House Speaker Nancy Pelosi, with Majority Whip James E. Clyburn, left, and Rep. George Miller (D-Martinez) after the vote, rallied her party for months.
resident Barack Obama stands with House Majority Whip James Clyburn, Rep. Joe Crowley, House Speaker Nancy Pelosi, House Majority Leader Steny Hoyer, Rep. Xavier Becerra and Rep. John Larson after a caucus meeting on Capitol Hill on Saturday.
House Majority Whip James Clyburn, President Barack Obama and Rep. John Larson leave after a caucus meeting on Capitol Hill. Obama spoke with members of the House Democratic Caucus about health care reform legislation.
President Barack Obama speaks about health care reform in the Rose Garden of the White House on Saturday.
President Barack Obama waves as he walks out of the Caucus Room with House Majority Whip James E. Clyburn, House Speaker Nancy Pelosi, House Majority Leader Steny Hoyer, Congressman John Larson and other leaders after a meeting on health care reform on Capitol Hill.
House Speaker Nancy Pelosi is joined by Majority Leader Steny Hoyer (left) and Rep. George Miller after the vote.
President Obama and House Speaker Nancy Pelosi achieved a stupendous - but still incomplete - victory Saturday, winning House passage of the biggest expansion of health care coverage since Medicare's creation in 1964, in the face of nearly unanimous Republican opposition.
As a matter of policy and politics, the 10-year, $1.05 trillion legislation, which passed 220-215 late Saturday night, is among the most complex and difficult Congress has ever considered. Enactment would prove the signal achievement of Pelosi's speakership. Success or failure will define Obama's presidency. In the hours before the vote, Obama traveled to Capitol Hill to urge fellow Democrats to answer a "call to history" and fulfill last year's voter mandate for change.
"This bill is change that the American people urgently need," Obama said Saturday in a Rose Garden speech. "This is their moment, this is our moment to live up to the trust that the American people have placed in us - even when it's hard; especially when it's hard."
Yet for all its significance, House passage would be but one step along a path to a White House signing ceremony that remains fraught with uncertainty. Senate action has stalled, and if it restarts, a long debate could widen already deep differences between the two chambers over new taxes and mandates on individuals to buy coverage and employers to offer it.
The House bill promises to expand coverage to 96 percent of Americans, but many key provisions, including a new insurance exchange where those without insurance could choose between a government option or private plans, would not take effect until 2013, after next year's midterm elections and after the 2012 presidential election.
In the interim, those denied insurance due to pre-existing conditions would have access to a government-subsidized high-risk pool. A potentially unpopular requirement that individuals buy insurance would also not begin until 2013.
Complex changes
Part of the delay is due to the complexity of implementing changes to a $2.6 trillion industry that consumes $1 of every $6 Americans spend; part is due to budget maneuvering that delays expenditures to meet Obama's pledge not to add to the burgeoning federal deficit within a 10-year budget window.
Pelosi spent months in tense negotiations to knit together the wide ideological spectrum of her caucus, from Bay Area liberals who insisted on a public option to moderate Democrats from GOP-leaning districts wary of rising deficits. Moderates succeeded in watering down the public option by untethering it from Medicare, and won a 240-194 vote on an amendment to expand a ban on public funds being used for abortion. Liberals accepted the amendment rather than bring down the entire bill.
Rep. Pete Stark, D-Fremont, a longtime advocate of a single-payer system run by the government, spoke to the House accompanied by his two young children, Hannah and Andrew. "At my age, I've learned to take what you can, when you can get it," he said.
Pelosi could afford to lose up to 40 Democrats and still prevail, and for some members from very conservative districts a yes vote would have been political suicide.
Rep. Mike Thompson, a moderate Blue Dog Democrat from St. Helena, said his constituents are divided, with about 60 percent for the bill, 30 percent against it and about 10 percent wanting a single-payer system.
Asked if he's gotten any complaints from constituents, Thompson said, "I've been getting blowback for 19 years about the health care system we have. I've been working my entire time in elected office trying to fix it."
Republicans - who led a "tea party" protest at the Capitol on Thursday - blasted the bill as a "job killer" filled with new taxes and mandates, the wrong prescription for the economy when the national unemployment rate is more than 10 percent.
GOP alternative
Waiting until a week before the vote, Republicans offered a much slimmer alternative that would barely expand coverage, but would seek to lower premiums through market-based mechanisms such as allowing insurance companies to sell policies across state lines.
Just one Republican voted for the Democrats' bill, Anh "Joseph" Cao, a Vietnam immigrant from Louisiana. All but Cao continued a GOP boycott of the Obama agenda that began with last fall's $787 billion fiscal stimulus. Republicans hope to tap growing displeasure with federal deficits and unemployment among independent voters, who last week handed the GOP big gubernatorial victories in Virginia and New Jersey.
The health care bill meets a key test of reducing deficits under Congressional Budget Office guidelines, through a combination of a 2.6 percent surtax on individuals earning more than $500,000 a year and cuts to private insurance companies under the Medicare Advantage program, along with reduced payments to doctors and hospitals. Democrats removed a $210 billion increase in payments to doctors and hospitals to achieve what many experts believe is a phantom budget neutrality.
Pilot programs
Experts also believe the legislation is too timid in its attempts, mainly limited to pilot programs, to attack the rise in overall health care costs that is driving premiums skyward. A notable exception is a provision Pelosi granted to Rep. Ron Kind, D-Wis., that could force changes to the fee-for-service payment method that rewards physicians for the quantity of services they deliver, a major factor in rising costs.
Democrats emphasized coverage expansions and the new security promised to millions whose employment-based coverage is threatened by rising premiums. The legislation would also impose new regulations on insurance companies, banning such practices as cancellation of policies when people get sick, and strip the industry of its antitrust exemption.
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