WASHINGTON — The Democratic-controlled Congress approved historic legislation Sunday night extending health care to tens of millions of uninsured Americans and cracking down on insurance company abuses, a climactic chapter in the century-long quest for near universal coverage.
On the cusp of succeeding where numerous past congresses and administrations have failed, jubilant House Democrats voted 219-212 late Sunday to send legislation to President Barack Obama. Republicans were unanimous in opposition, joined by 34 dissident Democrats.
The Senate-passed bill was widely viewed as dead two months ago.
"This is what change looks like," Obama said later in televised remarks that stirred memories of his 2008 campaign promise of "change we can believe in."
"We proved that this government — a government of the people and by the people — still works for the people."
Obama's young presidency received a much needed boost from passage of the legislation, which would touch the lives of nearly every American. The battle for the future of the health insurance system — affecting one-sixth of the economy — galvanized Republicans and conservative activists looking ahead to November's midterm elections.
However, Virginia Attorney General Ken Cuccinelli announced early Monday that his office would move forward with a lawsuit alleging the federal government's "unconstitutional overreach of its authority" as soon as Obama signs it into law.
The nonpartisan Congressional Budget Office said the legislation awaiting the president's approval would extend coverage to 32 million Americans who lack it, ban insurers from denying coverage on the basis of pre-existing medical conditions and cut deficits by an estimated $138 billion over a decade. If realized, the expansion of coverage would include 95 percent of all eligible individuals under age 65.
For the first time, most Americans would be required to purchase insurance, and face penalties if they refused. Much of the money in the bill would be devoted to subsidies to help families at incomes of up to $88,000 a year pay their premiums.
Obama watched the vote in the White House's Roosevelt Room with Vice President Joe Biden and about 40 aides. When the long sought 216th vote came in — the magic number needed for passage — the room burst into applause and hugs. An exultant president exchanged a high-five with his chief of staff, Rahm Emanuel.
A companion package making a series of changes sought by House Democrats to the larger bill, which already passed the Senate, was approved 220-211. The fix-it bill will now go to the Senate, where debate is expected to begin as early as Tuesday. Senate Democrats hope to approve it unchanged and send it directly to Obama, though Republicans intend to attempt parliamentary objections that could change the bill and require it to go back to the House.
Obama is expected to sign the larger bill early this week.
The complicated two-step process was made necessary because Senate Democrats lost their filibuster-proof supermajority in a special election in January, a setback that caused even some Democratic lawmakers to pronounce the yearlong health care effort dead. Under the relentless prodding of House Speaker Nancy Pelosi, in particular, it was gradually revived, and the fix-it bill will be considered under fast-track Senate rules that don't allow minority party filibusters.
"We will be joining those who established Social Security, Medicare and now, tonight, health care for all Americans," said Pelosi, D-Calif., partner to Obama and Senate Majority Leader Harry Reid in the grueling campaign to pass the legislation.
"This is the civil rights act of the 21st century," added Rep. Jim Clyburn of South Carolina, the top-ranking black member of the House.
GOP lawmakers attacked the legislation as everything from a government takeover to the beginning of totalitarianism, and none voted in favor. "Hell no!" Minority Leader John Boehner, R-Ohio, shouted in a fiery speech opposing the legislation. "We have failed to listen to America and we have failed to reflect the will of our constituents."
Sunday night's votes capped an unpredictable and raucous weekend at the capitol, with Democratic leaders negotiating around the clock for the final votes as hundreds of protesters paraded outside, their shouts of "Kill the Bill! Kill the Bill!" audible within the Capitol.
A last-minute deal with a critical group of anti-abortion lawmakers Sunday afternoon sealed Democrats' victory. The leader of the anti-abortion bloc, Rep. Bart Stupak, D-Mich., didn't get to add stricter anti-abortion language to the underlying bill, but was satisfied by an executive order signed by Obama affirming current law and provisions in the legislation that ban federal funding for abortions except in cases of rape, incest or danger to the life of the mother.
Republican abortion foes said Obama's proposed order was insufficient, and when Stupak sought to counter them, a shout of "baby killer" was heard coming from the Republican side of the chamber.
Far beyond the political ramifications — a concern the president repeatedly insisted he paid no mind — were the sweeping changes the bill held in store for Americans, insured or not, as well as the insurance industry and health care providers.
The second measure, which House Democrats demanded before agreeing to approve the first, included enough money to close a gap in the Medicare prescription drug coverage over the next decade, starting with an election-season rebate of $250 later this year for seniors facing high costs.
It also included sweeping changes in the student loan program , an administration priority that has been stalled in the Senate for months.
For the president, the events capped an 18-day stretch in which he traveled to four states and lobbied more than 60 wavering lawmakers in person or by phone to secure passage of his signature domestic issue. He also postponed an overseas trip to remain in Washington and push for the bill. According to some who met with him, he warned that the bill's demise could cripple his still-young presidency.
Now Obama will have to sell the bill to the public. Video: Breaking down the health reform bill
The measure would also usher in a significant expansion of Medicaid, the federal-state health care program for the poor. Coverage would be required for incomes up to 133 percent of the federal poverty level, $29,327 a year for a family of four. Childless adults would be covered for the first time, starting in 2014.
The insurance industry, which spent millions on advertising trying to block the bill, would come under new federal regulation. They would be forbidden from placing lifetime dollar limits on policies, from denying coverage to children because of pre-existing conditions and from canceling policies when a policyholder becomes ill.
Parents would be able to keep children up to age 26 on their family insurance plans, three years longer than is now the case.
A new high-risk pool would offer coverage to uninsured people with medical problems until 2014, when the coverage expansion would go into high gear.
After more than a year of political combat, Democrats piled superlative upon superlative across several hours of House debate.
Rep. Louise Slaughter of New York read a message President Franklin Roosevelt sent Congress in 1939 urging lawmakers to address the needs of those without health care, and said Democrat Harry Truman and Republican Richard Nixon had also sought to broaden insurance coverage.
Republicans readily agreed the bill would affect everyone in America, but warned repeatedly of the burden imposed by more than $900 billion in tax increases and Medicare cuts combined.
"The American people know you can't reduce health care costs by spending $1 trillion or raising taxes by more than one-half trillion dollars. The American people know that you cannot cut Medicare by over one-half trillion dollars without hurting seniors," said Rep. Dave Camp, R-Mich.
"And, the American people know that you can't create an entirely new government entitlement program without exploding spending and the deficit."
Obama has said often that presidents of both parties have tried without success to achieve national health insurance, beginning with Theodore Roosevelt early in the 20th century.
The 44th president's quest to succeed where others have failed seemed at a dead end two months ago, when Republicans won a special election for a Massachusetts Senate seat prompted by the death of Sen. Edward Kennedy, and with it, the votes to prevent a final vote.
But the White House, Pelosi and Reid soon came up with a rescue plan that required the House to approve the Senate-passed measure despite opposition to many of its provisions, then have both houses pass a fix-it measure incorporating numerous changes.
To pay for the changes, the legislation includes more than $400 billion in higher taxes over a decade, roughly half of it from a new Medicare payroll tax on individuals with incomes over $200,000 and couples over $250,000. A new excise tax on high-cost insurance policies was significantly scaled back in deference to complaints from organized labor.
In addition, the bills cut more than $500 billion from planned payments to hospitals, nursing homes, hospices and other providers that treat Medicare patients. An estimated $200 billion would reduce planned subsidies to insurance companies that offer a private alternative to traditional Medicare.
The insurance industry warned that seniors would face sharply higher premiums as a result, and the Congressional Budget Office said many would return to traditional Medicare as a result.
The subsidies are higher than those for seniors on traditional Medicare, a difference that critics complain is wasteful, but insurance industry officials argue goes into expanded benefits.
Speaking after Sunday's vote, Kennedy's son described the bill as "the best tribute my father could ever want."
"I'm just honored to have been able to be part of it and ... to cast a vote for it," said Rep. Patrick Kennedy, D-Mass.
NBC News, msnbc.com staff and The Associated Press contributed to this report.