Roughly 39 Democrats voted against it, including three in North Carolina.
One rural Democrat, who did vote yes, is already hearing from critics who own small businesses in his district.
"I think he's in a really tough position." Angier small business owner Sue Langley said.
Langley has operated an internet hair bow business for 25 years.
Langley personally knows her congressman, Democrat U.S. Rep. Bob Ethridge.
But she says she fears he cast a health care vote which could hurt small business.
"I'm sure it was hard for him, because he knows people like us are struggling in these little towns."
Langley is worried employers will be forced to insure their workers, or pay more in taxes.
Other small business owners say Ethridge got it wrong.
"I think it's going to hurt him," Harnett County Commissioner Jim Burgin said. "I sincerely believe that the public in Harnett County if he would have listened to us, he would have voted no."
Health reform which passed the House would not tax small businesses with pay-rolls below $500,000.
And Ethridge and other Democrats have said insurance costs are out of control.
"Everyone is worried about cost and that's always a problem," Etheridge said. "But the bigger problem of that is if you get sick and you lose everything you've got, that's a huge issue."
Langley says she hopes to open her store in January, but is worried about new health costs.
"Republicans take a little piece and say this is what it's going to be and Democrats take a little piece and say what it's going to be," she said.
And she says she's not sure if her congressman's vote will hurt or help.
Three North Carolina Democrats who voted against health care reform were Heath Shuler, Mike McIntyre, and Larry Kissell.