Senate Passes Set of Changes to Health Care Overhaul

By DAVID M. HERSZENHORN and ROBERT PEAR

WASHINGTON — After running through an obstacle course of Republican amendments and procedural objections, the Senate on Thursday afternoon approved of a package of changes to the Democrats’ sweeping health care overhaul, capping a bitter partisan battle over the most far-reaching social legislation in nearly half a century.

Republicans, raising procedural challenges, identified flaws that struck out minor provisions to the bill. Because of those changes, it now goes back to the House for one more vote, though passage seemed virtually assured.

Democrats said they were confident the measure would soon be on President Obama’s desk for his signature.

The vote, just after 2 p.m., was 56 to 43, with the Republicans unanimously opposed. Senators cast their votes standing individually at their desks, a ceremonial gesture reserved for historic occasions. Three Democrats opposed the measure, Senators Blanche Lincoln and Mark Pryor of Arkansas and Ben Nelson of Nebraska. Senator Johnny Isakson, Republican of Georgia, was ill and did not vote.

The bill, a budget reconciliation measure that the Republicans could not filibuster, also included a broad restructuring of federal student loan programs to pay for billions of dollars in school initiatives — a centerpiece of Mr. Obama’s education agenda that has been overshadowed by the larger health care fight.

With both sides girding for a last round of parliamentary challenges, Vice President Joseph R. Biden Jr. arrived in the chamber to preside over the session in his role as president of the Senate. Mr. Biden served for 36 years as a senator from Delaware, making him intimately familiar with the chamber, its rules and precedents, and the main combatants on the floor.

As Senator Judd Gregg formally made the procedural challenges, Mr. Biden twice replied, “The point of order is sustained.” Then, he added, “Both provisions are stricken.”

Once the roll call was completed, Mr. Biden said, “There are 56 yeas and 43 nays, the bill as amended is passed.”

The vote came after Senate Democrats defeated more than 40 Republican amendments aimed at delaying or derailing the legislation, including proposals related to insurance coverage of erectile dysfunction drugs for convicted sex offenders, the legality of gay marriage in the District of Columbia, and gun rights.

As the Senate worked into the pre-dawn hours of Thursday morning, the parliamentarian told lawmakers that he would strike out some provisions related to the education portion of the bill because they violated the complex budget reconciliation rules.

One provision sought to prevent any annual decrease in the maximum amount of Pell grants for students from low-income families. Democrats said they would omit the disputed provisions, and advance the legislation.

Republicans said they would carry their opposition to the bill into the fall election campaign, in an effort to win back majorities in Congress and repeal the measure.

The mid-afternoon vote came after nearly 24 hours of acrimonious debate — a fitting finale to the Senate’s role in a nearly year-long saga that included protracted drafting sessions at the Capitol, raucous town-hall meetings with constituents over the August recess, the approval of legislation by five different Congressional committees, passage of the House measure on Nov. 7, and adoption of the Senate bill on Christmas Eve after 25 straight days of floor debate.

The Senate action appeared to be the penultimate step in a series of intricate legislation maneuvers that Democrats were forced to undertake after a Republican, Scott Brown, won a special Senate election in Massachusetts on Jan. 19, stripping Senate Democrats of the 60th vote that they needed to surmount Republican filibusters.

Many Democrats credited the president with having saved the legislation from the brink of collapse. He held a remarkable, day-long televised forum with Congressional leaders of both parties, lobbied for the overhaul in campaign-style rallies around the country, attacked abuses by private insurance companies, and repeatedly told the stories of everyday Americans who had suffered in the existing health system.

With Mr. Obama having signed the main health care bill into law on Tuesday, the Senate’s passage of the reconciliation bill was all but certain. The only question was if Democrats could fend off the Republican parliamentary attacks aimed at knocking out key provisions, or making changes, to prolong the process by requiring another vote by the House.

Although the bulk of the Democrats’ overhaul was already the law of the land, the passage of the final revisions fulfilled a promise that the Senate majority leader, Harry Reid of Nevada, made to rank-and-file House Democrats before they took up the Senate version of the health care legislation and approved it on Sunday night by 219 to 212.

The House then approved the reconciliation measure by 220 to 211.

“The health care bill was passed because very, very, very heavy-duty promises were made to members of the House that reconciliation would be passed to address many of their concerns,” said Senator Bernard Sanders, independent of Vermont who caucuses with the Democrats. “Pelosi would not have had the votes in the House unless there was a strong promise that reconciliation would be passed.”

House Democrats had resisted approving the Senate measure because it contained a number of provisions they opposed, including some aimed at winning the support of individual senators, such as extra Medicaid money for Nebraska that was widely derided as the “Cornhusker kickback.”

The reconciliation measure makes a slew of changes to address the concerns of House Democrats, as well as to bridge differences between the original House and Senate bills and incorporate additional provisions sought by Mr. Obama.

Among the major changes was an adjustment to a tax on high-cost employer-sponsored insurance policies to delay the start of the levy until 2018 and to limit its impact, reflecting a deal that was struck by the White House and organized labor leaders.

The bill eliminated the extra money for Nebraska, and other similar provisions.

The overall health care proposal is expected to extend health benefits to 32 million uninsured Americans at a cost of approximately $938 billion over the next decade, according to the Congressional Budget Office.

The cost of the legislation would be more than offset by reductions in spending on government programs, particularly Medicare, and revenues from new taxes and fees so that it would reduce future federal deficits by $143 billion over a decade the budget office said.

While Democrats hailed the passage of the legislation as major expansion in the nation’s social safety net, and as the realization of a goal sought by presidents and lawmakers for nearly a century, Republicans blasted the measure as a dangerous expansion of government and an encroachment on the lives of ordinary citizens.

The bill would require most Americans to obtain health coverage, or pay financial penalties for failing to do so.

It would expand eligibility for Medicaid, the state-federal insurance program for low-income Americans, and would provide subsidies to help offset the cost of private insurance for citizens earning up to 400 percent of the federal poverty level, or about $88,200 for a family of four.

The bill also tightens government regulation of the insurance industry. Beginning later this year it bars insurers from denying coverage to children based on pre-existing medical conditions, and it will require insurers to allow adult children to remain on their parents’ insurance policies until their 26th birthday.

By 2014, it would require states to establish insurance exchanges, or marketplaces, where individuals and families and employees of small businesses could shop for policies by comparing benefits packages and premium prices.

Earlier on Wednesday, some Democratic lawmakers reported that they had received death threats as a result of their votes in favor of the health care bill, and they were likely to experience more direct feedback from constituents when they return to their home states and districts for a two-week recess beginning this weekend.