WASHINGTON — Senate passage of its sweeping health care legislation Thursday opened the final chapter of Democrats’ drive to enact the biggest social policy change in decades, launching a high-stakes effort to reconcile the substantial disparities between House and Senate versions of the bill.

But their hardened differences — on abortion, taxes, and the government’s role in the insurance market — may weaken under political pressure to act quickly on President Barack Obama’s goal of overhauling a medical system that provides world-class health care for many but is marked by huge gaps in insurance coverage, uneven quality and skyrocketing costs.

The 60-39 vote on strict party lines came in an unusual Christmas Eve session, with exhausted senators gathering at 7 a.m. EST. It was the 25th day of debate, and Vice President Joe Biden made a rare appearance to oversee the roll call.

Both of Maine’s senators voted against a landmark
health care bill that could usher in near-universal medical coverage for the
first time in the country’s history.

Collins says in a statement the bill doesn’t do enough to rein in the cost of
health care and give consumers more affordable choices.

Snowe said before the vote that the process was shortchanged by an
“artificial and arbitrary deadline” of completing the bill before Christmas.

Obama hailed the Senate action. “With today’s vote, we are now incredibly close to making health insurance reform a reality in this country,” he said after the vote. “Our challenge, then, is to finish the job. We can’t doom another generation of Americans to soaring costs and eroding coverage and exploding deficits.”

One of the most divisive issues among Democrats — the idea of creating a new government-run insurance program known as the public option — is now effectively off the table. And for all the differences between the two bills, they have vast expanses of common ground.

The bill that goes back to both chambers after the House-Senate conference will almost certainly increase by at least 30 million the number of people covered by government and private health insurance. It will for the first time require most individuals to buy health insurance. But it also will offer federal subsidies to help pay premiums, impose penalties on employers that do not offer workers affordable policies, and set up an insurance exchange where individuals can shop for coverage if they have no job-based coverage.

Insurance companies will have to end practices that have made it hard for people to get coverage when they get sick or have a chronic disease — setting caps on total payments, for example, or denying coverage on the basis of a pre-existing condition.

Young adults will be able to stay longer on their parents’ health plan. Families will pay nothing for preventive health care such as well-baby visits and mammograms.

And health care professionals will be given incentives to provide more cost-effective care — and face penalties of they do not.

“This is a victory because we’ve affirmed that the ability to live a healthy life in this great country is a right, not a privilege,” said Senate Majority Leader Harry Reid, D-Nev., after the vote.

All that comes with a price tag: The Senate bill would spend $871 billion over ten years, though it would raise taxes and cut spending in other areas by even more, and so reduce the deficit over time.

Despite bipartisan consensus that the health care status quo is unacceptable, the Senate’s debate began and ended in an especially bitter, personal and rancorous atmosphere of partisanship.

Not a single Republican voted for the bill; the only one who did not cast a “no” vote was Sen. Jim Bunning, R-Ky., who was absent because of family commitments, his office said.

GOP leaders did everything they could to delay the vote until Christmas Eve. They spent more than 80 hours in Senate floor speeches denouncing the Democrats’ bill as an expensive, ill-considered, pork-laden “monstrosity” that would do little to curb costs and rising insurance premiums.

Undaunted by the Senate vote, the Republicans promised to keep up the combat — not just in Congress but on the campaign trail during the 2010 mid-term elections.

“This fight isn’t over,” said Senate Republican Leader Mitch McConnell, R-Ky. “I guarantee you the people who voted for this bill are going to get an earful when they finally get home for the first time since Thanksgiving. They know there is widespread opposition to this monstrosity.”

Thursday’s outcome had been almost certain since last weekend, when Senate leaders persuaded the last two holdouts in their caucus — Sens. Joe Lieberman, I-Conn., and Ben Nelson, D-Neb. — to support the bill, giving Democrats the 60 votes needed to break the Republican filibuster.

But the path to passage was not easy. Lieberman joined the effort only after Reid dropped the most controversial part of the plan: the public option, which the House had included to compete with private companies and make premiums more affordable. Nelson also held out for further restrictions on federal funding for abortion.

Those issues will have to be revisited in House-Senate negotiations to craft a final compromise version of the bill, which will then have to go back to each chamber for approval.

The House and Senate will not formally reconvene until mid-January. Democrats hope to send a final bill to the White House before Obama delivers his State of the Union address, but they say it will likely take into early February. The date of Obama’s annual speech to a joint session of Congress has not yet been set, but it is expected in late January or early February.

Efforts to reconcile differences between the two versions of the bill are already underway an informal level, and Senate Finance Committee Chairman Max Baucus, D-Mont., said they will continue next week.

One of the thorniest issues is House-Senate differences on abortion. The Senate bill is not as strict as the House’s language, which was drafted by Rep. Bart Stupak, D-Mich., to prohibit anyone receiving federal premium subsidies from buying an individual policy that covers abortion through the new insurance exchange.

The Senate bill would only prohibit the use of federal funds for such coverage, and require insurance companies to segregate public and private funds to assure that. Stupak has pledged to fight the Senate language, but it is unclear how many anti-abortion Democrats would vote against the entire bill over that issue alone.

Another politically explosive question is how the bill will raise revenues to pay for the new programs. The Senate bill would impose a 40 percent excise tax on high-cost health insurance plans — a tax that analysts predict will be passed on to consumers in higher premiums or reduced benefits.

That so-called “Cadillac tax” is a deal-breaker for labor unions, who argue that their workers have given up wage increases in exchange for negotiating generous benefit packages.

After the Senate vote, AFL-CIO President Richard Trumka on Thursday criticized the tax in his bluntest, most ominous terms to date, saying it would impose “exorbitant new taxes” on one in five workers with employer-provided health coverage — or about 31 million people — in 2016.

“That’s the wrong way to pay for health care reform, and it’s political suicide,” Trumka said.

The House bill, instead, would impose an income tax surcharge of up to 5.4 percent on the wealthy — individual incomes over $500,000, families over $1 million.

Advocates of the Cadillac tax say it will help constrain the growth of health care costs by discouraging insurance companies and employers from offering high-end plans.

Negotiators may find room for compromise in another revenue source included in the Senate bill: an increase in the Medicare payroll tax imposed on upper income wage earners. The Senate would increase the payroll tax from 1.45 percent to 2.35 percent for people with incomes over $200,000 for individuals and $250,000 for couples, an idea to which House Democrats seem more receptive.

The tax issue was one of many aired in a Wednesday conference call of House Democrats convened by the leadership to discuss the upcoming negotiations. The session underscored the emotions and political pressures that will underlie the legislative endgame.

According to sources who participated in the call, Democrats expressed anger at the presumption that they would accede to the Cadillac tax and many concessions made by the Senate to appease conservatives. House Speaker Nancy Pelosi, D-Calif., assured her rank and file that the House would not just rubber-stamp the Senate bill.

Among the issues House Democrats may try to insist on, a Democratic leadership aide said, was having premium subsidies and insurance exchanges to take effect in 2013 — quicker than the Senate’s 2014 start date for many key provisions.

House Democrats also want to increase federal premium subsidies for low- and middle-income people over Senate levels, and make the exchanges a national marketplace, as in the House bill, rather than the state-based programs the Senate wants.

But if the Senate prevails on key points, it may make the bill more appealing to conservative Democrats who voted against the House bill, which could help Democratic leaders make up for possible defections among disillusioned liberals.

“I would be a lot more favorable if the bill looked more like the Senate’s bill,” said Rep. Jason Altmire, D-Pa., one of 39 Democrats who voted against the House bill. “I would suspect that they would be able to pick up a few people from the right to offset losses on the left.”