- Senate passage of its sweeping health care legislation Thursday opened the final chapter of Democrats' drive to enact the biggest social policy change in decades, launching a high-stakes effort to reconcile the substantial disparities between House and Senate versions of the bill.
But their hardened differences - on abortion, taxes and the government's role in the insurance market - may weaken under political pressure to act quickly on President Barack Obama's goal of overhauling a medical system that provides world-class care for many but is marked by huge gaps in insurance coverage, uneven quality and skyrocketing costs.
The 60-39 vote along strict party lines came in an unusual Christmas Eve session, with exhausted senators gathering at 7 a.m. It was the 25th day of debate, and Vice President Joe Biden made a rare appearance to oversee the roll call.
Obama hailed the Senate action. "With today's vote, we are now incredibly close to making health insurance reform a reality in this country," he said after the vote. "Our challenge, then, is to finish the job. We can't doom another generation of Americans to soaring costs and eroding coverage and exploding deficits." One of the most divisive issues among Democrats - the idea of creating a new government run insurance program known as the public option - is now effectively off the table. And for all the differences between the two bills, they have vast expanses of common ground.
The bill that goes back to both chambers after the House-Senate conference will almost certainly increase by at least 30 million the number of people covered by government and private health insurance. It will for the first time require most individuals to buy health insurance. But it also will offer federal subsidies to help pay premiums, impose penalties on employers that do not offer workers affordable policies and set up an insurance exchange where individuals can shop for coverage if they have no job-based coverage.
Insurance companies will have to end practices that have made it hard for people to get coverage when they get sick or have a chronic disease - setting caps on total payments, for example, or denying coverage on the basis of a pre-existing condition.
Young adults will be able to stay on their parents' health plan longer. Families will pay nothing for preventive health care such as well-baby visits and mammograms.
And health care professionals will be given incentives to provide more cost-effective care - and face penalties if they do not.
"This is a victory because we've affirmed that the ability to live a healthy life in this great country is a right not a privilege," said Senate Majority Leader Harry Reid of Nevada after the vote.
All that comes with a price tag: The Senate bill would spend $871 billion over 10 years, though it would raise taxes and cut spending in other areas by even more, and so reduce the deficit over time.
Despite bipartisan consensus that the health care status quo is unacceptable, the Senate's debate began and ended in an especially bitter, personal and rancorous atmosphere of partisanship.
Not a single Republican voted for the bill; the only one who did not cast a "no" vote was Sen. Jim Bunning of Kentucky, who was absent because of family commitments, his office said.
GOP leaders did everything they could to delay the vote until Christmas Eve. They spent more than 80 hours in Senate floor speeches denouncing the Democrats' bill as an expensive, ill-considered, pork-laden "monstrosity" that would do little to curb costs and rising insurance premiums.
Undaunted by the Senate vote, the Republicans promised to keep up the combat - not just in Congress but on the campaign trail during the 2010 midterm elections.
"This fight isn't over," said Senate Republican Leader Mitch McConnell of Kentucky. "I guarantee you the people who voted for this bill are going to get an earful when they finally get home for the first time since Thanksgiving. They know there is widespread opposition to this monstrosity."
Today's outcome had been almost certain since last weekend, when Senate leaders persuaded the last two holdouts in their caucus - Sens. Joe Lieberman, a Connecticut independent, and Ben Nelson, a Nebraska Democrat - to support the bill, giving Democrats the 60 votes needed to break the Republican filibuster.
But the path to passage was not easy. Lieberman joined the effort only after Reid dropped the most controversial part of the plan: the public option, which the House had included to compete with private companies and make premiums more affordable. Nelson also held out for further restrictions on federal funding for abortion.
Those issues will have to be revisited in House-Senate negotiations to craft a final compromise version of the bill, which will then have to go back to each chamber for approval.
The House and Senate will not formally reconvene until mid-January. Democrats hope to send a final bill to the White House before Obama delivers his State of the Union address, but they say it will likely take until early February. The date of Obama's annual speech to a joint session of Congress has not been set, but it is expected in late January or early February.
Efforts to reconcile differences between the two versions of the bill are under way at an informal level, and Senate Finance Committee Chairman Max Baucus, a Montana Democrat, said they will continue next week.
One of the thorniest issues is House-Senate differences on abortion. The Senate bill is not as strict as the House language, which was drafted by Rep. Bart Stupak, a Michigan Democrat, to prohibit anyone receiving federal premium subsidies from buying an individual policy that covers abortion through the new insurance exchange.
The Senate bill would only prohibit the use of federal funds for such coverage, and require insurance companies to segregate public and private funds to assure that. Stupak has pledged to fight the Senate language, but it is unclear how many anti-abortion Democrats would vote against the entire bill over that issue alone.
Another politically explosive question is how the bill will raise revenues to pay for the new programs. The Senate bill would impose a 40 percent excise tax on high-cost health insurance plans - a tax that analysts predict will be passed on to consumers in higher premiums or reduced benefits.
That "Cadillac tax" is a deal breaker for labor unions, which argue that their workers have given up wage increases in exchange for negotiating generous benefit packages.
After the Senate vote, AFL-CIO President Richard Trumka criticized the tax in his bluntest, most ominous terms to date, saying it would impose "exorbitant new taxes" on one in five workers with employer-provided health coverage - or about 31 million people - by 2016.
"That's the wrong way to pay for health care reform, and it's political suicide," Trumka said.
The House bill would impose an income tax surcharge of up to 5.4 percent on the wealthy - individual incomes of more than $500,000, family incomes of more than $1 million.