BY CARL HULSE and ROBERT PEAR
The New Yok Times
Handing President Obama a hard-fought victory, the House narrowly approved a sweeping overhaul of the nation’s health care system on Saturday, advancing legislation that the Democrats said could be their defining social policy achievement.
After a daylong clash with Republicans over what has been a Democratic goal for decades, lawmakers voted 220 to 215 to approve a plan that would cost $1.1 trillion over 10 years and that Democrats said would provide relief to Americans struggling to buy or hold on to health insurance.
“This is our moment to revolutionize health care in this country,” said Representative George Miller, Democrat of California and one of the chief architects of the bill.
Democrats were forced to make major concessions on insurance coverage for abortions to attract the final votes to secure passage, a wrenching compromise for the numerous abortion-rights advocates in their ranks. They hope to make changes to that amendment during negotiations with the Senate, which will now become the main battleground in the health care fight as Democrats there ready their own bill for what is likely to be extensive floor debate.
Democrats say the measure — paid for through new fees and taxes, along with cuts in Medicare — would extend coverage to 36 million people now without insurance and would create a government health insurance program. It would end insurance company practices like not covering pre-existing conditions or dropping people when they become ill.
The successful vote came after Mr. Obama traveled to Capitol Hill just before noon Saturday to make a personal appeal for lawmakers to “answer the call of history” and support the bill.
Only one Republican, Representative Anh Cao of Louisiana, voted for the bill, and 39 Democrats opposed it. The House also defeated the Republicans’ more modest plan, whose authors said it was a more common-sense and fiscally responsible approach.
Many Democrats in more conservative districts balked at the measure, signaling that those who could be vulnerable in next year’s midterm elections viewed voting for the measure as politically risky.
“Today’s may be a tough vote, but it was in 1935 when we passed Social Security,” Representative John Dingell, Democrat of Michigan and the dean of the House, said as the debate drew to a close late Saturday.
Some Democrats said they voted for the legislation so they could seek improvements in it. “This bill will get better in the Senate,” said Representative Jim Cooper, a Tennessee Democrat who has been outspokenly critical of some provisions of the bill but decided to support it. “If we kill it here, it won’t have a chance to get better.”
House approval moves the bill well beyond the health care overhaul attempted by President Bill Clinton in 1993. Lawmakers credited Mr. Obama with converting a final few holdouts during his appearance at a closed-door meeting with Democrats just hours before the vote.
A handful of remaining undecided lawmakers swung behind the proposal. And slightly more than 30 House Democrats were publicly lined up in opposition — not enough to deny the party a victory on one of the president’s top domestic initiatives, unless their ranks swelled by 10.
Another turning point was the decision by Speaker Nancy Pelosi late Friday night to allow anti-abortion Democrats to try to tighten restrictions on coverage for the procedure under any insurance plan that receives federal money. That concession eased a threat by some Democrats to abandon the bill, but also left Democrats who support abortion rights facing a choice between backing a provision they bitterly opposed or scuttling the bill. The new abortion controls were added to the measure on a vote of 240 to 194.
Mr. Obama made a rare weekend appearance on Capitol Hill as part of an all-out effort to rally Democrats to support the biggest health care legislation since the creation of Medicare for the elderly four decades ago.
During the private meeting with Democrats in the Cannon Caucus Room, the president acknowledged the political difficulty of supporting major legislation in the face of unanimous Republican opposition and tough criticism from conservatives.
But, those present said, he urged them on, saying, “When I sign this in the Rose Garden, each and every one of you will be able to look back and say, ‘This was my finest moment in politics.’ ”
Republicans and said the measure was too costly and would end up burdening the nation for decades to come. Some Democrats expressed the same view in explaining their opposition.
“This bill is a wrecking ball to the entire economy,” said Representative Jack Kingston, Republican of Georgia. “ We need targeted specific reforms to help people who have fallen through the health care cracks.”
But Democrats said that Republicans were intent on protecting the status quo in health care and that the new Democratic approach would vastly improve the ability of Americans to gain affordable health insurance.
“Now is the chance to fix our health care system and improve the lives of millions of Americans,” Representative Louise M. Slaughter, Democrat of New York and chairwoman of the Rules Committee, said as she opened the daylong proceedings.
In remarks later Saturday from the Rose Garden, Mr. Obama continued to ask lawmakers to press ahead with the legislation. “I urge members of Congress to rise to this moment,” he said. “Answer the call of history and vote yes for health insurance reform for America.”
The wall of Republican opposition gave Democrats little room to maneuver, and they were working to corral as many party members as they could. But the preliminary approval to clear the way for the debate came on a vote of 242-192, suggesting that Democrats had a victory within reach.
The difficult issue of how much to restrict new federal spending on abortion continued to complicate the outcome by creating a split between Democratic supporters and opponents of abortion rights and loomed as one last obstacle.
Unable to reach an agreement on compromise language on abortion coverage, House leaders decided to allow a vote on tight restrictions that would prohibit federal money from being used to pay for abortions, either through a new federal health insurance plan or under private plans that enroll people relying on federal subsidies.
“From Day 1, my goal has been to ensure federal tax dollars are not used to pay for abortions,” said Representative Brad Ellsworth, Democrat of Indiana and one of the authors of the abortion provision.
But the restrictions were assailed by Democrats who support abortion rights. Several Democrats said they expected those lawmakers to go along grudgingly with the anti-abortion proposal in the hope of changing it during later negotiations with the Senate.
The looming House vote was a significant step in the long-sought Democratic goal of enacting broad changes in the way health care is delivered in the nation. But the Senate has yet to bring its own emerging measure to the floor for debate, and should both the House and the Senate advance a measure, they will still need to negotiate and approve a final bill in the weeks ahead.
The struggle House Democrats had in lining up the minimum number of votes for the measure was a clear indication of how difficult it would be to get final legislation to the president’s desk.
The House legislation, running almost 2,000 pages, would require most Americans to obtain health insurance or face penalties — an approach Republicans compared to government oppression.
Most employers would have to provide coverage or pay a tax penalty of up to 8 percent of their payroll. The bill would significantly expand Medicaid and would offer subsidies to help moderate-income people buy insurance from private companies or from a new government insurance plan. It would also set up a national insurance exchange where people could shop for coverage.
Republicans planned to force a House vote on a much more modest plan that would expand coverage to just three million of the uninsured. But its authors said it would bring down the costs of private insurance premiums, which they said was the chief concern of most Americans.
“More taxes, more spending and more government is not the plan for reform the people support,” said Representative Virginia Foxx, Republican of North Carolina and one of the conservatives who relentlessly criticized the Democrats’ plan.
But Democrats said their proposal was long overdue, would relieve the mounting anxiety of Americans struggling to get and retain health insurance, and would ultimately improve the national economy by bringing spiraling health care costs under control.
“Our plan is not perfect, but it is a good start toward providing affordable health care to all Americans,” said Representative Peter A. DeFazio, Democrat of Oregon.
Among the final changes Democrats agreed to was using the measure to repeal a federal antitrust exemption for health insurance companies.
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