WASHINGTON — It was a day of history for the nation — and sweet vindication for President Barack Obama. His grin seemed wider than any in recent memory.
After more than a year of arguing, struggling and dealing, Obama signed into law a nearly $1 trillion health care overhaul that ranks among the biggest changes devised by Washington and will reshape the way virtually every U.S. citizen receives and pays for treatment. It will rework one-sixth of the economy and for the first time cement insurance coverage as the right of every citizen.
At the White House, jubilation was in the air Tuesday.
Democratic lawmakers and advocates, crowded into the East Room for the signing ceremony, hooted and hollered. They snapped photos of the president — and themselves.
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Vice President Joe Biden was caught whispering a profanity as he exclaimed to the president what a big deal it was.
It seemed more like a campaign rally than a bill signing.
It will be months before the November midterm election renders a verdict on whether the public approves of the bill the Democrats pushed through Congress without a single Republican vote. But after more than a year of hyperpartisan struggle — and numerous near-death moments for the measure — they sealed a victory denied to a line of presidents and Congresses stretching back more than a half-century.
Not everyone was cheering. Republicans said those Democratic lawmakers would pay dearly in this November's election. Polls show the public remains skeptical, and Obama will fly to Iowa on Thursday for the first of a number of appearances that will be more sales job than victory lap.
The White House hopes the victory — even as a companion "fix-it" bill moves through the Senate — will revitalize an Obama presidency that has been largely preoccupied with health care.
The core of the massive law is the extension of coverage to 32 million people who lack it, a goal to be achieved through a complex mix of mandates for individuals and employers, subsidies for people who can't afford to buy coverage, consumer-friendly rules imposed on insurers, tax breaks, and marketplaces to shop for health plans.
The law's most far-reaching changes don't kick in until 2014, including a requirement that most U.S. citizens carry health insurance — whether through an employer, a government program or their own purchase — or pay a fine. To make that a reality, tax credits to help cover the cost of premiums will start flowing to middle-class families and Medicaid will expand to cover more low-income people. Insurers could no longer deny coverage to those with health problems.
Gap for children
Among the new rules on insurers that take effect this year are banning lifetime dollar limits on policies and policy cancellations when someone gets sick. Insurers must let parents keep children on their plans up to age 26. But a much-touted provision to protect children in poor health has a gap.
Insurers would still be able to deny new coverage to kids with health problems until 2014, although they could no longer refuse to pay for a condition once the child is covered.
The changes are to be paid for with cuts in projected government payment increases to hospitals, insurance companies and others under Medicare and other health programs, an increase in the Medicare payroll tax for some, fees on insurance companies, drug makers and medical device manufacturers, a new excise tax on high-value insurance plans and a tax on indoor tanning.
For seniors, the plan gradually will close the "doughnut hole" prescription coverage gap and improve preventive care. But it also will cut funding for private insurance plans offered through Medicare Advantage. About one-quarter of seniors have signed up for such plans.
The president faces the task of selling to the public a bill that satisfies neither side of the political spectrum.
Liberals bemoan that a government-run plan to compete with private ones was shed. Conservatives fear an expansion of government and costs they say will bankrupt the country, despite an estimate from the nonpartisan Congressional Budget Office that the law will cut federal deficits by an estimated $143 billion over a decade.
Obama's explanatory hurdle is not an easy one, given the law's multilayered provisions and timetables.
Republicans face a challenge as well. Aware of traditional American suspicions of government intrusion, they cast themselves throughout the process as against major changes. They must explain to voters impatient for action in Washington why nothing was their best choice.
Several Republican senators introduced legislation to repeal the law.
"Repeal and replace," Senate Minority Leader Mitch McConnell, R-Ky., said.
Obama planned to sign an executive order today affirming existing law against federal funding of abortions, except in cases of rape, incest or danger to the woman's life. A critical bloc of Democrats who oppose abortion had pledged to vote against the bill unless given greater assurances that it wouldn't alter current law.
Attorneys general from 13 states acted on their opposition immediately, filing suit to stop the overhaul minutes after the bill signing.
Even as celebrations proceeded in Washington, Congress labored to finish the overhaul with a companion measure containing changes demanded by House Democrats. The Senate was poised to consider that bill, with Democratic leaders hoping for its completion by week's end.