By Shailagh Murray and Paul Kane
Washington Post Staff Writer
Sunday, November 22, 2009

The Senate voted along party lines Saturday night to overcome a Republican filibuster and bring to the floor a bill that would overhaul the nation's health-care system.

After days of indecision, the last two Democratic holdouts -- Sens. Blanche Lincoln (Ark.) and Mary Landrieu (La.) -- joined their caucus in supporting a motion to begin debate. The 60 to 39 vote marks a milestone in the decades-old quest for health-care reform, President Obama's top legislative priority.

"The road to this point has been started many times," Senate Majority Leader Harry M. Reid (D-Nev.) said before the vote. "It has never been completed."

The debate is expected to last weeks. Reid is aiming for final passage by Christmas.

The House passed a $1 trillion health bill two weeks ago; the $848 billion Senate version represents the work of two committees and hundreds of hours of hearings and deliberations, against a backdrop of fervent Republican opposition. But even as Democrats heralded their victory, they conceded that it represented the end of the beginning -- and not the other way around.

Like Sen. Ben Nelson (D-Neb.), a holdout until Friday, Lincoln and Landrieu said they will press Reid for further changes to the bill before committing to its final passage. Above all, the Democratic caucus remains bitterly divided over a government-run insurance option.

Reid quelled an uprising by liberal senators weeks ago by adding a public option to the legislation. But although he included an opt-out clause for states, some moderates -- including Landrieu and Lincoln -- have told Reid they will oppose the Senate bill on final passage unless the provision is dropped.

"My vote should in no way be construed by the supporters of this current framework as an indication of how I might vote on the final bill," said Landrieu, adding that she also will seek more generous tax credits for small-business health care.

For Democratic leaders, the weeks ahead are likely to bring additional concessions. Lawmakers are already requesting changes to the legislation, raising concerns related to Medicare, abortion and employer requirements.

To secure support for Saturday's vote, Reid had to agree to a 72-hour review period that Lincoln sought after the bill was introduced Wednesday night. He added a Medicaid clause worth up to $300 million for Landrieu's home state. Although many Democrats pressed Reid to include language to end a federal antitrust exemption for health insurers, he omitted the repeal to lock down Nelson's vote.

Republicans portrayed the vote as tantamount to an endorsement of the underlying bill, or "a vote for higher premiums, cuts to Medicare, and more taxes," as Sen. Lamar Alexander (Tenn.) declared.

"All those people who are concerned about the high cost of health care today aren't getting relief under the Democrat plan," said Sen. John Thune (S.D.). "In fact, their lives are going to get much, much worse."

But Democratic leaders said the vote provided a jolt of momentum that vastly improved prospects for a completed Senate bill before the Christmas break, leaving January for negotiations with the House. The goal now is to deliver final legislation to Obama in time for the State of the Union address in late January.

Reid requested that senators vote from their chairs, a formality generally reserved for such historic matters as the confirmations of Supreme Court nominees. Sen. George V. Voinovich (R-Ohio) was not present and did not vote.

Afterward, supporters of health-care reform gathered outside the Capitol to cheer Democratic lawmakers as they left the building. And a tearful Vicki Kennedy, widow of Sen. Edward M. Kennedy (D-Mass.), called Reid to applaud his efforts on her late husband's behalf.

"We know not all 60 senators in my caucus agree on every aspect of this bill," Reid told reporters. "But they agree on the vast, vast majority."

The Senate bill would provide coverage to 31 million uninsured Americans by vastly expanding Medicaid and creating insurance "exchanges" for individuals who do not have access to affordable coverage through their employers. For the first time, it would require most people to carry health coverage, although families with incomes up to 400 percent of the federal poverty level would receive subsidies to buy policies.

The legislation would also force widespread changes to the insurance industry to end discriminatory practices, including the rejection of coverage based on preexisting conditions. It would provide new incentives to encourage disease prevention and to institute the most effective treatments for chronic conditions such as diabetes and asthma.

On the revenue side, the Senate bill would extract about $400 billion in cost savings from Medicare and Medicaid, and would impose an excise tax on the most generous health-care policies, dubbed "Cadillac" plans. It would raise payroll taxes for high earners and levy a 5 percent tax on elective cosmetic surgery.

Even before he released the bill last week, Reid started work on securing the votes for Senate passage. He canvassed Democrats in private meetings and phone calls, and urged groups of senators with shared interests to work together on amendments. Leadership aides also drew up lists of potential Republican amendments to devise how Democrats would respond.

Along with the three Democratic moderates who have stepped forward, two other senators are likely to become frequent visitors to Reid's office in the weeks ahead. Like Nelson, Landrieu and Lincoln, independent Sen. Joseph I. Lieberman (Conn.) opposes the public option but agreed to support the start of debate. Unlike the moderate Democrats, Lieberman has stated unequivocally that he would oppose a government insurance plan in any form.

That leaves Reid with two options. Either he must persuade liberal lawmakers to give up the provision, or he must win back Olympia J. Snowe (Maine), the only Republican to support the Senate Finance Committee bill.

Nelson, Landrieu and other moderate Democrats have suggested they can support an alternative version of the public option proposed by Snowe; it would take effect only if private policies prove unaffordable. Democrats are hopeful they can win her back as the debate advances and said she has continued to negotiate with Reid. But Snowe said, "The conversations have to translate into something specific . . . and that hasn't happened."

Staff writer Lori Montgomery contributed to this report.