Presidents have been trying to cover the uninsured since LBJ sat in the Oval Office. None have succeeded. Until now. It doesn't matter whether one approves of the bill or thinks it likely to work or not, one should be able to recognise the legislative achievement and, hence, the scale of this Democratic victory. It's probably the most significant progressive-inspired* piece of legislation in 40 years.
So how did it happen? A bit of luck, some arm-twisting, a lot of perseverance from Nancy Pelosi and the rest of the House leadership and, with the benefit of hindsight, a spot of GOP blundering. There aren't, I suspect, 216 members of the House of Representatives who actually like this bill, far less 216 who could vote for it on the merits. But, as I suggested the other day, when substance runs into politics it's politics that usually wins. And so it was on this occasion too. (See Nate Silver's analysis too.)
Republicans, in retrospect, sealed their fate when it became clear that they weren't interested in doing a deal and when they decided that killing healthcare could a) revitalise the party's spirits, b) perhaps be the springboard for winning back the House in November and c) above all do terrible damage to the Obama presidency. At that moment this ceased - if it had ever been - being a question of health care or health insurance reform and became a brutal, bloody battle for political survival.
The GOP argument was, in the end, as odd as it was contradictory. In terms of the politics of the matter, the party argued that the bill's unpopularity (some genuine, some the product of some measure of scaremongering) ensured that, whether it passed or not, Democrats and the Obama administration were stuck with it and that this would, in the end, be the beginning of the end for both Pelosi and the President.
Simultaneously, however, they had to suggest to wavering Democrats that abandoning the bill was both a matter of good conscience and something that wouldn't really hurt the Democratic party. After all, Clinton recovered from his health care debacle didn't he? But that was in good economic times and, in any case, was a plan that never even made it onto the House floor. This would be different. Voting no would be to shatter progressive dreams just as the party was closer than ever before to passing this monumental piece of legislation. This time, in the midst of a terrible recession which threatens their health anyway, Republicans were asking Democrats to double down and betray their President (elected, like the Democratic House and Senate with a mandate for this stuff) - and they were promising that doing this would bring nothing but ruin upon the Democratic party. Some incentive!
Really, just about the only thing that can unite the Democratic party is the Republican party. Some achievement! As David Frum argues: heck of a job Rush.
Make no mistake: the more virulent GOP opposition to the plans became - and, if you like, the more hysterical - the more Democrats had to pass it if only to save face. Sceptical Blue Dogs, Pro-Lifers and Leftists were all forced to club together for the greater good of the party. Left to their own devices they almost certainly couldn't have agreed on a bill, any bill.
Will this bill pay for itself? I suspect the fiscal projections are bound to be on the optimistic side and that the revenue-raising measures are likely to be inadequate. But, unlike the GOP's last expansion of Medicare, there is at least an attempt to pay for this.
Democrats may well still pay a price at the mid-terms - though they'll argue that the economy is the cause of their troubles not the health bill - but they'll also gamble that their reforms will, in the end, prove surprisingly popular. And at the very least, around 30 million more Americans will have access to (affordable) health insurance.
Like I say, that's something Presidents of both parties have spent 40 years trying to achieve. And now, for better or worse and for all the side-deals and grubby compromises, it's happening. That's the sort of thing you're supposed to go into politics to accomplish. In theory, anyway. You don't have to be a Democrat or a Democratic sympathiser to appreciate that this is big.
Will it work? Ah well, that's a matter for another day. What next? A breather perhaps but then, in theory, banking regulation, cap and trade and maybe even comprehensive immigration reform. It's unlikely all that can or will pass but, just supposing it did, there'd hardly be any need for Obama to run for re-election.
For now, however, Democrats are sighing with relief and smiling in the slightly stunned silence brought on by achieving something that was always supposed to be an unachievable dream. And they couldn't have done it - or done it this way at least - without the Republican party.
*Welfare Reform needed Republican votes.