WASHINGTON—The biggest transformation of the U.S. health system in decades won approval on Capitol Hill late Sunday, the culmination of efforts by generations of Democrats to achieve near-universal health coverage.
Facing voters' judgment in the fall, Democrats bet they could overcome public misgivings on a bill that reshapes one-sixth of the U.S. economy. The final battle on the House floor exposed again the divisions that have riven Congress and the nation over the past year.
The House gave final passage to the Senate's health legislation on a climactic 219-to-212 vote, as Democrats muscled the measure through on the strength of the party's big majority. In the final roll call, no House Republican voted for the bill, and 34 Democrats voted no, many of them representing Republican-leaning districts.
A short while later, the House, voting 220 to 211, approved a companion bill making changes to the Senate bill, a measure necessary to attract support in the House. Those changes now head to the Senate, where action is expected this week. All Republicans voted against the companion bill, as did 33 Democrats.
President Barack Obama, who staked his presidency on the health-care overhaul, helped push it toward passage with a last-minute promise to issue an executive order making clear that no money dispensed under the $940 billion bill would pay for abortions. That persuaded Rep. Bart Stupak, a holdout Michigan Democrat, to vote yes and bring at least seven colleagues with him.
President Obama spoke just before midnight at the White House. "At a time when the pundits said it was no longer possible, we rose above the weight of our politics," he said in hailing the vote. "We proved that this government … still works for the people."
It was a tumultuous sprint to the finish for legislation that has brought Washington many dramas over the last year, ranging from a Christmas Eve Senate vote to the surprise January election of Massachusetts Republican Sen. Scott Brown that upended Democrats' plans.
"You will be joining those who established Medicare and Social Security and now, tonight, health care for all Americans," said House Speaker Nancy Pelosi (D., Calif.), urging Democrats to pull together. "This is an American proposal that honors the tradition of our country."
Minority Leader John Boehner (R., Ohio) condemned the legislation, and said Democrats are moving against the will of the public. "Shame on this body. Shame on each and every one of you who substitutes your will and your desire above your fellow countrymen," he said. "By our actions today we disgrace their value."
Republicans hope to use the health overhaul to drive Democrats into the minority, citing polls that show a plurality of Americans oppose it, while Democrats believe the immediate benefits brought by the bill will work to their credit.
The legislation will extend health coverage to 32 million Americans now without insurance, according to the Congressional Budget Office. It will mandate that almost every American carry health insurance—a provision that opponents are set to challenge in the courts. To help people get covered, the legislation expands Medicaid, the federal-state health program for the poor, and gives subsidies to families making as much as $88,000 a year.
Democrats are highlighting popular provisions, such as one that requires insurance companies to accept all comers, even people who are already sick. Republican critics are stressing new taxes in the bill and trims to Medicare spending needed to fund the subsidies.
The broad Senate bill was set to become law quickly following House passage. Some uncertainty remained over the package of changes now headed to the Senate. Democratic leaders there said they had the votes to approve it, but Republican efforts to torpedo it or change it could complicate passage. The changes would boost the value of the subsidies and nullify special deals for some senators that caused a storm of protest.
The CBO estimates the package will hold the federal budget deficit $143 billion lower over 10 years than it would otherwise be. Republicans called the estimate unrealistic. The CBO also estimated that 95% of legal U.S. residents would have insurance by 2019, up from 83% today.
The march toward action Sunday was greeted by protests from hundreds of Tea Party activists, who filled the Capitol grounds, and Republican complaints about the last-minute bargaining among Democrats. "Where has the transparency been? Why all the back-room deals?" asked Rep. Jack Kingston (R., Ga.).
The legislation, nearly left for dead in January after Democrats lost the 60-vote majority in the Senate needed to overcome Republican filibusters, fueled grass-roots anger. Tea Party activists chanted "kill the bill" at Democratic lawmakers as they walked through the hallways of Congress.
The focus Sunday was largely on resolving the abortion dispute. Several Democrats, led by Rep. Stupak, had been withholding support, saying the legislation didn't go far enough to keep federal funds from being used to pay for abortions. They praised Mr. Obama's executive order, while Roman Catholic bishops and other antiabortion groups said it wasn't good enough.
Someone from the Republican side of the House floor called out, "Baby killer!" at Mr. Stupak late Sunday as he defended the bill on the House floor.
A large swath of the business community opposed the changes, arguing the legislation was too broad and had too many taxes. "This will make us one of the highest-taxed regions in the world, and that's going to have an impact on the appetite for people to invest in medical innovation," said Bill Hawkins, chief executive of Medtronic Inc., which makes medical devices. He said his company could cut at least 1,000 jobs to absorb a new 2.3% excise tax on medical-device makers.
Insurers will see the heaviest regulations, with new rules that dictate how much they can reap in profit and whom they must cover.
Hospitals, doctors, drug makers and the seniors group AARP backed the overhaul, saying it will reduce the growth of health costs and make sure no one goes without care.
"This is not about health care," said Rep. James Clyburn of South Carolina, the House Democratic whip. "It's about trying to extend a basic fundamental right to people who are less powerful."
Francee Levin, a 57-year-old artist in Columbia, S.C., said she couldn't get health insurance after she was hit by a drunk driver. "I think I'll be able to get some kind of health insurance, which would be a godsend," she said.
But Catherine Calhoun of Saint Francisville, La., said she worried her husband's employer might drop coverage and force the family to go into newly created health-insurance exchanges to get coverage. That might force her to find new doctors for her 7-year-old son, Billy, who has a rare bone disease, she said.
"I might end up having to negotiate with someone who doesn't have any idea what he needs just to get out of bed in the morning,'' said Ms. Calhoun.
In the run-up to the vote, Mr. Obama urged House Democrats to focus on those helped by the bill and not worry about the difficult politics. "Good policy is good politics," he said.
Republicans said they expect big gains in the fall. "I'd rather be a Republican running against his bill and saying, 'Let's start over,'" said Sen. John Cornyn (R., Texas), chairman of the National Republican Senatorial Committee. "This will be the defining issue in November 2010, and if it passes, in 2012 when the president runs for re-election."
Under the legislation, consumers will see changes within months. Insurers won't be able to place lifetime limits on coverage. Children will be able to stay on their parents' insurance policies until their 26th birthday. The changes could be bumpy, because insurers warn they won't be able to make them so quickly.
The bulk of the legislation wouldn't take effect until 2014. Once the tax credits and Medicaid expansion are in place, most Americans will be required to carry health insurance or pay a fee, topping out at either $695 a year or 2.5% of income.
Employers would have to provide affordable insurance or pay a penalty of up to $3,000 per worker. Those figures assume the Senate ultimately adopts the package of changes the House approved.
Tax increases needed to finance the program would hit a range of industries, from insurers to tanning services. Over the next decade, $108 billion in new fees will fall on insurers, drug makers and medical-device companies. Families earning more than $250,000 a year will pay a higher Medicare payroll tax, and see that tax expanded to investment income such as dividends. High-value insurance plans would be hit with a 40% tax starting in 2018.
As part of the second bill, headed to the Senate, Mr. Obama was poised to accomplish another big goal: overhauling the federal student-loan program. It would end subsidies to banks and shift lending responsibilities to the federal government. That is part of the package of changes still requiring Senate approval.
Corrections & Amplifications:
The House's health legislation imposes a 2.3% excise tax on the sale of medical devices. A previous version of this article incorrectly said the tax was 2.9%.
—Louise Radnofsky and Amy Dockser Marcus contributed to this article. Write to Janet Adamy at firstname.lastname@example.org and Greg Hitt at email@example.com