After a debate that has consumed US politics for nine months, the House of Representatives was last night poised to pass the most sweeping healthcare reform in nearly half a century – reshaping a hugely expensive and inefficient sector that accounts for a sixth of the economy.
As the final showdown approached over a $940bn (£625bn) measure on which Barack Obama has virtually staked his presidency, Democratic leaders had apparently rounded up the 216 votes needed for a majority. The crucial breakthrough was the enlistment of the Michigan Congressman Bart Stupak, at the head of a small group of socially conservative Democrats who were refusing to vote for the measure as it did not place tough enough restrictions on federally backed insurance abortion funding.
Mr Stupak's change of heart, obtained by the promise of an executive order from President Obama tightening these regulations, appeared to doom the unrelenting Republican efforts to block the legislation. With all 178 House Republicans set to vote against, the Democrats had to find the 216 votes on their own. Three hours before the main vote, that goal finally seemed to be achieved.
Earlier, as the political temperature inside the Capitol building increased, tensions boiled over outside, where thousands of protesters had gathered to demonstrate. On Saturday evening, some of them heckled and hurled insults at black and gay lawmakers, as they came and went, among them the veteran Georgia Congressman John Lewis, a hero of the 1960s civil rights movement. "They were shouting the n-word," a colleague of Mr Lewis said. "It was like a page out of a time machine." Some protesters yelled "faggot" at the openly gay Barney Frank, chairman of the Financial Services committee.
Under the complex procedure settled on by Democrats, two critical votes were scheduled last night. In the first, the House was deciding whether to adopt the healthcare bill passed by the Senate on Christmas Eve. If approved, that measure would be sent to Mr Obama for his signature – expected almost immediately – and health reform would become law.
The second vote was on a package of fixes to meet House objections to the Senate version. If passed by the House, that package would go to the Senate under the so-called "reconciliation" procedure that requires a simple majority of 51 votes – not the 60-vote one that the Democrats lost in January.
But win or lose, the fight is not over. Having relentlessly opposed the measure from the outset, Republicans yesterday vowed to carry on to the point of promising its repeal should they regain control of Congress. They warned Democrats they would face terrible retribution from voters at November's mid-term elections should the bill become law. "The American people don't want this to pass. The Republicans don't want this to pass. There will be no Republican votes for this bill," Eric Cantor, the second-ranking Republican in the House, declared. Nor was Senate approval of the changes a sure thing. Even though Democrats still hold 59 of 100 seats, Republicans threatened "hundreds" of amendments.
Although the measure will cost $940bn over 10 years, according to the non-partisan Congressional Budget Office, it is forecast to reduce the federal deficit by $138bn. Far larger savings are likely thereafter. The US is the only advanced industrial country that does not provide guarantee coverage for all its citizens – despite spending $2.4 trillion (£1.6 trillion), or 16 per cent of GDP, on healthcare.
But this bill, the biggest overhaul of the system since the enactment of Medicare and Medicaid in the mid-1960s, will insure 32 million more people, extending coverage to 95 per cent of the population.
Almost every American will be affected by the changes. Medicaid, which provides coverage to the poor, will be expanded, while new fees and taxes will be levied on the better off. Insurance companies will be barred from turning away people with pre-existing medical conditions, and from abruptly rescinding or limiting coverage. Children will be able to stay on their parents' policies until they are 26.
In return, most people without coverage will be required to buy it, and face fines if they do not. The government will provide subsidies and tax credits for families earning less than $88,000 (£58,000).
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