WASHINGTON Congress gave final approval on Sunday to legislation that would provide medical coverage to tens of millions of uninsured Americans and remake the nations health care system along the lines proposed by President Obama.

By a vote of 219 to 212, the House passed the bill after a day of tumultuous debate that echoed the epic struggle of the last year. The action sent the bill to President Obama, whose crusade for such legislation has been a hallmark of his presidency.

<##IMAGE##> Democrats hailed the vote as historic, comparable to the establishment of Medicare and Social Security and a long overdue step forward in social justice. This is the civil rights act of the 21st century, said Representative James E. Clyburn of South Carolina, the No. 3 Democrat in the House.

After a year of partisan combat and weeks of legislative brinksmanship, House Democrats and the White House clinched their victory only hours before the voting started on Sunday. They agreed to a deal with opponents of abortion rights within their party to reiterate in an executive order that federal money provided by the bill could not be used for abortions, giving the Democrats the final votes. Democrats said that in expanding access to health coverage for uninsured Americans, they were creating a new program every bit as important as Social Security and Medicare, while also putting downward pressure on rising health care costs and reining in federal budget deficits.

Republicans said the plan would saddle the nation with unaffordable levels of debt, leave states with expensive new obligations, weaken Medicare and give the government a huge new role in the health care system.

The debate on the legislation has highlighted the deep partisan and ideological divides in the nation and set up a bitter midterm Congressional election campaign, with Republicans promising an effort to repeal it or block its provisions in the states.

Representative Marcy Kaptur, Democrat of Ohio, said the bill heralded a new day in America. Representative Doris Matsui, Democrat of California, said it would improve the quality of life for millions of American families.

But Representative Paul D. Ryan, Republican of Wisconsin, denounced the bill as a fiscal Frankenstein. Representative Lincoln Diaz-Balart, Republican of Florida, called it a decisive step in the weakening of the United States. Representative Virginia Foxx, Republican of North Carolina, said it was one of the most offensive pieces of social engineering legislation in the history of the United States.

The passions swirling round the bill were evident Sunday on the sun-splashed lawn south of the Capitol. Hundreds of protesters chanted, Kill the bill and waved yellow flags declaring, Dont Tread on Me. They carried signs saying, Doctors, Not Dictators.

The health care bill would require most Americans to have health insurance, would add 16 million people to the Medicaid rolls and would subsidize private coverage for low- and middle-income people, at a cost to the government of $938 billion over 10 years, the Congressional Budget Office said.

The bill would require many employers to offer coverage to employees or pay a penalty. Each state would set up a marketplace, or exchange, where consumers without such coverage could shop for insurance meeting federal standards.

The budget office estimates that the bill would provide coverage to 32 million uninsured people, but still leave 23 million uninsured in 2019. One-third of those remaining uninsured would be illegal immigrants.

The new costs, according to the budget office, would be more than offset by savings in Medicare and by new taxes and fees, including a tax on high-cost employer-sponsored health plans and a tax on the investment income of the most affluent Americans.

Cost estimates by the Congressional Budget Office, showing that the bill would reduce federal budget deficits by $143 billion in the next 10 years, persuaded some fiscally conservative Democrats that they should vote for the bill.

Democrats said Americans would embrace the bill when they saw its benefits, including some provisions that take effect later this year.

Health insurers, for example, could not deny coverage to children with medical problems or suddenly drop coverage for people who become ill. Insurers must allow children to stay on their parents policies up to their 26th birthday. Small businesses could obtain tax credits to help them buy insurance.

The Democratic effort to secure the 216 votes needed for passage of the legislation came together only after last-minute negotiations involving the White House, the House leadership and a group of Democratic opponents of abortion rights, led by Representative Bart Stupak of Michigan. On Sunday afternoon, members of the group announced that they would support the legislation after Mr. Obama promised to issue an executive order to ensure that federal funds are not used for abortion services.

Mr. Stupak described the order as a significant guarantee that would protect the sanctity of life in health care reform. But supporters of abortion rights and some opponents said the order merely reaffirmed what was in the bill.

The procedural vote on Sunday, approving the terms of debate, had put the House on track to approve the health care bill that was passed by the Senate on Dec. 24, on a party-line vote. That bill will soon become the law of the land, the White House said.

House Democrats were also poised to pass a separate measure that would make significant changes and corrections to the Senate bill. That measure would go to the Senate, where the majority leader, Harry Reid, Democrat of Nevada, has promised to take it up in short order. Mr. Reid said he had the votes to pass it, though he faces resistance from Republicans.

The House galleries were full, and the floor was unusually crowded, for the historic debate on health care. Passage of the bill would be a triumph for Mr. Obama and Speaker Nancy Pelosi. Working together, they revived the legislation when it appeared dead after Democrats lost their 60th vote in the Senate and with it their ability to shut off Republican filibusters.

Republicans said they would use the outcome to bludgeon Democrats in this years Congressional elections. The White House is planning an intensive effort to convince people of the bills benefits. But if Democrats suffer substantial losses in November, Mr. Obama could be stymied on other issues, including his efforts to pass major energy and immigration bills.


The campaign for health care overhaul began as a way to help the uninsured. But it gained momentum when middle-class families with health insurance flooded Congress with their grievances. They complained of soaring premiums. They said their insurance had been canceled when they got sick.

Its not just the uninsured, said Representative Jim McGovern, Democrat of Massachusetts. We also have to worry about people with insurance who find, for crazy reasons, that they are somehow going to be denied coverage.

The drive for universal insurance coverage was sustained by lawmakers like Representative Tammy Baldwin, Democrat of Wisconsin. Adding urgency to the debate were the strident complaints of employers, especially small businesses, who said they were being crushed by the cost of employee health benefits.

In the end, groups like the United States Chamber of Commerce and the National Federation of Independent Business tried to stop the bill, saying it would increase the cost of doing business. But other groups, including the American Medical Association and AARP backed it, as did the pharmaceutical industry. Lawmakers agreed that Sundays debate was historic, but they were poles apart in assessing the legislation.

Ms. Pelosi said the bill would free people to pursue their dreams without having to worry about being bankrupted by medical bills or losing health insurance when they switch jobs.

Its liberating legislation, Ms. Pelosi said. Its to free Americans to live their passion, reach their aspirations without being job-locked because they have to have health care, especially if they have someone in their family with a pre-existing condition.

Representative Rodney Alexander, Republican of Louisiana, said, You cannot expect to expand coverage to millions of individuals and to curb costs at the same time.

Republicans said the picture painted by the budget office was too rosy, because the new taxes and fees would start immediately, while the major costs would not show up for four years.

Moreover, Republicans said Democrats would pay a price for defying public opinion on the bill.

Are you so arrogant that you know whats best for the American people? Representative Paul Broun, Republican of Georgia, asked the Democrats. Are you so ignorant to be oblivious to the wishes of the American people?

Lawmakers spoke with deep conviction in explaining their votes.

Health care is not only a civil right, its a moral issue, said Representative Patrick J. Kennedy, Democrat of Rhode Island, who invoked the memory of his father, Senator Edward M. Kennedy, Democrat of Massachusetts, a lifelong champion of health care for all..