One by one, House Speaker Nancy Pelosi had leaned on her rank-and-file Democrats for months to cast off personal prerogatives for the sake of a history-making health care bill.

But for Connecticut Rep. Rosa DeLauro, this was too much to ask.

So when Pelosi announced late Friday that she would allow an amendment strictly limiting insurance coverage of abortions, it touched off an angry yelling match between DeLauro and another Pelosi confidant, California Rep. George Miller, and tears from some veteran female lawmakers, according to people in the room.

Some of the lawmakers argued that Pelosi was turning her back on a decades-long campaign by female Democratic members in support of abortion rights. Miller rose to Pelosi’s defense, which resulted in an angry confrontation between him and DeLauro, said the sources.

Miller told DeLauro that there were “more pro-life votes in the House than pro-choice” and that abortion-rights advocates had better acknowledge that reality.

In the end, Pelosi’s strategy paid off in a big win for her and President Barack Obama. After Rep. Bart Stupak’s (D-Mich.) amendment banning abortion funding was approved with 64 Democratic votes, Pelosi was able to push through the health care reform package on a virtually straight-line party vote, 220-215.

Pelosi wasn’t the only one getting pressure on the amendment. As rumors spread that Republicans might vote “present” in order to scuttle the entire bill, even Cardinal Francis George, archbishop of Chicago and president of the U.S. Conference of Catholic Bishops, called Republican leader John Boehner to make sure the GOP didn’t play any games with the Stupak amendment, sources said.

But the speaker’s decision — like so many others she made during the drafting of this bill — showed Pelosi, a Roman Catholic and committed supporter of reproductive rights, to be more ruthlessly practical than her frequent caricature as an activist, upper-crust liberal from San Francisco would suggest.

It wasn’t just that she was disappointing some members over a last-minute change they disagreed with. She had to take on her closest and senior-most lieutenants on an issue that for many of them is like an article of faith, a defining tenet of what makes them a Democrat. And when she needed the votes, that’s what she did.

In an interview, DeLauro denied yelling at Miller, although the Connecticut Democrat admitted that she made her views “strongly known” to those in the room. 

But in the end, DeLauro said, she and other pro-abortion-rights lawmakers weren’t willing to derail the entire health care bill over the issue.

“I stood my ground,” DeLauro said. “The speaker does that, Mr. Miller does that, [House Majority Leader Steny] Hoyer does that. We all stand our ground. We also know, we all know, that you must focus on the endgame, and that’s to pass health care.”

But if Pelosi defied her caricature in one regard, she lived up to another part of her reputation — as a diligent vote counter, who knew when to stroke the needs of her diverse membership and when to make the hard decisions to deliver the bill she and others in her caucus have long dreamed about.

The drama had built for months, pitting a group of Democrats against the Catholic Church. Priests and bishops were calling members to lobby for stricter language to limit abortion coverage, members and aides said last week.

But the final decision played out over a few furious hours Friday night as the fate of the broader bill still hung in the balance and stirred up long-dormant tensions within the Democratic Party over reproductive rights.

The beneficiary of this impasse was Stupak, an outspoken abortion-rights opponent whom the leadership had tried to circumvent, in order to pick up the votes he claimed to represent. After months of stalemate, the speaker was forced to accept language Stupak first drafted over the summer that would bar anyone receiving a federal subsidy from purchasing a private plan that covers elective abortion. In addition, under Stupak, the public plans would not be allowed to offer abortion coverage prohibited under the Hyde amendment.

“Normally, at the end of the day, you’re arguing over fine-tuning,” said an aide whose boss was involved in the negotiations. “But this is a sizable change to current policy. So everyone was kind of stunned.”

For more than a decade, the Hyde amendment has prohibited the federal government from paying for abortions through any existing government program. The law needs to be reauthorized each year as part of the appropriations process, but the two sides had come to something of a détente.

The health care fight, however, disrupted that balance, and a big bloc of anti-abortion Democrats were threatening to derail the entire bill unless party leaders agreed to stronger restrictions the church could accept. Since mid-September, House Majority Leader Steny Hoyer had been working closely with Rep. Brad Ellsworth (D-Ind.) to craft language that would thread what proved to be an impossible needle.

Ellsworth, in consultation with the U.S. Conference of Catholic Bishops, was trying to amend legislation passed out of the Energy and Commerce Committee to make sure insurance companies that receive federal funds under the programs created by the bill don’t use any of that money to pay for abortions.

By Thursday, Ellsworth, who was working closely with Rep. Mike Doyle (D-Pa.) realized the church wouldn’t accept anything less than a version of Hyde, so he and his staff started working on a version the bishops could accept, aides said.

Ellsworth reached out to Stupak on Thursday, and Friday evening they met with Pelosi, Hoyer and Rep. Henry Waxman, at which point the group agreed to include much stricter language than most thought they would.

But they realized they would need Republican votes to approve the rule — and win the support of the church and, in turn, wavering Democrats — meaning they needed to go much further than anyone anticipated to bring an avowed Democratic opponent, National Right to Life, on board, aides involved said afterward.

Pelosi met with members of the Pro-Choice Caucus repeatedly that day, and finally, during the contentious three-hour session that resulted in the DeLauro-Miller shouting match, Pelosi broke the bad news to abortion-rights supporters — she was going to allow a vote on the Stupak amendment.

Multiple sources said Pelosi’s decision angered DeLauro and other Democrats who support abortion rights, like Reps. Diana DeGette of Colorado, Louise Slaughter of New York and Lois Capps of California. Slaughter even boycotted her own Rules Committee while it debated the amendment.

“He moved the goal posts, and he said if he didn’t get his amendment made in order, he would vote against the bill,” DeGette said of Stupak. “The speaker concluded that she needed the votes.”

“I don’t believe any of us believe we can hold up what we’ve been fighting for ... and that’s health care,” Slaughter said before the vote.

The result produced plenty of ill will, but it was hardly the only major problem with the bill. Pelosi and other leaders knew that support for it had been waning all week. Any further delay could cripple their efforts. So they pressed ahead with a bill that no one loved but almost everyone still believed in.

The abortion fight was hardly the only delicate compromise. Liberals accepted a watered-down public option. Conservatives swallowed hard on the bill’s staggering costs. But these Democrats still backed the bill despite finding it “deeply flawed.”

CORRECTION: An earlier version of this story incorrectly stated the restrictions on abortion coverage in the Stupak amendment. The amendment would bar anyone receiving a federal subsidy from purchasing a private plan that covers elective abortion. It would also prevent public plans from offering abortion coverage as currently prohibited by federal law.