WASHINGTON — Rarely does the government pull off anything short of war that touches all lives with one act, one stroke of a president's pen. Such a moment arrived Sunday.
After a year of riotous argument, decades of failure and a century of spoiled hopes, the United States is reaching for a system of medical care that extends coverage to nearly all citizens. The change that's coming, after the tussle in the House went President Barack Obama's way, will reshape a sixth of the economy and shatter the status quo.
To the ardent liberal, Obama's health care plan is a shadow of what should have been, sapped by dispiriting downsizing and tradeoffs.
To the loud foe on the right, it is a dreadful expansion of the nanny state.
To history, it is likely to be judged alongside the boldest acts of presidents and Congress in the pantheon of domestic affairs. Think of the guaranteed federal pensions of Social Security, socialized medicine for the old and poor, the civil rights remedies to inequality.
Change is coming, it now appears, but in steps, not overnight. The major expansion of coverage to 30 million people is four years out — powered by subsidies, employer obligations, a mandate for most Americans to carry insurance, new places to buy it and rules barring insurance companies from turning sick people away.
In contrast, on June 30, 1966, after a struggle capped by the bill signing a year earlier, President Lyndon B. Johnson launched government health insurance for the elderly with three simple words, as if flicking a switch: "Medicare begins tomorrow."
Yet Obama and LBJ share a distinction: the only two presidents to succeed with a transcendent health care law.
Obama, a student of history, is probably aware of how LBJ captured the moment when Medicare became law with his pen. That happened in Independence, Mo., in the presence of the first American to sign up for the program: Harry Truman. The ex-president had ended a world war but could not achieve national health insurance in his time.
"Care for the sick, serenity for the fearful," Johnson promised that day. "In this town, and a thousand other towns like it, there are men and women in pain who will now find ease."
Said Truman: "I am glad to have lived this long."
Why is this so hard? In part, because self-reliance and suspicion of a strong central government intruding into people's lives are rooted in the founding of the republic, and still strong, according to historians.
The Colonial insurgents who dumped British tea into Boston Harbor inspired the name and agitating spirit of today's tea party protesters, who rolled a taped-together health care bill up the Capitol steps like toilet paper to show their disdain.
In 1854, President Franklin Pierce vetoed a national mental health bill on the basis that it would be unconstitutional to treat health as anything but a private matter that is none of the government's business.
Seventy-five years later, the American Medical Association denounced proposals for organized medical services as an "incitement to revolution" at the hands of "Medical Soviets."
The AMA's fierce opposition to collectivism included objections to private health insurance, the norm today, and the pooling of doctors into what became health maintenance organizations decades later.
Presidents besides Truman also fell short in trying to achieve national health insurance. Teddy Roosevelt couldn't do it — and he's carved into Mount Rushmore.
Franklin D. Roosevelt rewrote the social compact with his job and retirement security and regulatory expansion during the Depression, then took the nation to war. He made national health insurance a second-tier priority and it eluded him.
Richard Nixon was ready to force businesses to provide health insurance to their workers or pay heavy penalties, but he also failed.
Years after that, Bill Clinton aimed for health care overhaul and crashed.
In the end, Obama triumphed in part because he stood for more than the incremental steps that succeeded in the past, and for less than the towering ideas of the presidents who failed.