WASHINGTON -- A monumental overhaul of the nation's health insurance system passed the House last night, in a vote that split Western Pennsylvania Democrats.
The final tally was a razor-thin 220-215 in favor of passage, a victory for House Speaker Nancy Pelosi -- who spent the past few days furiously drumming up votes -- and President Barack Obama, who made health care reform his chief domestic priority.
The focus now turns to the Senate, where debate on health care reform could last weeks or months.
The House bill would reform insurance practices, expand Medicaid and provide subsidies for those who cannot afford their own insurance -- resulting in insurance coverage for an estimated 96 percent of Americans. Those who do not have health coverage through their employer would enter the health insurance exchange, where customers would have their choice of plans -- including a government-run "public option."
The bill's opponents decried its length (about 2,000 pages), its cuts to Medicare (about $500 billion) and, in their minds, its potential to lead to government-run health care for all -- a claim Democrats vehemently denied.
Over the next decade, the Congressional Budget Office said, the bill would reduce the deficit by $30 billion. But Republicans pointed out that the costly provisions of the bill do not kick in until 2013, while it starts collecting revenue in 2010. It also does not include increases in payments to doctors under Medicare, a $210 billion "doc fix" that will be voted on as separate legislation.
Blue Dog Democrats Jason Altmire, of McCandless, and Kathy Dahlkemper, of Erie, voted no and yes, respectively, after refusing to reveal their intentions prior to the vote.
Mr. Altmire said he informed the Democratic leadership of his final choice yesterday morning because his district wasn't behind the bill.
His primary concerns were related to cost containment and a tax on small businesses that do not provide employee health insurance. Though those issues improved as the bill progressed from committees to the floor, Mr. Altmire said they still did not meet his goals to rein in health care costs.
"I think we can do better and I want to do better and I want to be a part of the process going forward," he said.
Both Mr. Altmire and Ms. Dahlkemper expressed concerns about abortion language, a debate settled with the passage of an amendment authored by Rep. Bart Stupak, D-Mich., that explicitly forbids people who receive government subsidies to purchase insurance plans that cover abortions. Also, the public option will not offer abortion coverage.
Ms. Dahlkemper said the fact that the anti-abortion caucus stuck together was crucial to forcing the abortion language into the bill, and she would work to keep it in a potential conference with the Senate.
Once that hurdle cleared, Ms. Dahlkemper said she was prepared to vote for the bill, and she circled the floor seeking autographs on her copy of the massive legislation.
"There was a lot of energy all day long on the floor," Ms. Dahlkemper said. "As the final vote count came in and once it hit that 218 and the final passage, it was an incredible moment."
Among other members in the Western Pennsylvania delegation, Reps. Mike Doyle, D-Forest Hills, and John Murtha, D-Johnstown, voted for the bill. Reps. Tim Murphy, R-Upper St. Clair, Bill Shuster, R-Blair, and Glenn Thompson, R-Centre, voted no -- part of a near united Republican front against the bill.
One lone Republican, Joseph Cao, from Louisiana, voted in favor of the bill.
"I see this as a bill that hurts Medicare patients," Mr. Murphy said. "I think it continues to spend massively at a time when we're losing jobs and the government's going into massive debt. It does not directly address what was the stated purpose from Obama and others -- which was to save money."
Mr. Doyle was a lead negotiator on the abortion compromise, helping secure a floor vote for the Stupak amendment -- which Ms. Dahlkemper joined as a co-sponsor -- and the blessing of the U.S. Conference of Catholic Bishops, which endorsed the amendment and the goals of health care reform.
The amendment passed, 240-194, with Republicans' overwhelming support.
Mr. Doyle -- who was pacing and looking anxious during the Stupak vote, afraid that Republicans would abandon it at the last minute -- said the bishops' letter was crucial.
"I don't know that we pass a bill without it," Mr. Doyle said.
Capitol Hill was a frenzy of activity yesterday, with both sides acknowledging the high stakes of the bill.
The debate began under the gavel of Rep. John Dingell, D-Mich., the longest-serving member of Congress, who also presided over the passage of Medicare in 1965. His well-worn gavel was frequently employed during the fiery floor debate, reflecting the rancorous rhetoric that has consumed the issue.
Anti-abortion activists outside the Capitol held up gruesome signs depicting aborted fetuses, and several hundred gathered to chant "Kill the Bill" at an afternoon rally -- a smaller sequel to Thursday's "tea party" protest.
Across the street, Mr. Obama rallied House Democrats in a 30-minute speech in the Cannon House Office Building, pressing the historic importance of moving the bill.
Republicans, claiming the bill's tax increases would harm the middle class, offered a cheaper alternative that would reform medical malpractice lawsuits and break down state barriers to insurance sales. It did not make the structural reforms to the insurance industry that the Democratic bill did, and failed in a floor vote last night.
The Republicans followed with a motion to insert medical malpractice reform into the bill, and that failed as well.
Democratic leaders, who were skittish about whether they would have the votes as the weekend neared, gradually expressed more confidence as the day wore on.
Rep. Joe Sestak, D-Delaware County, a strong proponent of reform who is running against Sen. Arlen Specter, D-Pa., for his seat next year, said Democrats were three or four votes short in the afternoon. Then about an hour before the vote, Mr. Sestak said he received word that the bill would pass.
"This was one of those times when this was morally the right thing to do, and it's also an economic necessity," Mr. Sestak said.
At 11:07, culminating a rare Saturday night session of the House, the vote tally hit 218, prompting a loud cheer from the left side of the floor and the packed spectators' galleries. As Ms. Pelosi left the floor, her Democratic members rose in a standing ovation.
"It's kind of rare moments in history when we have those kind of evenings," Mr. Doyle said.
Daniel Malloy can be reached at firstname.lastname@example.org or 202-445-9980. Follow him on Twitter at PG_in_DC.