All 58 Democrats and two independents voted to approve the first -- and most crucial -- of three motions needed to break off action, as the Senate entered a fourth week of debate on the bill. All Republicans voted no.
The roll call, which began shortly after 1 a.m. Monday, was effectively a test vote for the sweeping bill. The action made clear the White House has enough votes to ensure passage -- likely on Christmas Eve -- of the broadest health legislation in a generation. The measure would ensure that some 30 million Americans will gain insurance coverage over the next decade, while taxes will rise on groups ranging from medical-device makers to customers of tanning salons.
The more than 2,000-page Senate bill needs to be reconciled with House-passed legislation, but is likely to form the core of any final bill presented to President Obama for his signature.
With the vote looming, Senate Minority Leader Mitch McConnell (R., Ky.) urged "Democrats to put party loyalty aside" and join with Republicans in derailing the bill. "It's not too late," he said, warning Democrats they would pay a price for moving the bill. "The impact of this vote will long outlive this one frantic, snowy weekend in Washington."
Democrats accused Republicans of engaging in scare tactics and insisted the legislation – while not popular in opinion polls – would meet an urgent national need. "We're going to move forward," said Sen. Tom Harkin (D., Iowa). "We're not going to vote fear. We're going to vote hope."
Months in the making, the Senate bill would sharply expand Medicaid -- the federal-state health program for the poor -- and create tax subsidies to help low- and middle-income people comply with a new mandate to carry insurance.
The Senate bill would generally leave the existing employer-based health-insurance system intact. Americans who already have coverage on the job wouldn't be likely to see big immediate changes. Larger companies would be required to pay a fee to the government if they didn't offer affordable insurance to employees and if the employees later sought government help paying for insurance.
Last-minute additions toughened restrictions on insurers. Starting next year, they would be barred from denying coverage to children with pre-existing conditions. As before, that provision would apply to adults starting in 2014. The bill would create a national exchange, or marketplace, where individuals and small businesses could buy insurance.
To pay for the program, the measure would impose cuts of some $480 billion over a decade in payments to providers of Medicare, the federal health program for the elderly and disabled. The provision is at the core of Republican objections. The bill also would impose new fees of billions of dollars a year on insurers, medical-device makers, pharmaceutical makers and others. And it would establish a tax on insurers offering high-value health policies.
Another late change would hit customers of indoor tanning salons, who would pay a 10% tax. That replaced a proposed tax on cosmetic surgery, which was projected to raise about $5 billion over a decade. The Senate bill doesn't directly affect income taxes.
The Congressional Budget Office estimated the bill would cost $871 billion over a decade and leave 31 million fewer people uninsured than if current law were in place -- although 23 million Americans, many on the edges of society, would still be uninsured. It projected the bill would hold federal deficits to $132 billion less than they otherwise would be over a decade, owing to new taxes and other changes.
If the Senate bill passes and goes to a conference committee with the House, as expected, the House is likely to do most of the reconciling. That's because Senate Majority Leader Harry Reid -- after battling for weeks to get the minimum number of votes needed to avert a Republican filibuster -- has little room to maneuver. The House passed its version on Nov. 7 on a 220-215 vote.
President Obama hopes to sign a final bill before his State of the Union address after the first of the year so he can turn to other issues, in particular the economy and jobs, in a bid to boost support for Democrats in the 2010 elections.