another year.”
Mr. Obama then proposed to raise taxes on the wealthiest Americans to help pay for a $634 billion investment in expanded government health coverage over 10 years. His efforts are complicated by the recession, which is draining the Medicare trust fund more quickly than expected, according to federal officials.
Ms. Sebelius’s nomination comes nearly a month after Mr. Obama’s first choice, former Senator Tom Daschle, withdrew upon revealing that he had owed $128,000 in back taxes and paid it only after being selected. The White House used the time not only to vet Ms. Sebelius, but also to make sure that the two Republican senators from Kansas, Sam Brownback and Pat Roberts, would not oppose her confirmation.
The governor is a Roman Catholic who supports abortion rights, and her vetoes of anti-abortion measures have drawn derision from social conservatives, including a request by the archbishop of Kansas City that she not take communion. Her spokeswoman declined an interview request for the governor, saying her schedule would not permit it.
Ms. Sebelius is said to have a wonkish understanding of health policy, but she has failed to make significant improvements in health coverage or costs during her two terms as governor. Although the proportion of Kansans who are uninsured remains well below the national average — 12.7 percent versus 15.3 percent — it has grown seven times as fast in the state than in the nation during her tenure, according to census figures.
Health insurance premiums in Kansas rank just below the national average and have increased at about the same rate as the nation’s, according to figures compiled by the federal Agency for Healthcare Research and Quality. The same was true during the previous eight years, when Ms. Sebelius served as state insurance commissioner.
In that job, Ms. Sebelius cast herself as a consumer champion by pushing to protect patients from rationed care by health maintenance organizations and rapid discharges by hospitals. She declined campaign contributions from the industry she regulated and, in her boldest move, rejected the 2002 purchase of the state’s largest insurer, Blue Cross and Blue Shield of Kansas, by Anthem Inc., based in Indianapolis.
No other state insurance commissioner had blocked such a sale, but Ms. Sebelius argued that it would result in higher premiums for Kansans. Litigation ensued, and she ultimately was upheld by the State Supreme Court.
“She rode that decision all the way to the governor’s office,” said Sandy Praeger, the current insurance commissioner and a Republican.
Legislators in both parties said that as governor, Ms. Sebelius’s efforts to reach across the aisle had seemed more strategic than instinctually bipartisan. She is skilled at exploiting the divisions between moderate and conservative Republicans, and has successfully forged coalitions with one caucus or the other on redistricting, school financing and the state budget, among other issues.
When she stood for re-election in 2006, she persuaded a former state Republican chairman, Mark Parkinson, to join her ticket as a Democrat (he will succeed her if she is confirmed for the cabinet position).
But when it comes to health care, the governor and the Legislature have been separated by a philosophical gulf, with Ms. Sebelius supporting a larger government role and the Republicans steadfastly resisting it.
“Both her proposals and her accomplishments have been limited to some extent by the political realities of the state that she governs,” said Dr. Robert F. St. Peter, president of the Kansas Health Institute, a research foundation.
In 2004, her second year in office, Ms. Sebelius proposed expanding the state’s low Medicaid thresholds to cover 70,000 of the state’s 300,000 or so uninsured, and to pay for it by raising tobacco taxes. The measure died.
The next year, she issued an executive order creating a new health policy agency that would centralize purchasing and planning in her office. The Legislature blocked the move, and instead created an agency controlled by legislative appointees. Ms. Sebelius went along.
In her 2007 State of the State address, Ms. Sebelius urged lawmakers to “commit ourselves to universal coverage.” Though she said little about how to achieve that, Republicans tarred her as an advocate of “socialized medicine” — or “Hillarycare,” as Melvin Neufeld, who was House speaker at the time, put it.
Ms. Sebelius, a former state representative, called on the Legislature to begin by covering all children up to age 5. Again, she made little headway, though in 2008, an election year, the Republicans expanded eligibility for the State Children’s Health Insurance Program without appropriating any money to do so.
Although she signed the bill, which also made a modest expansion of Medicaid for pregnant women, she called it the session’s biggest disappointment. She had also failed to win approval of a statewide indoor smoking ban.
“It has been something that I find puzzling and troubling and not a lot different from what’s happened in Congress and with the administration,” she said in a December interview with the Kansas Health Institute News Service.
Legislative leaders say Ms. Sebelius presses her case in occasional meetings and news conferences, but rarely cajoles or twists arms.
“I see her in the hall and say hello, and that’s it,” said State Representative Brenda K. Landwehr, a conservative Republican who heads the Health and Human Services Committee. “She’s never asked me to visit with her. I think she’s a very strong individual, that things are either done her way or the highway, with little room for compromise.”
The daughter of an Ohio governor, John Gilligan, and daughter-in-law of a Kansas congressman, Ms. Sebelius herself appears healthy and fit. She and her husband, Gary, a federal magistrate judge, have been married for 34 years and have two sons. She played basketball in college, runs three miles nearly every day and does not smoke. By all accounts, she remains popular in Kansas, scoring a 57 percent approval rating in one January poll.
Because the possibilities for change here have been so narrow, there is little sense of Ms. Sebelius’s views on broad questions like whether Americans should be required to have health insurance or whether, as Mr. Daschle proposed, health policy should be delegated to a board styled after the Federal Reserve.
As secretary, Ms. Sebelius would have considerable influence over government policy on abortion. Although she says she personally opposes abortion, she has consistently defended abortion rights in a state where the anti-abortion movement can be fierce. She has vetoed anti-abortion measures almost every year, including bills that would have required the licensing of abortion clinics and allowed relatives to petition a court to stop a late-term abortion.
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