House Democrats pass health-care bill
One Republican votes for plan Senate will act next on legislation

By Lori Montgomery and Shailagh Murray
Washington Post Staff Writer
Sunday, November 8, 2009

Hours after President Obama exhorted Democratic lawmakers to "answerthe call of history," the House hit an unprecedented milestone on thepath to health-care reform, approving a trillion-dollar package lateSaturday that seeks to overhaul private insurance practices andguarantee comprehensive and affordable coverage to almost everyAmerican.

After months of acrimonious partisanship, Democrats closed ranks ona 220-215 vote that included 39 defections, mostly from the party'sconservative ranks. But the bill attracted a surprise Republicanconvert: Rep. Anh "Joseph" Caoof Louisiana, who represents the Democratic-leaning district of NewOrleans and had been the target of a last-minute White House lobbyingcampaign. GOP House leaders had predicted their members wouldunanimously 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 chamberof Congress approved such a vast expansion of coverage. Action nowshifts to the Senate, which could spend the rest of the year debatingits version of the health-care overhaul. Majority Leader Harry M. Reid(D-Nev.) hopes to bring a measure to the floor before Thanksgiving, butlegislation may not reach Obama's desk before the new year.

At the Capitol, Obama urged the few Democrats who were stillwavering on Saturday afternoon to put aside their political fears andembrace the bill's ambitious objectives. "Opportunities like this comearound maybe once in a generation," he said afterward. "This is ourmoment to live up to the trust that the American people have placed inus. Even when it's hard. Especially when it's hard. This is our momentto deliver."

The House legislation would for the first time require everyindividual to obtain insurance, and would require all but the smallestemployers to provide coverage to their workers. It would vastly expandMedicaid and create a new marketplace where people could obtain federalsubsidies to buy insurance from private companies or from a newgovernment-run insurance plan.

Though some people would receive no benefits -- including about 6million illegal immigrants, according to congressional estimates -- thebill would virtually close the coverage gap for people who do not haveaccess 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 andsettled into a civil, if predictable, pattern, after a heated start.

Republicans had blasted the 1,990-page bill as an ominous blueprintfor a budget-busting government takeover of the private health-caresystem that would impose unprecedented mandates on individuals andemployers, raise an array of taxes and slash projected spending onMedicare, the federal health program for the elderly. At a time ofrecord budget deficits, Republicans argued that the country couldill-afford a new entitlement program that would cost an estimated $1.05trillion 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 abouttaking a giant first step toward a single-payer national health-caresystem. Washington will ultimately decide what doctors you can see,what treatments you deserve . . . and, when you're sick, will you beworth their cost?"

Throughout the debate, Republican after Republican warned that thelegislation would rob Americans of their right to make choices abouttheir health care, cost the nation jobs and unfairly financially burdenfuture generations.

Pelosi needed to corral at least 218 of 258 Democrats to push thebill across the finish line. That task appeared to grow easier afterparty leaders broke a weeks-long impasse over abortion by agreeing tohold 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, alsowould prohibit people who received insurance subsidies from purchasingprivate plans that covered abortion.

The deal cleared the way for dozens of antiabortion Democrats toback the package. The most passionate advocates of abortion rights werenot happy, but few were prepared to vote down legislation that promisesto achieve so many long-held party goals.

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

For the elderly, the group that has been most skeptical of Obama'sinitiative, the House package would immediately offer discounts onprescription drugs and reduce a gap in Medicare prescription drugcoverage, closing it entirely by 2019. Uninsured people who cannot getcoverage could join temporary high-risk insurance pools, and unemployedworkers would be permitted to keep their COBRA benefits until thepublic 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 offertheir workers insurance or pay a fine of as much as 8 percent ofpayroll. Individuals would be required to obtain insurance or pay afine of as much as 2.5 percent of income. States would be required toextend Medicaid coverage to as many as 15 million additional people.Low- and middle-income individuals who still could not afford coveragecould apply for federal subsidies through an insurance marketplace thatwould negotiate with private insurers to provide comprehensive policiesalongside a government-run "public option."

Congressional budget analysts say the package would cover anadditional 36 million Americans, leaving 18 million people withoutinsurance by 2019, about a third of them illegal immigrants. To avoidincreasing the deficit, Democrats would pay for the coverage expansionby slicing more than $400 billion from Medicare over the next decade,and by imposing a variety of new taxes, primarily a 5.4 percentsurcharge on annual income over $500,000 for individuals and $1 millionfor families. Initially, the tax would hit only 0.3 percent oftaxpayers, but that number would climb rapidly, because the incomethresholds would not be indexed to inflation.

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

The sticking points were clear from the start. Conservatives opposedthe bill's price tag and limited efforts to cut costs. Moderates, whoface the toughest 2010 reelection battles, were wary of big-governmentovertones in the public option. Democrats from wealthy districtsopposed the tax on high earners, which originally would have affectedtaxpayers 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 thestrong objections of about 40 Democrats to a provision in thelegislation that appeared to allow federal funding of abortion. Stupaksaid they would oppose the bill unless the language was changed. Pelosiwas noncommittal.

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

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

In his lunchtime speech to House Democrats, Obama did not touch onany of those issues. But he acknowledged the anxiety felt by lawmakerswho watched independent voters abandon Democratic candidates inVirginia and New Jersey in Tuesday's elections, and he warned thatvoting down the most significant legislation of his young presidencywould only complicate the party's political future.

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