In a victory for President Obama, the Democratic-controlled House narrowly passed landmark health care legislation Saturday night to expand coverage to tens of millions who lack it and place tough new restrictions on the insurance industry. Republican opposition was nearly unanimous.
The 220-215 vote cleared the way for the Senate to begin a long-delayed debate on the issue that has come to overshadow all others in Congress.
A triumphant Speaker Nancy Pelosi likened the legislation to the passage of Social Security in 1935 and Medicare 30 years later -- and Obama issued a statement saying, "I look forward to signing it into law by the end of the year."
"It provides coverage for 96 percent of Americans. It offers everyone, regardless of health or income, the peace of mind that comes from knowing they will have access to affordable health care when they need it," said Rep. John Dingell, the 83-year-old Michigan lawmaker who has introduced national health insurance in every Congress since succeeding his father in 1955.
In the run-up to a final vote, conservatives from the two political parties joined forces to impose tough new restrictions on abortion coverage in insurance policies to be sold to many individuals and small groups. They prevailed on a roll call of 240-194.
Ironically, that only solidified support for the legislation, clearing the way for conservative Democrats to vote for it.
The legislation would require most Americans to carry insurance and provide federal subsidies to those who otherwise could not afford it. Large companies would have to offer coverage to their employees. Both consumers and companies would be slapped with penalties if they defied the government's mandates.
Insurance industry practices such as denying coverage on the basis of pre-existing medical conditions would be banned, and insurers would no longer be able to charge higher premiums on the basis of gender or medical history. In a further slap, the industry would lose its exemption from federal antitrust restrictions on price fixing and market allocation.
At its core, the measure would create a federally regulated marketplace where consumers could shop for coverage. In the bill's most controversial provision, the government would sell insurance, although the Congressional Budget Office forecasts that premiums for it would be more expensive than for policies sold by private firms.
A cheer went up from the Democratic side of the House when the bill gained 218 votes, a majority. Moments later, Democrats counted down the final seconds of the voting period in unison, and let loose an even louder roar when Pelosi grabbed the gavel and declared, "the bill is passed."
The bill drew the votes of 219 Democrats and Rep. Joseph Cao, a first-term Republican who holds an overwhelmingly Democratic seat in New Orleans. Opposed were 176 Republicans and 39 Democrats.
From the Senate, Majority Leader Harry Reid of Nevada issued a statement saying, "We realize the strong will for reform that exists, and we are energized that we stand closer than ever to reforming our broken health insurance system."
In his written statement, Obama praised the House's action and said, "now the United State Senate must follow suit and pass its version of the legislation. I am absolutely confident it will."
Shortly after the bill's passage, the president sent out an e-mail solicitation asking for donations to the Organizing for America, saying "the coming days will put our efforts to the ultimate test. Winning will require each of us to give everything we can, starting right now."
Nearly unanimous in their opposition, minority Republicans cataloged their objections across hours of debate on the 1,990-page, $1.2 trillion legislation.
“This was a difficult decision; one that I have struggled with for months. But at the most basic level, my support for this bill is based on my strong belief that we literally cannot afford to leave this challenge unaddressed," Rep. Brad Ellsworth, D-Ind., said.
United in opposition, minority Republicans cataloged their objections across hours of debate on the 1,990-page, $1.2 trillion legislation.
"We are going to have a complete government takeover of our health care system faster than you can say, `this is making me sick,"' jabbed Rep. Candice Miller, R-Mich., adding that Democrats were intent on passing "a jobs-killing, tax-hiking, deficit-exploding" bill.
But with little doubt about the outcome, the rhetoric lacked the fire of last summer's town hall meetings, when some critics accused Democrats of plotting "death panels" to hasten the demise of senior citizens.
The bill is projected to expand coverage to 36 million uninsured, resulting in 96 percent of the nation's eligible population having insurance.
To pay for the expansion of coverage, the bill cuts Medicare's projected spending by more than $400 billion over a decade. It also imposes a tax surcharge of 5.4 percent on income over $500,000 in the case of individuals and $1 million for families.
The bill was estimated to reduce federal deficits by about $104 billion over a decade, although it lacked two of the key cost-cutting provisions under consideration in the Senate, and its longer-term impact on government red ink was far from clear.
Democrats lined up a range of outside groups behind their legislation, none more important than the AARP, whose support promises political cover against the cuts to Medicare in next year's congressional elections.
The nation's drug companies generally support health care overhaul. And while the powerful insurance industry opposed the legislation, it did so quietly, and the result was that Republicans could not count on the type of advertising campaign that might have peeled away skittish Democrats in swing districts.
Over all, the bill envisioned the most sweeping set of changes to the health care system in more than a generation, and Democrats said it marked the culmination of a campaign that Harry Truman began when he sat in the White House 60 years ago.
Debate on the House floor had already begun when Obama strode into a closed-door meeting of the Democratic rank and file across the street from the Capitol to make a final personal appeal to them to pass his top domestic priority.
Later, in an appearance at the White House, he said he had told lawmakers, "to rise to this moment. Answer the call of history, and vote yes for health insurance reform for America."
It appeared that a compromise brokered Friday night on the volatile issue of abortion had finally secured the votes needed to pass the legislation.
As drafted, the measure denied the use of federal subsidies to purchase abortion coverage in policies sold by private insurers in the new insurance exchange, except in cases of incest, rape or when the life of the mother was in danger.
But abortion foes won far stronger restrictions that would rule out abortion coverage except in those three categories in any government-sold plan. It would also ban abortion coverage in any private plan purchased by consumers receiving federal subsidies.
Disappointed Democratic abortion rights supporters grumbled about the turn of events, but pulled back quickly from any thought of opposing the health care bill in protest.
One, Rep. Jan Schakowsky, D-Ill., detailed numerous other benefits for women in the bill, including free medical preventive services and better prescription drug coverage under Medicare. "Women need health care reform," she concluded in remarks on the House floor.
A Republican alternative was rejected on a near party line vote of 258-176.
It relied heavily on loosening regulations on private insurers to reduce costs for those who currently have insurance, in some cases by as much as 10 percent. But congressional budget analysts said the plan would make no dent in the ranks of the uninsured, an assessment that highlighted the difference in priorities between the two political parties.
The Associated Press contributed to this report.