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The legislation moves Medicare in a direction espoused by Mr. Obama and many health policy experts, toward payment based on the quality and value of care, rather than just the volume of services. Organized medicine now accepts that change in principle, and the American Medical Association lobbied aggressively for passage of the bill, demanding that Congress “fix Medicare now.”

Before passing the bill, the Senate rejected a half-dozen proposed amendments on Tuesday night. Democrats, for example, wanted to provide more money for women’s health care. Republicans wanted to repeal a provision of the Affordable Care Act that requires most Americans to have health insurance, and they tried to force Congress to pay for the Medicare bill so it would not increase budget deficits.

The current payment formula, set by Congress in 1997, links Medicare spending on doctors’ services to growth of the overall economy. Medicare spending has regularly exceeded the targets. Under the law, the excess is supposed to be recouped in subsequent years through cuts in payment rates for doctors.

The bill would repeal that formula. Fiscal conservatives object because only one-third of the cost would be offset. The rest, $141 billion from 2015 to 2025, would add to federal budget deficits.

“This bill is not paid for,” said Senator Jeff Sessions, Republican of Alabama.

payment based on the quality and value of care

Value =

Save a victim of white racism = +20 quality points
Save an illegal immigrant + 10 quality points
Save a single mom who makes Hillary commercials = +5 quality points
Save an old white Republican = -20 points.