WASHINGTON — Rarely does the government, that big, clumsy, poorly regarded oaf, pull off anything short of war that touches all lives with one act, one stroke of a president's pen. Such a moment has come.
After a year of riotous argument, decades of failure and a century of spoiled hopes, the United States is reaching for a system of medical care that extends coverage nearly to all citizens. The change that's coming will reshape a sixth of the economy and shatter the status quo.
To the ardent liberal, President Barack Obama's health care plan, passed by the House on Sunday night, is a shadow of what should have been, sapped by dispiriting downsizing and trade-offs.
To the loud foe on the right, it is a dreadful expansion of the nanny state.
To history, it is likely to be judged alongside the boldest acts of presidents and Congress in the pantheon of domestic affairs. Think of the guaranteed federal pensions of Social Security, socialized medicine for the old and poor, the civil rights remedies to inequality.
Change is coming, but in steps, not overnight. The major expansion of coverage to 32 million people — powered by subsidies, employer obligations, a mandate for most Americans to carry insurance, new places to buy it and rules barring insurance companies from turning sick people away — is four years out.
In contrast, on June 30, 1966, after a titanic struggle capped by the bill signing a year earlier, President Lyndon Johnson launched government health insurance for the elderly with three simple words, as if flicking a switch: "Medicare begins tomorrow."
Obama practically needs a spreadsheet to tell people what's going on and when with the law he will sign after the Senate takes final action this week.
Yet he and Johnson share a distinction: They are the only two presidents to succeed with a transcendent health care law.
"We rose above the weight of our politics," Obama said late Sunday night in relishing the House victory on a 219-212 vote. "We proved that we are still a people capable of doing big things."
You can be sure Obama, a student of history, is aware of how Johnson captured the moment when Medicare became law with his pen. That happened in Independence, Missouri, in the presence of the very first American to sign up for the program: Harry Truman. The ex-president had ended a world war but could not achieve national health insurance in his time.
"Care for the sick, serenity for the fearful," Johnson promised that day. "In this town, and a thousand other towns like it, there are men and women in pain who will now find ease."
Said Truman: "I am glad to have lived this long."
Ted Kennedy lived long enough to see a goal of his lifetime take shape but not long enough for it to happen. His death last summer was almost the death of the whole plan because a Republican won his Senate seat, changed the voting balance and left despondent Democrats in search of a second wind, which they found.
Why is this so hard? In part, because self-reliance and suspicion of a strong central government intruding into people's lives are rooted in the founding of the republic, and still strong.
In 1854, President Franklin Pierce vetoed a national mental health bill on the basis that it would be unconstitutional to treat health as anything but a private matter that is none of the government's business.
Seventy-five years later, the American Medical Association denounced proposals for organized medical services as an "incitement to revolution" at the hands of "Medical Soviets."
And that wasn't even about government-run health care. The AMA's fierce opposition to collectivism included objections to private health insurance, the norm today, and the pooling of doctors into what became health maintenance organizations decades later.
No wonder would-be health reformers were thwarted one generation after another even as they made deep imprints on the nation in other ways.
Teddy Roosevelt couldn't do it — and he's one of the four U.S. presidents whose faces are carved into the monument Mount Rushmore.
Franklin D. Roosevelt rewrote the social compact with his job and retirement security and regulatory expansion, all in the jagged teeth of the 1930s Depression, then took the nation to war. He made national health insurance a second-tier priority and it eluded him.
Even so, social responsibility for medicine grew.
In 1930, citizens paid nearly 80 percent of the nation's medical costs from their own pocket. Government at all levels covered a mere 14 percent, with industry and philanthropy picking up the few remaining crumbs. Insurance was barely in the picture.
Federal and state programs now cover half the cost of health care purchased in the country and were expected to go over 50 percent in the next year or two even absent Obama's plan. By that measure, the government takeover of health care that opponents warn about is happening regardless of congressional action.
Why the creep of government in health care? In part, because individualism isn't the entire American story. The idea of watching out for each other is also in the nation's fabric.
Besides, as much as Americans hate overbearing government and higher taxes, give them a federal benefit and then just try to take it away. Today's hot potato becomes tomorrow's cherished check.
That's one reason government programs grow — and why Democrats dared to push for a less than popular package mere months from congressional elections, when people were telling their leaders to create jobs instead.
Johnson, after his Medicare victory, realized all of this.
"The doubters predicted a scandal; we gave them a success story," he crowed a month after the law took effect, as hundreds of thousands of patients entered hospitals for treatment covered by the government and some 6 million children and needy adults began getting benefits.
"Where are the doubters tonight?" he asked. "Where are the prophets of crisis and catastrophe? Well, some of them are signing their applications; some of them are mailing in their Medicare cards because they now want to share in the success of this program."
Obama can only hope for such a first-blush reception. He took on the cause of universal coverage after a campaign in which he did not promise it, intending only to secure insurance for all children and shrink the pool of uninsured adults. His health care ambition grew in office, quickly.
More than a quarter century before, Ted Kennedy came close to the prize with none other than the Republican president, Richard Nixon, who embraced ideas that mainstream Republicans today cannot tolerate. Nixon was ready to force businesses to provide health insurance to their workers or pay heavy penalties.
Sound familiar? It will.
At its core, Nixon's proposal is a pillar of Obama's plan today. Nixon's willingness to subsidize coverage for the working poor is also seen in the plan, though writ larger.
Back then, Kennedy's union and liberal allies gambled that by spurning Nixon, they'd get something better later. They didn't. In similar fashion years after that, President Bill Clinton aimed high and crashed hard.
Clinton no doubt drew on his own failure when, in December, he advised Democrats to pass what they could manage and not make it an all-or-nothing fight. "America," he said, "can't afford to let the perfect be the enemy of the good."
Obama absorbed these lessons.
For him, a system with government as the sole or principal payer of everyone's medical bills was a nonstarter, nice for the ideologues and other countries but not the American way. He would have liked the option of a government-run plan competing in the marketplace, but didn't need it.
For months he stood so far back from the legislative nitty-gritty that it was hard to tell what he stood for.
In the end, he stood for more than the incremental steps that succeeded in the past, and for less than the towering ideas that failed.