Triumph in their grasp, President Barack Obama and House Democrats demonstrated command of the votes needed to pass landmark health care legislation Sunday night, writing a climactic chapter in a century-long quest for near universal coverage.
The House argued its way through a thicket of Republican objections toward a late-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.
The measure cleared a critical early test vote, 224-206, a few hours after Obama and House leaders reached a compromise with anti-abortion Democrats.
A shouting band of protesters outside the Capitol dramatized their opposition, and one man stood up in the House visitor's gallery yelling, "Kill the bill" before he was ushered out — evidence of the passions the yearlong debate over health care has stirred.
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 would go to the Senate.
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, said Rep. Bart Stupak of Michigan, swinging behind the bill after leading the holdouts in a rebellion that had left the outcome in doubt.
Democratic aides confirmed his vote count, and Republicans did not dissent.
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 Rep. Louise Slaughter, D-N.Y., a clear reference to GOP 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 and raise taxes by nearly $1 trillion combined. Rep. David Dreier, R-Calif., 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.
"Health care isn't only a civil right, it's a moral issue," said Rep. Patrick Kennedy, D-R.I. He said his late father, Sen. Edward M. Kennedy, D-Mass., 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 for a Massachusetts Senate seat, and with it, the votes to prevent a final vote.
But the White House, House Speaker Nancy Pelosi, D-Calif., and Senate Majority Leader Harry Reid, D-Nev., 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 houses pass a fix-it measure incorporating numerous changes.
Under the order of the day, set down by Democrats, the House was voting first on the Senate-passed bill, sending it to Obama for his signature. A final vote on the fix-it bill would follow. Its passage would set up a final showdown in the Senate, where Reid says the votes are in hand for its final approval.
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. Coverage would be required for incomes up to 133 percent of the federal poverty level, $29,327 a year for a family of four. Childless adults would be covered for the first time, starting in 2014.
The insurance industry would come under new federal regulation. They would be forbidden from placing lifetime dollar limits on policies, from denying coverage to children because of pre-existing conditions and from canceling policies when a policyholder becomes ill.
Parents would be able to keep older kids 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 consumers could shop for individual coverage that meets federal standards.
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. A new excise tax on high-cost insurance policies was significantly scaled back in deference to complaints from organized labor.
In addition, the bills cut more than $500 billion from planned payments to hospitals, nursing homes, hospices and other providers that treat Medicare patients. An estimated $200 billion would reduce planned subsidies to insurance companies that offer a private alternative to traditional Medicare.
The insurance industry warned that seniors would face sharply higher premiums as a result, and the Congressional Budget Office said many would return to traditional Medicare as a result.
The subsidies are higher than those for seniors on traditional Medicare, a difference that critics complain is wasteful, but insurance industry officials argue goes into expanded benefits.
Associated Press writers Jim Kuhnhenn and Erica Werner contributed to this report.