WASHINGTON - President Barack Obama and House Democratic leaders struck a last-minute deal Sunday with abortion foes to secure the final few votes needed to remake America's health care system, writing a climactic chapter in a century-old quest for near universal coverage.
The House argued its way through a thicket of Republican objections toward an evening vote on the bill to extend coverage to 32 million Americans who lack it, ban insurers from denying coverage on the basis of pre-existing medical conditions and cut deficits by an estimated $138 billion over a decade.
Passage of a central health care bill already cleared by the Senate would send it to Obama for his signature. That still would leave one more step, a companion package of changes that would go to the Senate.
In the first of three showdown votes Sunday, a "rule" to establish guidelines for the ensuing health care debate was approved by a 224-206 margin. That indicated the Democratic leadership had the votes for later approving the Senate-passed bill and then the fix-it bill. Its passage would set up a final showdown in the Senate in the days ahead, where Majority Leader Harry Reid says at least 50 votes are in hand for its final approval under a fast-track procedure known as reconciliation.
The stakes could not have been higher for Obama's presidency. Obama has made health care reform the defining issue of his first year in office. Republicans hoped that by blocking the legislation, they would be able to thwart Obama's ambitious domestic agenda, including immigration reform and climate change legislation.
While national health care has long been a goal of presidents stretching back decades, it has proved elusive, in part because self-reliance and suspicion of a strong central government remain strong in the U.S.
A shouting band of protesters outside the Capitol dramatized their opposition, and one man stood up in the House visitor's gallery shouting, "Kill the bill" before he was ushered out — evidence of the passions the yearlong debate over health care has stirred.
Obama lobbied by phone from the White House, then took the crucial step of issuing an executive order that satisfied a small group of Democrats who demanded that no federal funds be used for elective abortions.
"We're well past 216" votes, a majority needed for passage, said Democratic Rep. Bart Stupak, swinging behind the bill after leading the anti-abortion holdouts in a rebellion that had left the outcome in doubt.
Democratic aides confirmed his vote count.
Obama, on the verge of securing one of the most significant legislative triumphs in decades, planned to make a statement to the nation Sunday night after the House takes its final vote on the health care legislation.
After more than a year of political combat — certain to persist into the fall election campaign for control of Congress — debate on the House floor fell along predictable lines.
"The public has been grievously and purposely lied to," by Republicans in their efforts to defeat the legislation, said Democratic Rep. Louise Slaughter, a clear reference to Republican accusations that included the claim that there would be death panels for elderly patients.
Republicans opposed the measure as a takeover of government health care that would cut Medicare for the elderly and raise taxes by nearly $1 trillion combined. Republican Rep. David Dreier criticized the Democrats for their tactics on the House floor, but said, "the greatest outrage has always been for the bill itself."
Over and over, Democrats stressed the historic nature of the day. The measure represents the biggest expansion of the social safety net since Medicare and Medicaid were enacted in 1965 during President Lyndon B. Johnson's administration to provide government-funded health care coverage to the elderly and poor.
"Health care isn't only a civil right, it's a moral issue," said Democratic Rep. Patrick Kennedy. He said his late father, Sen. Edward M. Kennedy, had worked his entire career for nationwide health care, and President John F. Kennedy before him.
Slaughter, read a message President Franklin Roosevelt sent Congress in 1939 urging lawmakers to address the needs of those without health care, and said Democrat Harry Truman and Republican Richard Nixon had also sought to broaden health insurance coverage.
Obama has said often that presidents of both parties have tried without success to achieve national health insurance, beginning with Theodore Roosevelt early in the 20th century.
The 44th president's quest to succeed where others have failed seemed at a dead end two months ago, when Republicans won a special election to fill Edward Kennedy's Massachusetts Senate seat, and with it, enough votes to prevent a final vote.
But the White House, House Speaker Nancy Pelosi and Senate Majority Leader Reid soon came up with a rescue plan that required the House to approve the Senate-passed measure despite opposition to many of its provisions, then have both chambers pass a fix-it measure incorporating numerous changes.
Under the legislation, most Americans would be required to purchase insurance, and face penalties if they refused. Much of the money in the bill would be devoted to subsidies to help families at incomes of up to $88,000 a year pay their premiums.
The legislation would also usher in a significant expansion of Medicaid, the federal-state health care program for the poor.
The insurance industry would come under new federal regulation. They would be forbidden from placing lifetime dollar limits on policies, from denying coverage because of pre-existing conditions and from canceling policies when a policyholder becomes ill.
Parents would be able to keep older children on their coverage up to age 26. A new high-risk pool would offer coverage to uninsured people with medical problems until 2014, when the coverage expansion goes into high gear.
Once enacted, the two bills would create a series of so-called "insurance exchanges" beginning in 2014 where self-employed people and small businesses could pool together to shop for health care coverage.
To pay for the changes, the legislation includes more than $400 billion in higher taxes over a decade, roughly half of it from a new Medicare payroll tax on individuals with incomes over $200,000 and couples over $250,000.