Ending the Democrats' decades-long quest to create a healthcare safety net to match Social Security, the House of Representatives on Sunday night approved sweeping legislation to guarantee Americans access to medical care for the first time, delivering President Obama the biggest victory of his young presidency.
The bill, which passed 219 to 212 without a single Republican vote, would make a nearly $1-trillion commitment in taxpayer money over the next decade to help an estimated 32 million uninsured Americans get health coverage.
On the House floor, Democrats erupted into cheers of "Yes, we can!" at 10:45 p.m. Eastern time as the decisive 216th "yes" vote was recorded, capping a tortuous campaign that several senior lawmakers linked to the historic battle for civil rights two generations earlier.
"This is the Civil Rights Act of the 21st century," said Democratic Rep. James E. Clyburn of South Carolina, the top-ranking black member of the House.
Thirty-four Democrats, most from Republican-leaning districts, voted against the main legislation approving the blueprint for healthcare.
Rep. Pete Sessions (R- Texas), chairman of the National Republican Congressional Committee, promised that GOP candidates would turn the 2010 midterm elections into a referendum on healthcare. "We will run on a promise of repeal," he said.
Many Republicans say the overhaul will drive the nation deeper into debt at a time when it is still struggling to recover from recession.
But after a final flurry of negotiating defused an intraparty dispute over abortion and locked down the last votes, Democratic lawmakers, some of whom have spent decades in Congress pushing for universal health coverage, were celebrating the payoff of a monumental gamble.
Obama and his congressional allies succeeded in pushing through the most sweeping piece of social legislation since the 1965 Medicare bill, despite a crippling recession and an increasingly angry electorate.
Now, Democrats must steer a package of fixes to the healthcare bill through the Senate by using the arcane budget reconciliation process.
The maneuver allows Senate Democrats to skirt a GOP filibuster and pass the package with only 51 votes rather than 60. But if Republicans succeed in making any changes to the package on the Senate floor -- as Democratic officials acknowledge is possible -- the House would have to take another healthcare vote.
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"This will be one of those events that every textbook writer is going to have to put in his books," said presidential scholar William Leuchtenburg, author of Franklin D. Roosevelt and the New Deal.
After more than a year of debate, including heated summer town-hall meetings and an icy winter summit between Obama and Republicans, Democrats had to go it alone.
"It's not the desirable way to enact major social policy, but it might be the only way," said Robert Reischauer, president of the nonpartisan Urban Institute and a former Congressional Budget Office director.
Polls continue to show Americans split down the middle on the issue, and both sides claim momentum.
Nearly lost in Sunday's focus on protests, process and politics was the stunning array of new federal policies included in the legislation. Dingell, 83, who succeeded his father in the House 55 years ago, called it a natural successor to Medicare.
"We were solving an enormous problem, the health concerns of the elderly in this country," he said of that vote 45 years ago. "Today, we are doing what we intended to be the second step, and that is addressing the health concerns and the health problems of all of the people. Unfortunately, it's been a very slow national progression."
The package of changes would provide coverage to 32 million people through Medicaid, subsidies to families and tax credits to small businesses that can't afford to cover their workers. It would pay for the expansion with the Medicare cuts, new taxes on upper-income workers and expensive insurance plans, and fees on the manufacturers of prescription drugs and medical devices.
It also would prohibit insurers from denying coverage based on pre-existing conditions, dropping people when they get sick and limiting lifetime benefits. Children could be covered on their parents' policies up to age 26, and seniors would receive improved coverage for Medicare prescription drugs. Most individuals would be required to have insurance, and businesses with 50 or more employees would have to provide it or pay a fee.
Faced with all those provisions and more, Washington's lobbying industry has weighed in with full force. The number of corporations, trade associations and other organizations that disclosed their efforts on health care grew from 398 during the first months of 2009 to 1,541 by the end of the year. Health professionals and health insurers spent more than $576 million on lobbying, up from $515 million in 2008 and $210 million a decade ago.
In the end, most stakeholders endorsed Obama's plan, including major trade groups representing doctors, hospitals, pharmaceutical companies and the AARP, the nation's largest seniors' organization. Two groups — the U.S. Chamber of Commerce and America's Health Insurance Plans — opposed it with multimillion dollar ad campaigns.
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Not everyone was cheering the new law.
Attorneys general from 13 states filed suit to stop the overhaul just minutes after the bill signing, contending the law is unconstitutional. Florida Attorney General Bill McCollum took the lead in the lawsuit, joined by colleagues from South Carolina, Nebraska, Texas, Michigan, Utah, Pennsylvania, Alabama, South Dakota, Louisiana, Idaho, Washington and Colorado. Other GOP attorneys general may join the lawsuit later or sue separately.
In Washington, Republicans remained firm in their opposition to the giant remake of the nation's health system, declaring it much too costly and unlikely to produce the results that Obama claims. The Republicans pledged to see Democrats punished in this fall's elections for approving the legislation over deep public skepticism.
"By signing this bill, President Obama is abandoning our founding principle that government governs best when it governs closest to the people," said House Minority Leader John Boehner, R-Ohio. "Never before has such a monumental change to our government been carried out without the support of both parties. This debate has fostered unprecedented division at a time when this nation needs to come together and address the serious challenges we face."
With that in mind, and with many of the law's most sweeping changes not to take effect for years, Obama emphasized the overhaul's most immediate impacts, including the ability of young adults to remain on their parents' health plans and a ban on insurers denying coverage to sick children.
"We have now just enshrined the core principle that everybody should have some basic security when it comes to their health," the president said.
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