Hours after President Obama exhorted Democratic lawmakers to "answer the call of history," the House hit an unprecedented milestone on the path to health-care reform, approving a trillion-dollar package late Saturday that seeks to overhaul private insurance practices and guarantee comprehensive and affordable coverage to almost every American.

After months of acrimonious partisanship, Democrats closed ranks on a 220-215 vote that included 39 defections, mostly from the party's conservative ranks. But the bill attracted a surprise Republican convert: Rep. Anh "Joseph" Cao of Louisiana, who represents the Democratic-leaning district of New Orleans and had been the target of a last-minute White House lobbying campaign. GOP House leaders had predicted their members would unanimously oppose the bill.

Democrats have sought for decades to provide universal health care, but not since the 1965 passage of Medicare and Medicaid has a chamber of Congress approved such a vast expansion of coverage. Action now shifts to the Senate, which could spend the rest of the year debating its version of the health-care overhaul. Majority Leader Harry M. Reid (D-Nev.) hopes to bring a measure to the floor before Thanksgiving, but legislation may not reach Obama's desk before the new year.

At the Capitol, Obama urged the few Democrats who were still wavering on Saturday afternoon to put aside their political fears and embrace the bill's ambitious objectives. "Opportunities like this come around maybe once in a generation," he said afterward. "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. This is our moment to deliver."

The House legislation would for the first time require every individual to obtain insurance, and would require all but the smallest employers to provide coverage to their workers. It would vastly expand Medicaid and create a new marketplace where people could obtain federal subsidies to buy insurance from private companies or from a new government-run insurance plan.

Though some people would receive no benefits -- including about 6 million illegal immigrants, according to congressional estimates -- the bill would virtually close the coverage gap for people who do not have access to health-care coverage through their jobs.

"For generations, the American people have called for affordable, quality health care for their families," House Speaker Nancy Pelosi (D-Calif.) said before the vote. "Today, the call will be answered."

The debate on the House floor extended for about 12 hours and settled into a civil, if predictable, pattern, after a heated start.

Republicans had blasted the 1,990-page bill as an ominous blueprint for a budget-busting government takeover of the private health-care system that would impose unprecedented mandates on individuals and employers, raise an array of taxes and slash projected spending on Medicare, the federal health program for the elderly. At a time of record budget deficits, Republicans argued that the country could ill-afford a new entitlement program that would cost an estimated $1.05 trillion over the next decade.

"Big government doesn't mean better health care," said Rep. Kevin Brady (R-Tex.). "This is not the reform families need. This is all about taking a giant first step toward a single-payer national health-care system. Washington will ultimately decide what doctors you can see, what treatments you deserve . . . and, when you're sick, will you be worth their cost?"

Throughout the debate, Republican after Republican warned that the legislation would rob Americans of their right to make choices about their health care, cost the nation jobs and unfairly financially burden future generations.

Pelosi needed to corral at least 218 of 258 Democrats to push the bill across the finish line. That task appeared to grow easier after party leaders broke a weeks-long impasse over abortion by agreeing to hold a vote on an amendment -- offered by antiabortion Democrats -- that would explicitly bar the public plan from` covering the procedure. The amendment, approved 240 to 194, with 64 Democrats in favor, also would prohibit people who received insurance subsidies from purchasing private plans that covered abortion.

The deal cleared the way for dozens of antiabortion Democrats to back the package. The most passionate advocates of abortion rights were not happy, but few were prepared to vote down legislation that promises to achieve so many long-held party goals.

The House bill

The complex package would affect virtually every American and fundamentally alter vast swaths of the health insurance industry. Starting next year, private insurers could no longer deny anyone coverage based on preexisting conditions, place lifetime limits on coverage or abandon people when they become ill. Insurers would be required to disclose and justify proposed premium increases to regulators, and could not remove adult children younger than 27 from their parents' family policies.

For the elderly, the group that has been most skeptical of Obama's initiative, the House package would immediately offer discounts on prescription drugs and reduce a gap in Medicare prescription drug coverage, closing it entirely by 2019. Uninsured people who cannot get coverage could join temporary high-risk insurance pools, and unemployed workers would be permitted to keep their COBRA benefits until the public plan and insurance exchanges started in 2013.

In four years, the measure would establish a new insurance system. Businesses with payrolls exceeding $500,000 would be required to offer their workers insurance or pay a fine of as much as 8 percent of payroll. Individuals would be required to obtain insurance or pay a fine of as much as 2.5 percent of income. States would be required to extend Medicaid coverage to as many as 15 million additional people. Low- and middle-income individuals who still could not afford coverage could apply for federal subsidies through an insurance marketplace that would negotiate with private insurers to provide comprehensive policies alongside a government-run "public option."

Congressional budget analysts say the package would cover an additional 36 million Americans, leaving 18 million people without insurance by 2019, about a third of them illegal immigrants. To avoid increasing the deficit, Democrats would pay for the coverage expansion by slicing more than $400 billion from Medicare over the next decade, and by imposing a variety of new taxes, primarily a 5.4 percent surcharge on annual income over $500,000 for individuals and $1 million for families. Initially, the tax would hit only 0.3 percent of taxpayers, but that number would climb rapidly, because the income thresholds would not be indexed to inflation.

Obstacles overcome

Introduced on July 14, the House package was approved in sections by three House committees. Since August, Pelosi has huddled behind closed doors with various factions of her diverse caucus to merge the three parts into comprehensive legislation.

The sticking points were clear from the start. Conservatives opposed the bill's price tag and limited efforts to cut costs. Moderates, who face the toughest 2010 reelection battles, were wary of big-government overtones in the public option. Democrats from wealthy districts opposed the tax on high earners, which originally would have affected taxpayers with annual incomes as low as $280,000.

One after another, the obstacles were overcome -- except for the simmering dispute over abortion. In early October, Rep. Bart Stupak, an antiabortion Democrat from Michigan, met with Pelosi to express the strong objections of about 40 Democrats to a provision in the legislation that appeared to allow federal funding of abortion. Stupak said they would oppose the bill unless the language was changed. Pelosi was noncommittal.

Late Friday, the Stupak coalition was still holding strong, and had gained a powerful ally in the U.S. Conference of Catholic Bishops, whose leadership has close connections to Pelosi. Over the strong objections of Democrats who support abortion rights, the speaker relented to Stupak, awarding him the only Democratic amendment on the floor.

The Senate bill

Attention will now shift back to the Senate. If the Senate acts, negotiations to iron out differences between the two chambers could be wrenching. Among the toughest issues: whether the public option should include an "opt out" clause for states, as Reid has proposed; whether to require employers to provide coverage to their workers or take the less punitive approach preferred by Senate moderates; and whether to tax the rich or tax high-cost health-care policies, as the Senate proposed -- a provision economists call the most important provisions in either bill for reining in costs.

In his lunchtime speech to House Democrats, Obama did not touch on any of those issues. But he acknowledged the anxiety felt by lawmakers who watched independent voters abandon Democratic candidates in Virginia and New Jersey in Tuesday's elections, and he warned that voting down the most significant legislation of his young presidency would only complicate the party's political future.

"If you think the Republicans are not going to go after you if you vote no," the president said, according to several people present, "think again."

www.washingtonpost.com/wp-dyn/content/article/2009/11/07/AR2009110701504_pf.html