WASHINGTON — Kathleen Sebelius has been facing down opponents since she was a schoolgirl campaigning for her father — a gregarious, outspoken liberal Democrat in Cincinnati, then one of the most reliably Republican big cities in the nation.
Christopher Gregory/The New York Times
Kathleen Sebelius, the health secretary, in Washington in April. She has been a state legislator and governor in Kansas.
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“My father was routinely called a Communist in Cincinnati,” Ms. Sebelius’s older brother, Donald D. Gilligan, said in an interview. “When he first ran for City Council, Republicans ran ads against him printed on pink paper in The Cincinnati Enquirer. Kathleen was used to being called bad names from childhood on. When your father is being called a Communist, you take a measured view of that kind of criticism.”
Now, Ms. Sebelius, 65, the secretary of health and human services, is the No. 1 public advocate for the health care law, the president’s top domestic initiative, and, just like her father, an easy target for Republicans.
Her job is to deliver health insurance to more than 25 million people, to nudge the nation toward a new era in which health care is a right, not a privilege — all this over the opposition of Republicans in Congress and in many state capitols, who are poised to pounce on any misstep.
Ms. Sebelius is on the defensive more than ever now that the White House has delayed a major provision of the law that requires larger employers to offer health insurance to full-time employees. Republicans say she has given a far too rosy picture of progress in carrying out the law. And they are demanding that she explain why people should be required to carry insurance next year if employers are not required to offer it.
In her zeal to make the health care law work, Ms. Sebelius has tested the limits of her authority. After Congress refused to provide as much as she wanted for a nationwide campaign publicizing the new insurance options, she shuffled money between government accounts and sought cash from outside groups.
Her actions have riled Republicans like Senator Lamar Alexander of Tennessee, a former governor and cabinet secretary who complained that Ms. Sebelius was circumventing Congress in possible violation of federal law.
She is defending herself and her fund-raising activities, even as she defends the law.
Ms. Sebelius gets high marks from Democrats for standing up to Republican pressure — what Representative John F. Tierney, Democrat of Massachusetts, described as “an unrelenting effort to delegitimize the law day in and day out.”
Her father, John J. Gilligan, served one term in Congress — the historic 89th Congress, which created Medicare and Medicaid in 1965. He lost his bid for re-election to Robert Taft Jr., scion of a powerful Republican family based in Cincinnati. Mr. Gilligan, an early opponent of the Vietnam War, was elected governor of Ohio in 1970, but narrowly lost a bid for re-election after he secured passage of the state’s first income tax.
“There’s a lot of her father in Kathleen,” said Mark Shields, the political commentator, who has known the family for more than 40 years, since he managed Mr. Gilligan’s unsuccessful campaign for the United States Senate in 1968.
Ms. Sebelius’s role as health secretary is larger than expected. In passing the health care law, Congress assumed that each state would set up its own regulated insurance marketplace, or exchange. But more than half the states have balked, leaving the job to federal officials.
The law greatly expands federal authority over health insurance, but Ms. Sebelius said that as a former state official, she recognized the vital role of states and had tried to give them flexibility.
Instead of defining a uniform national set of “essential health benefits,” she has allowed each state to specify the benefits that must be provided in 10 broad categories. She is working with states like Arkansas that do not want to expand the traditional Medicaid program but would like to use federal Medicaid money to subsidize the purchase of private insurance instead.
And she agreed to an unorthodox arrangement under which Utah would run an exchange for small businesses while the federal government would run a separate exchange offering insurance to individuals.
“She realizes that you need to work with each state on an individual basis because we are all different,” said Gov. Steven L. Beshear of Kentucky, a Democrat. “Her door has always been open.”
Still, Ms. Sebelius said she did not anticipate the concerted, continuing opposition to the law. Recent public opinion polls showed that the law is no more popular today than when it was enacted in 2010.
As secretary, Ms. Sebelius also supervises the world’s largest biomedical research enterprise and runs Medicare and Medicaid, which provide health insurance to one in three Americans. She signed up for Medicare’s hospital insurance coverage in May, when she turned 65. She stays in shape by running about four miles a day, four or five days a week.
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After marrying the son of a Republican congressman from Kansas in 1974, Ms. Sebelius moved to the state and quickly rose in Kansas politics, winning four terms as a state legislator, two as state insurance commissioner and two as governor.
As a state official, she worked with moderate Republicans on education, health care and other issues. When she ran for governor in 2002 and 2006, her running mates were Republicans who switched parties just before joining her ticket as candidates for lieutenant governor.
In Washington, by contrast, her relations with Republicans are cool to nonexistent.
“I’ve never really talked to her,” said John Barrasso of Wyoming, the chairman of the Senate Republican Policy Committee and a point man for the party on health care. “I’ve said hello to her and shaken her hand, but have never had a discussion with her.”
Representative Michael C. Burgess, Republican of Texas and chairman of the Congressional Health Care Caucus, said: “Secretary Sebelius is operating with a fortress mentality. She goes out of her way not to interact with members of the governing majority in the House.”
Some of the skills she honed in Topeka have worked less well in Washington.
In Kansas, she was a prodigious fund-raiser, and she increased her influence by distributing money to other candidates through a political action committee. As health secretary, she touched off a political furor when she tried to raise money for Enroll America, a private nonprofit group working with the White House to cover the uninsured.
Ms. Sebelius has less autonomy than when she was governor. But she is pursuing many of the same goals with the same discipline and determination.
“She has always been a gifted politician,” said Kent L. Glasscock, a moderate Republican and a former speaker of the Kansas House of Representatives. “Very few people have her ability to blend policy and politics. She is intent and focused, always has a plan, and is relentless.”
Her instincts were on display in 2011 when she overruled the Food and Drug Administration and blocked over-the-counter sales of emergency contraceptives to girls under age 17.
A federal district judge found that Ms. Sebelius had put politics ahead of science. “The secretary’s action was politically motivated, scientifically unjustified, and contrary to agency precedent,” said the judge, Edward R. Korman of the Eastern District of New York, in Brooklyn.
Republicans have long outnumbered Democrats in Kansas, but the state has taken a sharp right turn.
Sandy Praeger, the Kansas insurance commissioner and a friend of Ms. Sebelius, is trying to carry out many provisions of the health care law, despite the opposition of Gov. Sam Brownback.
Asked if a visit by Ms. Sebelius would help, Ms. Praeger said: “It wouldn’t do a bit of good. It would probably hurt.”
Ellen M. Gilligan, the secretary’s sister, said Ms. Sebelius was not discouraged because “she takes the long view,” beyond the nasty politics and personal attacks, and had been imbued with “social justice values” at home and in Catholic schools.
“The nuns and their social values had a tremendous impact on all of us,” Ms. Gilligan said.