"Let's make history," said Sen. Tom Harkin, D-Iowa, shortly before the bill's supporters demonstrated their command of the Senate floor in an extraordinary holiday season showdown.
The bill would extend coverage to more than 30 million Americans who now lack it, while banning insurance company practices such as denial of benefits on the basis of pre-existing medical conditions.
The atmosphere was intensely partisan, but the outcome preordained as senators cast their votes from their desks, a practice reserved for issues of particular importance. Administration officials who have worked intensely on the issue watched from the visitor's gallery despite the hour. So, too, Vicki Kennedy, the widow of Sen. Edward M. Kennedy, D-Mass., who championed health care across a Senate career that spanned more than 40 years.
Nebraska Sen. Ben Nelson's announcement Saturday that he had decided to support the bill — in exchange for a variety of concessions — cemented the Democrats' 60-vote majority behind a bill assembled at the direction of Majority Leader Harry Reid of Nevada.
Republicans conceded Democrats had the votes, but said they hadn't heard the end of it.
"One can stop it, or everyone will own it," said Sen. Mitch McConnell of Kentucky, the Republican leader, a thinly disguised warning that his party will use the issue in the 2010 midterm elections.
In a strong attack on Obama, he said, "a president who was voted into office on the promise of change said he wanted lower premiums. That changed. He said he wouldn't raise taxes. That changed. He said he wanted lower costs. That changed. He said he wouldn't cut Medicare benefits. That changed."
But Reid countered with a list of Nevadans whom he said have suffered at the hands of insurance companies. "On average, an American dies from lack of health insurance every 10 minutes. That means that in the short time I have been speaking, our broken system has claimed another life."
Still, McConnell called the vote the culmination of a long debate, an acknowledgment that it was the single most important vote. Democrats must post 60 votes twice more, and Republicans can delay final passage until Christmas, but not prevent it.
Nelson came in for strong criticism from Republicans in Washington, who complained that he had won favorable treatment for his home state's Medicaid program. In a bit of political theater, they sought to open the bill up to extend it to all 50 states, but Democrats objected.
Nelson's agreement to an abortion-related change in the bill drew criticism from Nebraska Right to Life, a longtime supporter, and the state's Catholic bishops, who issued a statement that they were "extremely disappointed" in him.
His rebuttal came in the form of his vote, as well as a statement. "Too many Nebraskans struggle more each year to pay rising health care costs," he said. "Too many fear or face bankruptcy and too many are left behind, unable to obtain basic health coverage for themselves and their families."
The House has already passed legislation, and attempts to work out a compromise are expected to begin in the days after Christmas.
The Congressional Budget Office has estimated the legislation would reduce deficits by about $132 billion over a decade, and possibly much more in the 10 years that follow. Republicans counter those figures are illusory, because they depend on cuts to Medicare that will never take place.
At its core, the legislation would create a new insurance exchange where consumers could shop for affordable coverage that complies with new federal guidelines. Most Americans would be required to purchase insurance, with subsidies available to help families making up to $88,000 in income afford the cost.
In a bow to Senate moderates, the measure lacks a government-run insurance option of the type that House Democrats placed in their bill. Instead, the estimated 26 million Americans purchasing coverage through new insurance exchanges would have the option of signing up for privately owned, nonprofit nationwide plans overseen by the same federal agency office that supervises the system used by federal employees and members of Congress.
The full extent of Reid's maneuvering was still unclear.
Nelson won numerous changes, including tougher restrictions on abortion coverage and an estimated $45 million in federal Medicaid funds, enough to completely cover his state's costs of complying with an expansion of the program mandated by the bill.
Vermont and Massachusetts also won additional Medicaid funds; plastic surgeons were persuasive in their bid to strip out a proposed tax on elective plastic surgery; hospitals in the Dakotas, Wyoming and Montana won additional Medicare funds; and there was more money for hospitals in Hawaii to treat the uninsured.
While Nelson's vote was the decisive one to fall into place for the Democrats, only an unpredictable series of events has left them with the ability to gain 60 without any help from Republicans.
They began the year with a caucus of 58, including 56 Democrats and two independents. Pennsylvania Sen. Arlen Specter added to their ranks in April when he suddenly bolted from the Republican party, and Sen. Al Franken made it 60 when he was sworn into office in July after a long Minnesota recount.
It was only a few weeks before Massachusetts Sen. Edward M. Kennedy, a longtime advocate of universal health care, succumbed after a long battle with brain cancer and Democrats reverted to 59 seats.
With a heavy push from Reid and the White House, and a request Kennedy wrote not long before his death, Democrats in the Massachusetts Legislature quickly changed state law so Gov. Deval Patrick could appoint a temporary replacement.
Paul Kirk, a longtime Kennedy associate and former chairman of the Democratic National Committee, was sworn in Sept. 25. "We're prepared to go to work," he said.
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