The US Congress narrowly passed an historic health overhaul, taking the United States closer to universal medical care and handing Barack Obama the biggest triumph of his presidency.
After weeks of behind the scenes wheeler-dealing and bitter debate, the Democrat-held House of Representatives voted 219-212 late Sunday to approve a bill extending health coverage to 32 million more Americans in the most sweeping social policy shift in four decades.
"Tonight we answered the call of history as so many Americans have before us. We did not avoid our responsibility we embraced it. We did not fear our future, we shaped it," Obama said after the vote.
No Republicans voted for the bill, already passed by the Senate, and they have warned that Obama will face a political backlash for the measure which will cost hundreds of billions of dollars over the next decade.
But the president, who was expected to sign the bill into law within days, praised lawmakers for defying the predictions that the mammoth legislation would collapse in the face of political setbacks and unyielding partisan rifts.
Tired after a week in which he met or spoke to nearly 100 lawmakers, but evidently savoring the hard-fought triumph on his top domestic goal, Obama told the US public: "This is what change looks like."
As the vote count crept past the 216 needed to ensure passage, Democrats clapped, cheered, hugged and called out Obama's "Yes, we can" 2008 campaign slogan.
All 178 Republicans and 34 conservative Democrats opposed the measure, spurred on by hundreds of protesters who chanted "Kill the bill" during a loud day-long vigil outside the Capitol.
With Vice President Joe Biden at his side, Obama acknowledged Republican warnings that Democrats would pay a steep political price in November mid-term elections that will decide control of Congress.
"I know this wasn't an easy vote for a lot of people. But it was the right vote," said the president, who has vowed to help Democrats in swing districts win re-election.
The Senate now takes up a free-standing package of changes, which the House approved 220-211, as early as Tuesday in a bid to complete its work on the overhaul.
Together, the Senate bill and changes would remake US health care a century after President Teddy Roosevelt called for a national approach, extending coverage to 95 percent of the under-65 population.
The bill bans insurance company practices like denying care for preexisting conditions, imposing lifetime caps on coverage, while providing subsidies to buy private insurance in newly-created marketplaces called "exchanges."
It also raises some taxes on the wealthy while expanding a government-run program for needy Americans.
"This bill is complicated, but it's also very simple: Illness and infirmity are universal, and we are stronger against them together than we are alone," Democratic House Majority Leader Steny Hoyer said before the vote.
But Republican Minority Leader John Boehner argued that by voting in support of the reform package, lawmakers were disgracing the fundamental values put forward by America's founding fathers.
"Shame on us!" Boehner said. "Shame on this body! Shame on each and every one of you who substitutes your will and your desires above those of your fellow countrymen."
Thirty-four Democrats joined all 178 Republicans in voting "no."
Republicans also vowed to keep up the fight in the Senate -- the next battleground -- and repeal the broadly unpopular bill if they win back majorities in November.
After a year of often bitter debate, Obama cleared the way to his victory with an 11th-hour deal to sign an executive order reaffirming a longstanding US ban on government funding for abortions, winning support for the bill from a group of conservative Democratic holdouts.
The Senate was expected this week to take up the changes and approve them separately, under rules that prevent Republicans from using a parliamentary tactic, the filibuster, to indefinitely delay and therefore kill the measure.
Senate Republican Minority Leader Mitch McConnell said Republicans "will now do everything in our power" to fight the bill, while another top Republican described plans to besiege the legislation with "hundreds of amendments."
Democrats have highlighted the independent Congressional Budget Office's estimate that the bill would cost 940 billion dollars over the next 10 years, while cutting 143 billion dollars from the bloated US deficit through 2019 and 1.2 trillion over the following decade.