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House Passes Health Care Overhaul Bill

By Alex Wayne, CQ Staff

November 7, 2009 -- The most ambitious overhaul of the U.S. health care system in 40 years squeaked through the House late Saturday, allowing President Obama to win a preliminary round in what could still be a long battle for his top domestic priority.

The 220–215 vote for the trillion-dollar effort to extend health coverage to millions of Americans who currently lack it capped a long debate during which a soporific tone belied the tension within the majority Democratic caucus.

Democratic supporters of the legislation counted down the seconds as time expired on the final roll call vote. But despite the best efforts of the president and party leaders, 39 Democrats voted against the bill.

Things could have been worse for the Democrats, who had expected Republicans to offer a motion to add more restrictive immigration language to the bill—perhaps making it unacceptable to members of the Democrats' Hispanic Caucus.

The only Republican to back the measure was freshman Anh "Joseph" Cao of Louisiana, who won cheers from House Democrats when he cast his "yea" vote despite a last-minute plea at the back of the chamber from Minority Whip Eric Cantor, R-Va.

Passage of the measure (HR 3962) proved far more difficult than Obama and House leaders expected following the Democratic election sweep of 2008. It took months longer than they had hoped, making it increasingly doubtful Congress will send a final bill to the White House by year's end. Indeed, it is not clear the Senate will be able to pass its version before the first session comes to an end shortly before Christmas—let alone reach agreement with the House in conference.

Senate Majority Leader Harry Reid, D-Nev., said after the House vote that he looks forward to Senate floor action as soon as possible.

Democrats hailed the House vote as historic, with Speaker Nancy Pelosi, D-Calif., likening the achievement to the creation of Medicare in 1965. "For generations, the American people have called for affordable, quality health care for their families. Today that call will be answered," she said.

The bill, she declared, "improves quality, lowers costs and expands coverage to 36 million more people."

When Obama first called for enactment of a health care overhaul, he called for bipartisanship. The White House reached out to multiple elements of the health care industry, striking deals with many of them on key provisions of the bill.

But Republicans complained they were never given a voice in drafting the legislation. Minority Leader John A. Boehner, R-Ohio, and his allies repeatedly denounced the Democrats' legislation as a "jobs killer" and the prelude to a government takeover of the U.S. health care system.

"The American people have spoken and they've made it perfectly clear that the health care bill that's on the floor today, they want no part of," Boehner said. "We're going to do everything we can to try to stop this from becoming law and urge the Speaker to work with us in a bipartisan way to enact common sense, step-by-step reform to make health insurance more affordable for more Americans."

Pelosi was frequently targeted by Republicans during the heated debate on the legislation. But Democrats credited the Speaker with quarterbacking them to victory.

Majority Leader Steny H. Hoyer, D-Md., jokingly hailed a "bipartisan victory" and touted the work of Majority Whip James E. Clyburn, D-S.C., whose job it is to keep the diverse Democratic caucus moving in one direction. Clyburn said he believes the health care debate brought Democratic factions closer together.

"For all of those who have been assaulting me in the hallway and asking me if we had the votes. the answer is 'yes,' " Hoyer said.

Pelosi paid special tribute to John D. Dingell, D-Mich., who like his father before him has championed universal health care throughout his 54-year House career. Dingell presided as the House debated the rule governing consideration of the bill, just as he wielded the gavel 40 years ago when the House considered the Medicare bill.

Pelosi also hailed the late Sen. Edward M. Kennedy, D-Mass., whose drive to achieve health coverage for all Americans equaled Dingell's.

Getting to 'Yes'
Obama went to Capitol Hill late Saturday morning to make a final pitch for the bill. He warned Democrats that their election opponents next year would assail them no matter how they voted, and he urged them to support the bill.

Hoyer acknowledged that the measure doesn't please everyone. "It isn't a simple bill. It isn't a perfect bill. But it is the product of months and months of careful debate, sometimes animated debate, yes, even angry debate, careful scrutiny, hard work and citizen input. It's the right response to this time of economic insecurity in which we have been called to lead," he said.

Many of those who voted against the legislation, despite the appeals of the White House and their leadership, represent conservative districts whose voters are deeply suspicious of government activism.

Among them were freshmen such as Frank Kratovil Jr. of Maryland and John Adler of New Jersey. Kratovil captured a GOP seat in a district that gave Arizona Republican Sen. John McCain a double-digit lead over Barack Obama in 2008, making him one of the Republicans' top targets in next year's midterm elections. Adler also is counted as a vulnerable Democrat, after his narrow win last year in a longtime Republican district.

To cobble together the 218 Democratic votes they needed to pass the bill, Pelosi and her leadership team were forced to permit lawmakers opposed to abortion rights led by Bart Stupak, D-Mich., to offer an amendment that essentially would extend an existing ban on federal funding for abortion to the health care bill.

Stupak's amendment was adopted by 240-194, as 64 Democrats joined 176 Republicans. If the provision becomes law, insurers selling plans through a new "exchange," or marketplace, including a government-run public option, could not offer policies covering elective abortion to people who receive federal subsidies for their premiums.

Abortion-rights supporters were distinctly unhappy about that development and but ultimately swallowed hard and many voted for the amended bill. "We've got a lot of work to do. We hope the conferees will do something about it," said abortion rights supporter Lois Capps, D-Calif.

The Democrats were unified in rejecting a Republican substitute amendment to their bill that was offered by Boehner. That measure, which failed on a 176 to 258 vote, would have made only minimal changes to the current health care system, potentially extending coverage to only about3 million of the 54 million people who would be uninsured by 2019, according to Congressional Budget Office estimates.

Republicans made a more targeted effort to sink the Democratic bill with a motion to recommit the package and amend it to change the medical malpractice liability system, including caps on damages in lawsuits. The $54 billion the motion is estimated to save over 10 years would be used to increase spending on the Medicare Advantage program that would see cuts under the Democrat's measure.

But that effort was easily turned aside, 187-247, with only 13 Democrats voting for the GOP motion.

Key Provisions
The bill would require most individuals to buy health insurance if they don't get it through their jobs, beginning in 2013. Families with incomes up to 400 percent of the federal poverty level could qualify for financial assistance. Employers with annual payrolls over $500,000 would be required to provide coverage or contribute to a fund for such coverage. It would create an "exchange" in each state where individuals and certain small businesses could shop for insurance policies, and it would create a public insurance plan to compete with offerings from private companies.

Insurance companies could no longer refuse to cover customers with pre-existing medical conditions, impose annual or lifetime benefit limits or cancel a policy when someone files expensive claims.

The measure also would expand eligibility for Medicaid to individuals and families with incomes up to 150 percent of the poverty level.

Payments under the Medicare Advantage program would be reduced and the Medicare prescription drug program would be enhanced by phasing out a coverage gap.

The bill would impose a tax surcharge of 5.4 percent on couples with gross incomes of more than $1 million and individuals with incomes of more than $500,000, and a 2.5 percent excise tax on the sale or lease of medical devices.

The Congressional Budget Office estimates that the gross cost of the bill would be almost $1.1 trillion through fiscal 2019, but the net cost, after taxes, fees and penalties are taken into account, would be $894 billion. As a result of tax provisions and spending reductions in the bill, it would actually reduce the deficit by $104 billion, CBO estimates.

Leah Nylen contributed to this story.

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