Politically speaking, the health-care reform legislation passed by Democrats on Sunday constitutes an act of political willpower on the part of President Barack Obama and House Speaker Nancy Pelosi that itself appears historic.

Even many ardent supporters did not think it was possible. Opponents will be loath to concede as much, but many of those voting "aye" did so knowing their careers are in serious jeopardy as a result. Like the result or not, their votes took courage.

That said, the sweeping legislation now before the nation promises changes in American society that do not stop at the mere provenance of health care.

Its consequences - real and symbolic, intended and unintentional - will be unfolding for years and decades to come.

The immediate and most obvious impact will be contending with the cost of it. The relatively modest predictions of the severely constrained Congressional Budget Office notwithstanding, the price tag is destined to be enormous.

One of the primary "savings" anticipated from the legislation would result from a substantial cut in Medicare payments to doctors and hospitals that almost certainly will not occur. An amended CBO report released shortly before Sunday's vote predicted the health-care bill that included this restoration of cuts - the so-called "doc fix" - would add $59 billion to the deficit over the first 10 years.

Another substantial savings is anticipated from higher Social Security payments, the result of anticipated increases in employee wages. But those are funds that now won't be used to shore up the anticipated trillions of dollars of unfunded liabilities facing Social Security. File that under "Borrowing From Peter To Pay Paul."

Even before the health-care bill passed, the CBO predicted federal spending well into the knowable future at 25 percent of the gross domestic product, a figure far above the 40-year average of 20 to 21 percent. The health-care bill cements those spending levels at 25 percent, thus ensuring we will not soon run short of concerns about how to pay for our new entitlement.

There are other serious ramifications beyond the financial ones. As a measure owned politically by the Democrats, all the program's future foibles will be laid at their feet. Certainly, there will be success stories to be told, but nothing this enormous occurs without pratfalls and chaos.

Much has been said recently about Sunday's vote being the culmination of a 100-year struggle of political liberals and progressives to attain universal health care. That's one way of looking at it.

Another is that "Obamacare" is the price Republicans now have paid for refusing to confront health-care reform seriously over the years. They had a real chance to effect market-based reform after the party's 1994 takeover of Congress. GOP leaders preferred impeaching Bill Clinton and merely snickering at the proposals of Rep. John Shadegg, R-Ariz. Now, they have paid the price for their follies.

These are profound changes. Until now, the rights of Americans have been defined mostly as "negative" rights - the right to be free of an oppressive, intrusive government. A right to health care that largely flows from the federal government and through intensely regulated private health-care utilities (organizations formerly known as insurance companies) changes that dynamic.

We are in a brave, new health-care world. And we know but a fraction of what that means. The Arizona Republic