Senate Democrats pushed through a procedural wall Saturday night and formally opened the floor debate on their effort to overhaul the nation's $2.5 trillion health care system. The Senate mustered 60 votes, the exact number required to prevent a Republican filibuster against consideration of the bill, in a straight party-line vote.
"We finally have the opportunity to bring this debate where it belongs," said Senate Majority Leader Harry Reid, who called the vote historic and called on Republicans to engage in the debate to come.
"Do not let history show that when given the chance to debate and defend your position, to work with us for the good of our country and constituents, you ran and hid. You cannot wish away a great emergency by closing one's eyes and pretending it doesn't exist," Reid added.
In the final hours before the vote, conservative Democratic holdouts, Sens. Mary Landrieu of Louisiana and Blanche Lincoln of Arkansas agreed to join the rest of their party majority in taking up the measure. Thirty-nine Republicans voted against; the 40th, George Voinovich of Ohio, did not vote.
"I've decided that there are enough significant reforms and safeguards in this bill to move forward, but much more work needs to be done," Landrieu said.
In her statement on the floor, Lincoln said her vote would not be dictated by pressure from political opponents or liberal interest groups that are threatening to come down hard on her during next year's mid-term elections.
"I believe it's more important that we begin this debate to improve our nation's health care system for all Americans rather than simply drop the issue and walk away," Lincoln said.
Both senators warned that their votes were not guaranteed going forward.
"I am opposed to a new government-administered health care plan as a part of comprehensive health care reform," Lincoln said. "I will not vote in favor of the proposal that has been introduced by Leader Reid as it is written."
The bill as written is designed to cover 31 million more of the uninsured. It requires all citizens to get health insurance, imposes penalty fees on those who don't and provides subsidies to low-income families who can't afford to. It would have states establish insurance marketplaces called exchanges where people can shop, compare and apply for private health coverage.
But Reid's version of the proposal includes a new government-run insurance option that would compete with private insurers, an option that individual states could decide not to allow.
Like the House bill passed earlier this month, the proposed legislation would prevent insurers from capping lifetime premiums or from denying coverage to those with pre-existing conditions. But unlike the House measure, which relies in part on taxing millionaires, the Senate bill is partly paid for by taxing the most expensive, so-called "Cadillac" insurance plans. The Senate proposal also imposes fees on drug makers, medical device manufacturers and private health insurers.
Republicans seized on those tax increases and the proposed cuts in Medicare spending as reasons to oppose the plan. They also devoted a full hour of Saturday's debate to criticizing language in the bill dealing with abortion. The Senate legislation would demand that health insurance exchanges offer at least one plan that covered abortion and one that did not. Health plans that did cover elective abortions would have to guarantee that only money from private premiums was being used to pay for the procedure — not government funds.
Republicans called this abortion provision a "clever accounting gimmick" and called on Democrats to include legislative language similar to the House bill instead. The House approach would ban abortions from public option plans altogether and also from any private plans offered to recipients of government subsidies that help pay for their health care.
"We shouldn't have it as part of the federal funding program," said Kansas Republican Sam Brownback. "We shouldn't be using taxpayer dollars to fund for abortion."
Other Republicans seized on the costs of the bill. The nonpartisan Congressional Budget Office has priced the senate legislation at $849 billion over the next 10 years, and Democrats have played up CBO estimates that the measure would actually reduce the federal deficit by $130 billion in that time.
Republican Sen. John McCain of Arizona said those numbers are misleading because much of the legislation would not go into effect until 2014.
"It's really unfair to American people," McCain said.
"To tell them that they are going to have to start paying taxes and footing the bill for it and only four years later would any benefits come to them, I think that's a really, really, really wrong thing to do to the American people."
But Democrats such as Sen. Charles Schumer of New York argued that the costs of not moving to reform the health care and health insurance industry would be even greater in the long run.
"The consequences of failure are simply too high — premiums will climb higher, benefits will erode further, businesses will buckle under the costs of insurance, and Medicare will go bankrupt."
Despite the intensity of the rhetoric, both sides know this vote is just the beginning in the Senate. Conservative Democrats who went along with launching formal debate on the bill said they did so in order to have an opportunity to change it. Hundreds of amendments are expected to be filed when lawmakers return from their Thanksgiving recess and begin formal debate on the Senate floor Nov. 30. And although President Obama has called for a completed bill by Christmas, Senate debate could stretch into January.