WASHINGTON — Bringing one of the most complex, controversial and elusive public policy goals to the brink of reality, the House of Representatives approved sweeping health care legislation late Sunday after a last-minute push by President Barack Obama to allay concerns over abortion funding.
The $940 billion overhaul, which would affect nearly every American and extend coverage to 32 million people who lack it, passed by only three more votes than the 216 needed.
Not one Republican voted in favor and 34 Democrats joined in dissent. But supporters — including every Florida Democrat — declared it a historic victory, one that has been out of reach for a string of presidents beginning with Theodore Roosevelt.
An exultant Obama, who made the issue his top priority, spoke from the White House East Room shortly before midnight.
"Tonight, at a time when the pundits said it was no longer possible, we rose above the weight of our politics," he said, standing next to Vice President Joe Biden. Obama was to issue an executive order reaffirming existing restrictions on the use of federal funds for abortion.
The House took three major votes Sunday. The first was to approve procedural rules, and the 224-206 vote foreshadowed success. The second, by 219-212, approved the plan passed by the Senate on Christmas Eve. The third vote was to sign off on numerous "fixes" to that legislation.
Obama will sign the Senate bill into law, while the revised language goes to the Senate for passage under streamlined debate rules, called reconciliation, which allow for a simple majority vote and work around a Republican filibuster. Democratic leaders say they have the votes.
Outside the U.S. Capitol, however, was a vivid reminder that the battle is not over. Hundreds of conservative activists kept up their war chant — "kill the bill" — well into the warm spring night. To them, the legislation is a massive government intrusion, one that directly challenges the slogan on the flags they carried — Don't tread on me. Their chants turned into screams as House Speaker Nancy Pelosi, D-Calif., began her closing speech after 10 p.m.: "Vote no. Vote no. Vote no …"
In a sign of solidarity after racial and gay slurs were directed at some lawmakers Saturday, Pelosi led a group of Democrats into the House on Sunday. "We're doing this one for the American people," she said just before debate began at 1 p.m.
The 10 hours that followed brought passionate closing arguments from both sides, months of tension spilling into the chamber for a climactic finish. "There are those who told us to wait, they've told us to be patient," bellowed Rep. John Lewis, D-Ga., his tone and message reminiscent of the civil rights era debates.
"We cannot wait. We cannot be patient," he went on. "On this day, at this hour, stand with the American people and not with the big insurance companies. On this day, at this moment, in this chamber, answer the call of history."
Repeatedly, Republicans assailed the plan as a vast entitlement program underwritten by hundreds of millions in new taxes. "This bill is a fiscal Frankenstein," scoffed Rep. Paul Ryan, R-Wis. Others predicted the public would exact revenge at the ballot box.
"If we pass this bill," said Minority Leader John Boehner of Ohio, "there will be no turning back."
Democrats have cast it as landmark reform, on par with the 1965 creation of Medicare, which Republicans pointed out passed with bipartisan support. Comprehensive health care has been a goal for decades. The last president to take it on, Bill Clinton, saw the issue implode in part because his administration crafted the plan largely out of public view.
Obama left it up to lawmakers to work out the plan, a gambit that nearly collapsed on itself.
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Getting to this point has taken a year of intense, often bitter, debate. It appeared dead two months ago when Massachusetts elected Republican Scott Brown to the U.S. Senate.
Florida is emblematic of the partisan divide. None of the state's 15 Republicans voted for the original House plan in November, while 2 of 10 Democrats joined their dissent, citing cost concerns.
On Sunday, Republicans held their line, while Democrats Suzanne Kosmas of New Smyrna Beach and Allen Boyd of Monticello changed positions and voted yes. Both cited a report from the nonpartisan Congressional Budget Office which said the plan would cut the deficit by $138 billion over a decade and $1.2 trillion in the decade to follow. Critics have questioned those conclusions.
"I know this bill isn't perfect … but seldom are they the first time around," Boyd said, noting it would help 67,000 uninsured people in his district. About 20 percent of Floridians lack insurance.
It remains to be seen how the change will affect re-election efforts for Kosmas and Boyd, who represent districts that favored John McCain over Obama. Democrats were already on the offense, paying for recorded calls Sunday in Tallahassee and elsewhere across Boyd's district that praised him for "standing up to insurance companies."
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Though the Florida lawmakers helped give Democrats momentum, the outcome Sunday was not certain. But a major break came about 4 p.m. when a small coalition of lawmakers concerned over funding of abortions accepted a deal in which Obama would sign an executive order stating no public money shall be used for that purpose.
"While the legislation as written maintains current law, the executive order provides additional safeguards to ensure that the status quo is upheld and enforced, and that the health care legislation's restrictions against the public funding of abortions cannot be circumvented," said White House spokesman Dan Pfeiffer.
That was enough to satisfy the leading critic, Rep. Bart Stupak of Michigan, who appeared with six other Democrats during a news conference minutes after the deal was released.
The National Organization for Women said it was "incensed" by Obama's move, saying he was going against his word as a pro-choice candidate. "The message we have received today is that it is acceptable to negotiate health care on the backs of women, and we couldn't disagree more."
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Some of the most far-reaching aspects of the plan would not go into effect until 2014, such as the mandate that everyone have insurance or pay a fine; the expansion of Medicaid to cover more Americans; and the creation of state-based insurance "exchanges" that small businesses, the self-employed and uninsured could pick plans from. A tax on high-cost insurance plans would be delayed until 2018.
The package also includes items specifically fought for by Florida lawmakers, including hundreds of new medical school residency slots to address a doctor shortage. "It's very important," said Rep. Kathy Castor, D-Tampa, who also worked to include funding for scholarships for people entering the medical field.
One thing it does not include: a provision by Democratic Sen. Bill Nelson to shield 800,000 Floridians from cuts to Medicare Advantage plans. Branded "gator-aid" by critics, it was one of several special deals senators worked into the bill that added to growing unrest over the proposal.
The health care overhaul will play prominently in upcoming Florida elections. Both Republican candidates for U.S. Senate, Marco Rubio and Charlie Crist, have criticized the plan.
Republican Attorney General and candidate for governor Bill McCollum said, if passed, he will file a lawsuit challenging the mandate that people purchase health care insurance.
Times senior correspondent Lucy Morgan contributed to this report. Alex Leary can be reached at firstname.lastname@example.org. Follow him on Twitter at learyspt.