Health care bill changes won't happen overnight

(AP) - In a defiant last stand against a newly passed health care overhaul, opponents are trying everything they can to stop it from becoming the law of the land.

Republicans in the Senate are planning parliamentary maneuvers to keep a companion bill from reaching the president's desk. And lawmakers in at least 30 states are working to prevent what they say is an unconstitutional mandate forcing Americans to have health insurance.

Experts say none of it is likely to work, but it will keep the issue, and the outrage, alive until Election Day.

"I am surprised by the mobilization of the states. It does strike me as a kind of civil disobedience, a declaration that we're not going to follow the law of the land," said Mark Hall, a professor of law and public health at Wake Forest University.

"It doesn't make sense. The federal Constitution couldn't be any clearer that federal law is supreme," Hall added.

The House passed the plan late Sunday, sparking a variety of protests and threats less than a day later.

By Monday, at least nine state attorneys general had promised to file suit against the federal government as soon as Obama signs the bill. The states were Alabama, Florida, South Carolina, Pennsylvania, Texas, Utah, Michigan, Nebraska, Washington. Officials in North Dakota were weighing whether to join the case.

Virginia and Idaho have passed legislation aimed at blocking the bill's insurance requirement from taking effect in their states.

In Michigan, a petition drive was launched to put a measure on the ballot asking voters if they want to exempt the state from the overhaul.

In Arizona, lawmakers approved a constitutional amendment that will be put on the ballot in November. And in Colorado, a citizens' group was collecting signatures to put a comparable amendment on the ballot.

Regardless of whether such measures are enacted, they will give opponents of the federal bill a chance to keep the issue in front of voters until the fall.

For the states, it's a question of individual rights. Many say Congress does not have the authority to require citizens to buy goods or services they may not want.

"Just by virtue of being a resident of the United States, never before in history have we been required to purchase something," said Brian Gottstein, a spokesman for Republican Virginia Attorney General Kenneth Cuccinelli II.

In Washington, Obama's health care overhaul isn't completely finished. Although the main bill has passed both houses of Congress, a series of changes sought by House Democrats was headed to the Senate, where debate is expected to begin as early as Tuesday.

Senate Democrats hope to approve the revisions and send the complete bill directly to Obama, but Republicans are determined to drag out the process by offering scores of amendments.

Republican Sen. John McCain told KTVK in Phoenix that the Senate maneuvering is only the first line in the battle against a measure passed in an "unsavory, sausage-making, Chicago-style process."

"We will fight in the courts, and we will fight in the rallies and the tea parties and the town hall meetings. And we will fight in the ballot booth, and we will prevail. And we will defeat this because the United States of America and Arizona can't afford this," McCain said.

"People are mad, and they're more angry than I've ever seen them, and they should be."

Several of the state proposals to block the plan surfaced in Republican-controlled states, but some were put before Democratic-controlled legislatures.

In Alabama, four bills to block some provisions have been introduced in the Legislature. The Democratic House leader, Rep. Ken Guin, said he will start studying the proposals but was doubtful they could move forward with only 10 days left in the legislative session. He said he wants to study the bill Congress passed before he takes a position.

The state proposals would establish a state right for citizens to pay medical services out of their own pockets and would prohibit penalties against those who refuse to buy health insurance.

Many constitutional scholars say the so-called "health care freedom" laws and amendments do not have any chance of succeeding for one simple reason: The Constitution establishes that national laws take precedence over state laws.

"They can sue, but I can't imagine a scenario in which a judge would enjoin the implementation of the federal health care bill," said Lawrence Friedman, a law professor who teaches constitutional law at the New England School of Law in Boston.

"Federal law is supreme. There's really no room for doubt that federal law controls," he said.

But others say it is not that simple.

Dave Roland, a lawyer and policy analyst at the Show-Me Institute, a nonpartisan think tank in St. Louis, said the state constitutional amendments, which focus on creating new rights for individuals, could make a plausible court challenge to the federal health care mandates.

"I think there is a very distinct possibility that the Supreme Court might say that where you have a freedom secured by a state constitution that it might warrant protection, even against a federal statute," Roland said.

States challenging the federal bill say they will also argue that the Constitution's commerce clause - which was intended to allow the free flow of goods among the states - is not broad enough to allow Congress to require citizens to purchase goods or services they may not want, such as health insurance.

"I suspect that we will see a tsunami of litigation," said Clint Bolick, litigation director for the conservative Goldwater Institute in Phoenix, which helped draft a constitutional amendment in Arizona that will be on this November's ballot.

Because the individual mandate does not take effect until 2014, the states challenging that have time to work on legislation.

Michael Boldin, founder of the Tenth Amendment Center, a think tank named for the constitutional amendment that says powers not granted to the federal government are reserved for the states, said there have been other state efforts to circumvent federal laws, most notably in the case of medical marijuana.

Boldin said 14 states now allow the use of marijuana for medical purposes, even though it is prohibited under federal law.

"To me what that indicates is when there are enough people refusing to comply with the federal government and enough states passing laws that also refuse to comply, it's very difficult for the federal government to enforce their laws," Boldin said.

---
Associated Press writers Bob Johnson in Montgomery, Ala., and Erica Werner in Washington contributed to this report.

WASHINGTON (AP) - A transformative health care bill is headed to President Barack Obama for his signature as Congress takes the final steps in Democrats' improbable and history-making push for near-universal medical coverage.

On the cusp of succeeding where numerous past congresses and administrations have failed, jubilant House Democrats voted 219-212 late Sunday to send legislation to Obama that would extend coverage to 32 million uninsured Americans, reduce deficits and ban insurance company practices such as denying coverage to people with pre-existing medical conditions.

"This is what change looks like," Obama said later in televised remarks that stirred memories of his 2008 campaign promise of "change we can believe in."

"We proved that this government - a government of the people and by the people - still works for the people."

Obama will travel outside Washington on Thursday as he now turns to seeing a companion bill through the Senate and selling the health care overhaul's benefits on behalf of House lawmakers who cast risky votes. It is most likely that he will sign the bill on Tuesday, but the plans are not yet final, said a senior administration official, who spoke on condition of anonymity to discuss as-yet unannounced strategy.

Obama's presidency received a much needed boost from passage of the legislation, which would touch the lives of nearly every American. The battle for the future of the health insurance system - affecting one-sixth of the economy - galvanized Republicans and conservative activists looking ahead to November's midterm elections.

A companion package making a series of changes sought by House Democrats to the larger bill, which already passed the Senate, was approved 220-211. The fix-it bill will now go to the Senate, where debate is expected to begin as early as Tuesday. Senate Democrats hope to approve it unchanged and send it directly to Obama, though Republicans intend to attempt parliamentary objections that could change the bill and require it to go back to the House.

Sen. John McCain said Monday morning that Democrats have not heard the last of the health care debate, and said he was repulsed by "all this euphoria going on."

Appearing on ABC's "Good Morning America," McCain, who was Obama's GOP rival in the 2008 presidential campaign, said that "outside the Beltway, the American people are very angry. They don't like it, and we're going to repeal this."

McCain, who is in a tough Republican primary fight in his home state, said the GOP "will challenge it every place we can," and said there will be reprisals at the polls, in Congress and in the courts.

The complicated two-step approval process was made necessary because Senate Democrats lost their filibuster-proof supermajority in a special election in January, a setback that caused even some Democratic lawmakers to pronounce the yearlong health care effort dead. Under the relentless prodding of House Speaker Nancy Pelosi, in particular, it was gradually revived, and the fix-it bill will be considered under fast-track Senate rules that don't allow minority party filibusters.

"We will be joining those who established Social Security, Medicare and now, tonight, health care for all Americans," said Pelosi, D-Calif., partner to Obama and Senate Majority Leader Harry Reid in the grueling campaign to pass the legislation.

"This is the civil rights act of the 21st century," added Rep. Jim Clyburn of South Carolina, the top-ranking black member of the House.

GOP lawmakers attacked the legislation as everything from a government takeover to the beginning of totalitarianism, and none voted in favor. "Hell no!" Minority Leader John Boehner, R-Ohio, shouted in a fiery speech opposing the legislation. "We have failed to listen to America and we have failed to reflect the will of our constituents."

Thirty-four Democrats also voted "no" on the Senate-passed bill.

Sunday night's votes capped an unpredictable and raucous weekend at the capitol, with Democratic leaders negotiating around the clock for the final votes as hundreds of protesters paraded outside, their shouts of "Kill the Bill! Kill the Bill!" audible within the Capitol.

A last-minute deal with a critical group of anti-abortion lawmakers Sunday afternoon sealed Democrats' victory. The leader of the anti-abortion bloc, Rep. Bart Stupak, D-Mich., didn't get to add stricter anti-abortion language to the underlying bill, but was satisfied by an executive order signed by Obama affirming current law and provisions in the legislation that ban federal funding for abortions except in cases of rape, incest or danger to the life of the mother.

Republican abortion foes said Obama's proposed order was insufficient, and when Stupak sought to counter them, a shout of "baby killer" was heard coming from the Republican side of the chamber.

Far beyond the political ramifications - a concern the president repeatedly insisted he paid no mind - were the sweeping changes the bill held in store for Americans, insured or not, as well as the insurance industry and health care providers.

The nonpartisan Congressional Budget Office said the legislation awaiting the president's approval would cut deficits by an estimated $138 billion over a decade. For the first time, most Americans would be required to purchase insurance, and face penalties if they refused. Much of the money in the bill would be devoted to subsidies to help families at incomes of up to $88,000 a year pay their premiums.

The second measure, which House Democrats demanded before agreeing to approve the first, included enough money to close a gap in the Medicare prescription drug coverage over the next decade, starting with an election-season rebate of $250 later this year for seniors facing high costs.

It also included sweeping changes in the student loan program, an administration priority that has been stalled in the Senate for months.

For the president, the events capped an 18-day stretch in which he traveled to four states and lobbied more than 60 wavering lawmakers in person or by phone to secure passage of his signature domestic issue. He also postponed an overseas trip to remain in Washington and push for the bill.

Obama watched the vote in the White House's Roosevelt Room with Vice President Joe Biden and dozens of aides, exchanged high fives with Rahm Emanuel, his chief of staff, and then telephoned Pelosi with congratulations.

Now Obama will have to sell the bill to the public, and a White House aide said he was likely to take at least one trip this weekend to emphasize the legislation's benefits.

The measure would also usher in a significant expansion of Medicaid, the federal-state health care program for the poor. The insurance industry, which spent millions on advertising trying to block the bill, would come under new federal regulation. Parents would be able to keep children up to age 26 on their family insurance plans.

To pay for the changes, the legislation includes more than $400 billion in higher taxes over a decade and cuts more than $500 billion from planned payments to hospitals, nursing homes, hospices and other providers that treat Medicare patients.