At 11:05, there remained fully 10 Democrats not having cast their vote, with rumors that one or two Republicans might also "defect" and join the Democratic majority in voting for passage. At 11:07 pm EST, the tally of yea votes reached 218, the threshold necessary to pass the comprehensive healthcare reform bill. The voting would remain open for 15 minutes, allowing for the possibility of a change in one or more votes. 

At 11:10 pm, the impossible occurred, when the final Republican voting cast a yea vote, leaving only one Democrat to vote. The final vote, at 11:11 pm, was in favor, making the vote 220 in favor to 215 opposed. The vote means the House of Representatives passed healthcare reform weeks before the tentative Thanksgiving deadline, handing Pres. Obama a major legislative victory. 

At 11:15 pm EST, Speaker of the House Nancy Pelosi dropped the gavel and declared to raucous applause that the bill had passed by a margin of 220 yeas to 215 nays. The vote was immediately followed by a 5-minute vote to honor those who died in the shooting tragedy at Fort Hood, Texas, 2 days earlier. Rep. Anh Joseph Cao (R-LA) was the lone Republican voting to pass the reform bill. 

Louisiana is one of the states tat suffers from the least competition among health insurance providers, with high rates of denied claims, dropped coverage and uninsured, a large low-income population and serious budgetary challenges. His vote may put added pressure on Democratic Senator Mary Landrieu, also of Louisiana, to join her party in supporting passage. 

The vote marks the first time either house of the US Congress has passed legislation that would extend healthcare coverage to nearly every American, after 100 years of attempts, some bold and visionary, some less daring and less developed. That historic achievement has been part of Pres. Obama's rhetoric throughout the process, and the White House is expected to stress that achievement in declaring its efforts vindicated by tonight's vote. 

Earlier in the day, however, some difficult concessions were made in order to win support from conservative Democrats. The Stupak amendment will bar use of federal funds to purchase coverage under any plan that permits elective abortion procedures. As Politico is reporting:

After hours of negotiations with a group of abortion opponents, led by Indiana Rep. Brad Ellsworth, and the United States Conference of Catholic Bishops, Pelosi made a final painful sacrifice to pick up crucial support, allowing a vote on an amendment sponsored by Ellsworth and Michigan Rep. Bart Stupak that would bar any insurance company participating in the exchange program from covering the procedure.

Rep. Diana DeGette, of Colorado, said the amendment —which passed with 240 votes in favor— has left many "furious" and that it marks a rolling back of women's basic reproductive rights. The Stupak amendment will continue to be a point of serious contention, as there will surely be demands to remove it from the conference committee bill, if the Senate passes its reform bill.

Sen. Harry Reid, the majority leader, commended Speaker Pelosi on her leadership and said the House vote was "another mile traveled on the road to reforming our broken healthcare system". Speaker Pelosi announced at 11:37 pm that she had received a congratulatory phone call from Pres. Obama, who she said "provided the vision and the momentum", adding that without Pres. Obama in the White House, the process itself would not have been possible.

The Speaker personally commended Rep. John Dingell, who has introduced a universal healthcare coverage bill every year since he entered the House, as did his father, going back to the 1940s. Steny Hoyer praised Speaker Pelosi for "Her focus, her vision, her tenacity, her energy, her commitment" and said her leadership had served the future of America's children. Rep. James Clyburn, the Democratic whip said the process had greatly strengthened the Democratic caucus.

The process of passing the legislation has only just begun, however, as the Senate still needs to finalize, present for debate, clear from debate and vote on it's version of the reforms. Once that is done, the bills will go to conference committee to be reconciled into one merged bill, which both Houses will again have to pass, before Pres. Obama will have anything on his desk to sign into law. 

UPDATE, 8 November 2009, 13:39 EST: Anh Joseph Cao has said he came to understand the need to vote to pass the sweeping healthcare reform program, after listening to the concerns of constituents desperate to find a way to secure reliable, affordable coverage for basic and/or emergency healthcare. A release on his website reads as follows:

Tonight, Congressman Anh “Joseph” Cao (LA-2) voted in favor of the comprehensive health reform bill, H.R. 3962, the Affordable Health Care for America Act.

Of his vote, Cao said: “Tonight, I voted to keep taxpayer dollars from funding abortion and to deliver access to affordable health care to the people of Louisiana.

Cao said: “I read the versions of the House [health reform] bill. I listened to the countless stories of Orleans and Jefferson Parish citizens whose health care costs are exploding – if they are able to obtain health care at all. Louisianans needs real options for primary care, for mental health care, and for expanded health care for seniors and children.

The bill passed the House at a 220-215 vote.

Cao said: “Today, I obtained a commitment from President Obama that he and I will work together to address the critical health care issues of Louisiana including the FMAP crisis and community disaster loan forgiveness, as well as issues related to Charity and Methodist Hospitals. And, I call on my constituents to support me as I work with him on these issues.

Cao said: “I have always said that I would put aside partisan wrangling to do the business of the people. My vote tonight was based on my priority of doing what is best for my constituents.

PoliticsDaily has put out a list of the 39 Democrats who voted against healthcare reform, their party's banner legislative effort of the year. The list is as follows:

John Adler (NJ)
Jason Altmire (PA)
Brian Baird (WA)
John Barrow (GA)
John Boccieri (OH)
Dan Boren (OK)
Rick Boucher (VA)
Allen Boyd (FL)
Bobby Bright (AL)
Ben Chandler (KT)
Travis Childers (MS)
Artur Davis (AL)
Lincoln Davis (TN)
Chet Edwards (TX)
Bart Gordon (TN)
Parker Griffith (AL)
Stephanie Herseth Sandlin (SD)
Tim Holden (PA)
Larry Kissell (NC)
Suzanne Kosmas (FL)
Frank Kratovil (MD)
Dennis Kucinich (OH)
Jim Marshall (GA)
Betsy Markey (CO)
Eric Massa (NY)
Jim Matheson(UT)
Mike McIntyre (NC)
Michael McMahon (NY)
Charlie Melancon (LA)
Walt Minnick (ID)
Scott Murphy (NY)
Glenn Nye (VA)
Collin Peterson (MN)
Mike Ross (AR)
Heath Shuler (NC)
Ike Skelton (MO)
John Tanner (TN)
Gene Taylor (MS)
Harry Teague (NM)

Some, but not all, of the 39 defectors are members of the Blue Dog Coalition, a caucus of conservative Democrats. The leaders of the Blue Dog Coalition had pushed for a broader uniform opposition among their membership to the passage of a public option. In the end, only three of the four leaders of the coalition —Herseth Sandlin, Melancon and Shuler— voted against passage, while Rep. Baron Hill (IN-09) voted for passage.

A statement published on Hill's website explained his reasoning:

As an elected representative I have been tasked with the weighty responsibility of acting as a good steward of the general welfare of my constituents and a good steward of their money. My vote in support of the Affordable Health Care for America Act is a fulfillment of those responsibilities.

Out [sic] great nation has been debating how to responsibly reform our health care system for decades. And the debate has grown increasingly important as health costs have escalated sharply – growing at nearly twice the rate of inflation, premiums rising four times faster than wages, and more than 60 percent of bankruptcies due to insurmountable medical bills. Inaction is both irresponsible and dangerous.

H.R. 3962 will allow those Hoosiers who work so hard every day but cannot afford health insurance for their families to secure it. Southern Indiana is currently home to 52,000 uninsured residents – a number that will significantly decrease under this bill.

Like Republican Rep. Ahn Joseph Cao, of Louisiana, Hill's explanation appears to make clear that ideology aside, he was convinced it was in the immediate interest of his constituents that the reform legislation be passed. Having consistently run as a conservative Democrat, Hill's vote is important, because it shows he viewed the virtue of public service as directing a vote to pass, something conservatives in the Senate may be forced to consider more closely.