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Washington

After a vote that went down to the wire, House Democrats cheered a vast overhaul of the US healthcare system early Sunday morning. In a phone call to House leaders, President Obama called it “a great victory for the American people.”

The $1 trillion-plus measure could add some 36 million people to the ranks of the insured by expanding the scope of Medicaid, creating exchanges where individuals could shop for insurance, and including a public option – a government-run insurance plan that would compete with private insurers. The legislation would also ban insurance companies from refusing or dropping coverage on the basis of health status.

Under the terms of the bill, which passed 220 to 215, individuals would be required to purchase health insurance and employers to cover their workers, with penalties for noncompliance. Costs would be covered by a surtax on high-income Americans and by reducing costs, especially in Medicare.

But Saturday’s vote signals tough negotiations ahead in the next phases of the legislation, including a potential conference between House and Senate versions of the bill. The Senate has yet to take a full vote on health reform, but if it does pass legislation, that version is expected to differ widely from the House’s.

With one lone Republican vote Saturday, freshman Rep. Anh “Joseph” Cao of Louisiana, House Democrats can expect little help from the minority. In the run-up to the vote, GOP whip Eric Cantor of Virginia predicted that Speaker Nancy Pelosi would “get no help from us in passing this gargantuan, trillion-dollar overhaul.”

In the Senate, only one Republican, Sen. Olympia Snowe of Maine, voted for either of two committee bills now being merged by Democratic majority leader Harry Reid. But she has since backed off her support over objections to a proposed public option.

To carry the momentum forward, Democrats must close rifts in their own ranks. One point of contention: a fragile, 11th-hour agreement with some 40 social conservatives to exclude public funding of abortions. The amendment passed, 240 to 197, with 64 Democrats voting with Republicans on the measure.

The agreement, which would require women to secure a separate policy to cover abortion costs, riled many Democrats in the liberal and progressive wing of the caucus – and is not expected to pass in the Senate.

“No woman plans an unplanned pregnancy,” said Rep. Jan Schakowsky (D) of Illinois during debate over the antiabortion amendment on the floor of the House. “This amendment is a disservice and an insult to millions of women in this country.”

The vote reopened what has been a major fault line in congressional politics. “This is one of the most significant pro-life votes since Roe v. Wade,” said Tony Perkins of the conservative Family Research Council, after the vote.

Since the antiabortion amendment is unlikely to survive a vote in the Senate, that puts greater pressure on finding votes from fiscal conservatives, who accounted for most of the 39 Democratic defections in the House. Members of the so-called Blue Dog caucus worry about expanding entitlements at a time of soaring federal deficits.

“I am concerned about the impact the legislation could have on rural hospitals and doctors,” said Rep. Ike Skelton (D) of Missouri, citing the impact of proposed reductions in Medicare reimbursements in a statement after the vote. “I also oppose the creation of a new government run public option and continue to have serious concerns about its potential unintended consequences for Missourians who have private insurance plans they like.”

The nonpartisan Congressional Budget Office, which scored the House bill, estimates that enacting it would result in a net reduction in federal budget deficits of $129 billion from 2010 to 2019. But, it adds, “those estimates are all subject to substantial uncertainty.”

A wild card in the next weeks is whether healthcare groups affected by the bill will engage their corporate war chests to undermine it. The American Medical Association last week endorsed the bill, but only on condition that the House also pass a $210 billion fix to a formula that requires cuts in payments to physicians treating Medicare patients. That vote, expected the week of Nov. 16, is controversial with fiscal conservatives, because the costs are not offset.

Insurers, who stand to gain millions of new customers if the bill is passed, object to the robust public option in the House bill. “A new government-run plan will cause millions to lose their existing coverage and draconian Medicare Advantage cuts will force millions of seniors out of the program entirely,” said Karen Ignagni, president and CEO of America’s Health Insurance Plans (AHIP), in a statement after the vote.

Still, the greatest risk in the long run for Democrats may be the failure to secure bipartisan support.

“In the past, legislation that passed on straight party-line votes becomes an obstacle to acceptance of the legislation by some segments of the population,” says Ross Baker, a political scientist at Rutgers University in New Brunswick, N.J. “But Democrats have come to the conclusion that if healthcare is going to be done, it’s got to be done with Democratic votes alone – and that’s preferable to not doing it at all.”

See also:

Healthcare reform: Obama cut private deals with likely foes

On healthcare reform, House lawmakers get past the abortion hurdle

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