WASHINGTON — The House of Representatives Saturday passed, by a vote of 220 to 215, historic health care legislation that would require virtually all Americans to obtain health insurance and create a government-run health insurance plan to help them do so.
If passed by the Senate, the bill would bring about the most sweeping change in the American health care system since Medicare was created 44 years ago.
Supporters of the measure burst into cheers and applause on the House floor as it became clear the measure had won, but the vote was excruciatingly close, just two more than the bare minimum needed. One Republican, Joseph Cao of Louisiana, voted for the bill; 39 Democrats voted against.
President Barack Obama made a personal plea for passage before the all-day debate began.
"Now is the time to finish the job," Obama said in brief remarks in the White House Rose Garden after meeting with House Democrats.
The job is far from finished. The Senate hopes to act by the end of the year, and if successful, the two Houses would then craft a compromise that would need approval of each chamber.
The House vote came with a warning: Getting enough votes later this year or early in 2010 will not be easy. Thirty-nine Democrats, most from conservative districts or freshmen who narrowly won their 2008 elections, voted against the House bill, joining 176 Republicans. In the Senate, eight to 12 moderates have expressed reservations about that chamber's proposal.
In addition to creating the so-called public option government run insurance program, the House-passed bill would bar insurers from denying people coverage because of pre-existing conditions and set up health care "exchanges," or marketplaces, where consumers could easily shop for coverage.
The changes are expected to mean that by 2019, 96 percent of eligible Americans would have health insurance, up from the current 83 percent.
During his half hour appearance on Capitol Hill Saturday, Obama took no questions from lawmakers, but his presence was a vivid reminder that the president has put health care overhaul at the top of his domestic agenda — a change that has eluded presidents for nearly a century.
"He came here to say, 'This is what we said we would do in the campaign. Let's do it,' " said House Majority Leader Steny Hoyer, D-Md.
On the House floor, Democratic leaders appealed to members' sense of history, reminding them this was one of the most significant votes, short of war, that they were likely to take.
"There are few moments when we have the opportunity to do so much good with one vote. This is one of those moments," said Majority Leader Steny Hoyer, D-Md.
Republicans countered with arguments that the health care plan did little to improve coverage or affordability.
"Astoundingly, Democrats are bringing to the floor a bill today that will not reduce the costs of health insurance, it will grow the size of government," said GOP Conference Chairman Mike Pence, R-Ind..
Democratic leaders said that they doubted Obama changed many votes, but "the energy he brought to this debate will be helpful," said Majority Whip Jim Clyburn, D-S.C.
A bigger boost may have come from a deal to bar coverage by government-subsidized insurance policies of elective abortions.
As originally written, the measure would have required insurers to separate public and private money, so that only private funds could be used for elective abortions. Abortion opponents were concerned that such a policy would effectively expand the government's role in improving access to abortion, and as many as 40 Democrats threatened to withhold support from the health care bill unless changes were made.
After tense negotiations Friday night — with White House officials and representatives of the U.S. Conference of Catholic Bishops as well as key Democratic members of Congress — House Democratic leaders agreed to allow a vote Saturday on sweeping changes to the abortion provision.
The measure was approved, 240 to 194, as 64 Democrats joined 176 Republicans to back the change.
The change would permit abortion coverage for people receiving federal aid for their insurance only in the case of rape or incest or where the mother's life is endangered. That change is consistent with a 1970s-era federal law governing public funding of abortion.
Under the new provision, only people buying private insurance with their own funds would have an elective abortion covered.
Many abortion rights advocates were angry, and the brief debate often pitted Democrat against Democrat.. "This amendment is government interference in the decision between a woman and her physician," said Rep. Lois Capps, D-Calif. "Unnecessary and reprehensible," added Rep. Nita Lowey, D-N.Y.
"Today we're on the brink of passing health care reform that honors and respects life in every state," countered Rep. Brad Ellsworth, D-Ind.
With that agreement, House Democratic leaders were assured they would get the 218 votes needed to pass. Democrats control 258 seats.
Republicans tried throughout the day to create more doubt and delay, loudly shouting objections to routine parliamentary requests by objecting when Democratic women tried to discuss their concerns on the House floor.
GOP members then pushed their own plan, which would make it easier for small businesses to band together to purchase competitively-priced coverage, allow consumers to buy policies across state lines, and effect strong medical malpractice reforms.
It was easily defeated on a largely party line vote, 258 to 176.
The bigger obstacle for Democrats was fellow Democrats, as dozens of members continued to express reservations about the bill.
Some were freshmen elected by slim margins in conservative districts.
Rep. Walt Minnick, D-Idaho, wanted to see more cost-cutting. "Unfortunately, the new health-care bill in the House does not adequately meet those goals, so I will vote 'no.' " he said.
Some were veteran members of the Blue Dog Coalition, a group of 52 Democratic conservatives. Many objected to the bill's price tag and worried it would increase the federal deficit.
"The House bill misses a critical opportunity to address access, quality and costs on the one hand, and solidify our fiscal future on the other hand," said Rep. Stephanie Herseth Sandlin, D-S.D.
The nonpartisan Congressional Budget Office estimated the bill's net cost would total $891 billion over 10 years and reduce the deficit by $109 billion. But many Democrats were wary.
"While the Congressional Budget Office predicts this bill is paid for over 10 years, there is no mechanism in the bill to force spending cuts if those complicated projections turn out to be wrong," said Rep. Chet Edwards, D-Texas.
But enough Blue Dogs and freshmen backed the leadership — which was stressing how the bill could be changed later — that passage seemed likely.
In the Senate, where moderates' concerns have stalled progress, Democratic leaders are hoping for a debate and vote before the end of the year.
"My vote is not an endorsement of all the provisions of the bill, because I find much of the bill to be deeply flawed," said Rep. Jim Cooper, D-Tenn., a Blue Dog who backed the measure. "My reason for voting 'yes' is to advance the cause of health care reform by forcing the Senate to act."
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