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The stakes in the elections of 2010 and 2012 have just increased exponentially.

Although many obstacles remain, the House's narrow approval of health care reform last weekend bettered the odds that President Obama will sign legislation vastly expanding the number of insured Americans. But the near-unanimous opposition of House Republicans to the bill signaled that the GOP may resist and challenge the initiative for years. That means, if the overhaul becomes law, the coming elections could determine whether nearly universal health care joins Social Security and Medicare as a central branch of the American social-welfare system -- or whether Republicans acquire the leverage to repeal or severely prune the new program before it takes root.

Since last Saturday's vote, much attention has focused on the formidable hurdles still confronting reform legislation in the Senate and on the House blueprint's imperfections, particularly its lack of key cost-containment measures, such as the independent Medicare commission proposed in the Senate Finance Committee's bill. But that focus, while understandable, has obscured the historic significance of the House's 220-215 vote approving the plan.

Some senior House Republicans have already pledged to repeal any health care bill if they regain the majority.

Franklin Roosevelt, Harry Truman, Richard Nixon, and Bill Clinton all pursued universal coverage, but none could advance such a bill as far as a floor vote in either chamber. "There is still a long way to go, but the House vote really was an historical marker," says political scientist James Morone of Brown University, the co-author of The Heart of Power, a new book analyzing how presidents since FDR have handled health care. "We have had brilliant, successful, charismatic leadership at various times in American history. And no one has gotten as far as this Congress and this president."

If Obama does sign a reform bill, which appears more likely than not, Republicans will face a momentous choice between consolidation and repudiation -- between accepting the new program and seeking to dismantle it. The alternative paths are neatly captured by the GOP's contrasting reactions to the two central cords of America's existing social safety net. After FDR got Social Security approved in 1935, Alf Landon, his Republican challenger in 1936, denounced it as "unjust ... stupidly drafted [and] ... folly." Roosevelt's landslide victory over Landon (and subsequent re-elections) provided Social Security the time to build impregnable support. But many congressional Republicans kept fighting the program until President Eisenhower, a Republican, declared a truce after his election in 1952.

By contrast, Republicans largely accepted Medicare soon after President Johnson signed it into law in 1965. Although conservative Republicans such as Barry Goldwater and Ronald Reagan had fiercely condemned the program before its creation, Nixon during the 1968 campaign spared Medicare from his criticism of the Great Society's cost. Once elected, he quickly "became a strong supporter of Medicare" and effectively ended challenges to its existence, Morone notes.

Which path might Republicans follow if Obama signs universal health care? Several factors point toward confrontation. The GOP accepted Medicare so quiescently partly because the program began dispensing benefits just one year after passage and rapidly became too popular to assail. Social Security, though, was phased in over many years--as health care reform is slated to be. Such delay can invite "fierce and protracted ... guerrilla war," notes Harvard sociologist Theda Skocpol.

Also encouraging confrontation is the breadth of Republican opposition. Almost all House Republicans at the time voted to derail Medicare and Social Security by "recommitting" the bills to committee. But once those challenges failed, about half of House Republicans backed Medicare on final passage and four-fifths supported Social Security. House Republicans last week voted 176-1 against the health care bill.

Some senior House Republicans have already pledged to repeal any health care bill if they regain the majority. And many GOP challengers in 2010 will surely echo them. But with Obama holding a veto pen, Republicans probably couldn't mount a real threat unless they won the White House in 2012. One top adviser to a possible 2012 GOP presidential contender says that, given the GOP base's hostility to the reform plan and independents' unease, it is likely that "most potential [Republican] candidates will argue for wholesale replacement with their own version of health care reform."

If Obama passes health reform and Republicans then seek its repeal, the next presidential election could lastingly redefine America's social safety net. Like 1936 and 1968, 2012 looms as a crossroads in the relationship between Americans and their government.