WASHINGTON — Rarely does the government, that big, clumsy, poorly regarded oaf, pull off anything short of war that touches all lives with one act, one stroke of a president's pen. Such a moment now seems near.
After a year of riotous argument, decades of failure and a century of spoiled hopes, the United States is reaching for a system of medical care that extends coverage to nearly all citizens. The change that's coming, if today's tussle in the House goes President Barack Obama's way, would reshape a sixth of the economy and shatter the status quo.
House Democrats are poised today to pass the most sweeping change to the nation's health care system since the creation of Medicare nearly half a century ago. The 10-year, $940 billion health care package is expected to extend medical insurance coverage to 32 million people by 2019.
Democrats will take a straight up-or-down vote on the health care bill that passed the Senate last year, after party leaders scrapped plans to use a controversial procedural maneuver to approve Senate legislation. The House will hold a second vote on amendments to modify some provisions of the Senate legislation and expand its scope to satisfy House Democrats' demands.
Senate Majority Leader Harry Reid said he has the 51 votes needed to pass the amendments package.
At a rally Saturday, Obama brought Democratic lawmakers to their feet with a fiery speech reminding them of the historic opportunity they have: "Don't do it for me. Don't do it for the Democratic Party," the president said. "Do it for the American people. They're the ones looking for action right now."
To the ardent liberal, Obama's health care plan is a shadow of what should have been. To the foe on the right, it is a dreadful expansion of the nanny state.
To history, it is likely to be judged alongside the boldest acts of presidents and Congress in the pantheon of domestic affairs: Think of the guaranteed federal pensions of Social Security, socialized medicine for the old and poor, the civil rights remedies to inequality.
Shift won't happen quickly
This time, change will come in steps. The major expansion of coverage to 30 million people — powered by subsidies, employer obligations, a mandate for most Americans to carry insurance, new places to buy it and rules barring insurance companies from turning sick people away — is four years out.
In contrast, on June 30, 1966, after a titanic struggle capped by the bill signing a year earlier, President Lyndon Johnson launched government health insurance for the elderly with three simple words, as if flicking a switch: "Medicare begins tomorrow."
Obama practically needs a spreadsheet to tell people what's going on and when. Yet if the overhaul goes through, he and LBJ will share a distinction: the only two presidents to succeed with a transcendent health care law.
You can be sure Obama, a student of history, is aware of how LBJ captured the moment when Medicare became law with his pen. That happened in Independence, Mo., in the presence of the first American to sign up for the program: Harry Truman. The ex-president had ended a world war but could not achieve national health insurance.
"Care for the sick, serenity for the fearful," Johnson promised that day. "In this town, and a thousand other towns like it, there are men and women in pain who will now find ease."
Said Truman: "I am glad to have lived this long."
Ted Kennedy lived long enough to see a goal of his lifetime take shape but not long enough for it to happen. His death last summer was almost the death of the whole plan because a Republican won his Senate seat.
Why is this so hard? In part, because self-reliance and suspicion of a strong central government intruding into people's lives are rooted in the founding of the republic and still are strong.
The colonial insurgents who dumped British tea into Boston harbor inspired the name and agitating spirit of today's tea party protesters, who rolled a health care bill up the Capitol steps like toilet paper to show their disdain.
In 1854, President Franklin Pierce vetoed a national mental health bill on the basis it would be unconstitutional to treat health as anything but a private matter that is none of the government's business.
Would-be health reformers were thwarted one generation after another.Franklin D. Roosevelt rewrote the social compact with his job and retirement security and regulatory expansion, all in the jagged teeth of the Depression, then took the nation to war. He made national health insurance a second-tier priority and it eluded him.
In 1930, citizens paid nearly 80 percent of the nation's medical costs from their own pocket. Government at all levels covered a mere 14 percent, with industry and philanthropy picking up the few remaining crumbs. Insurance was barely in the picture.
Federal and state programs now cover half the cost of health care purchased in the country and are expected to go over 50 percent in the next year or two, even absent Obama's plan. By that measure, the government takeover of health care is happening regardless of what's about to happen next.
Tradition of caring for each other
Why the creep of government in health care? In part, because individualism isn't the entire American story. The idea of watching out for each other is also in the nation's fabric.
More than a quarter century before, Ted Kennedy came close to the prize with none other than Republican President Richard Nixon, who embraced ideas that mainstream Republicans today cannot tolerate. Nixon was ready to force businesses to provide health insurance to workers or pay heavy penalties.
Back then, Kennedy's union and liberal allies gambled that by spurning Nixon, they'd get something better later. They didn't. Likewise, President Bill Clinton aimed high and crashed hard.
Obama absorbed these lessons. For him, a system with government as the sole or principal payer of everyone's medical bills was a nonstarter, nice for the ideologues and other countries but not the U.S. way. He would have liked the option of a government-run plan competing in the marketplace, but didn't need it.
In the end, he stood for more than the incremental steps that succeeded in the past, and for less than the towering ideas that failed.
The Chicago Tribune contributed to this report.