On March 21, the U.S. House of Representatives voted 219 to 212 to concur with the Senate Amendments Patient Protection and Affordable Care Act. The Republicans, who voted unanimously against the motion, were joined by 34 Democrats but could not block a historic piece of legislation that will transform U.S. healthcare. Most of the bill takes effect in 2014; the 32 million Americans currently uninsured — in a total population of 308 million — will be covered. All businesses employing 50 people or more will have to pay a fee of $2000 per employee or offer insurance; part-time staff are included. State-level exchanges will be created where small businesses, the self-employed, and those uninsured will be able to choose from a range of insurance schemes. For households, there will be tax credits, and capped insurance premiums will be available to families on low incomes. It is highly significant that gender discrimination, age limits, and exclusion for pre-existing conditions will be banned, as will lifetime dollar limits on policies. The popular Medicaid programme, started in 1965, for people on low incomes will be expanded; there will be some expansion of the equally popular Medicare system, also dating from 1965, which is for many of those retired or over 65. Current estimates are that the implementation of the bill, which now goes to President Obama to be signed into law, will cost $940 billion over 10 years.

Healthcare reform in the U.S. has always been politically fraught, and the Obama administration has worked extremely hard to obtain Congressional approval for the bill. Many Democrats supported it only on condition that federal funds would not be available for abortion; that will have to be paid for separately by those who buy health insurance. Furthermore, individual States will be able to ban abortion on insurance offered through the proposed exchanges, though exceptions will hold for rape, incest, and danger to the mother's life. Secondly, the so-called public option, whereby a federal government scheme would offer insurance paid for solely from premiums, was a casualty of the earlier political battles. Mr. Obama has, nevertheless, taken almost the only opportunity available to persuade Congress to pass the bill while he is also dealing with the economic stimulus package, the bank bailouts, and the wars in Iraq and Afghanistan. The Republicans will certainly mount all possible resistance at State level and will try to cause maximum damage to the Democrats in November's mid-term Congressional elections. That much of the $3.47 billion spent on lobbying Congress in 2009 was used for opposing health reform shows how bitter the opposition is to Mr. Obama's single biggest domestic policy commitment, as do the lies and smears levelled at supporters of reform. Mr. Obama's success with this bill amounts to a notable political triumph.

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