ACA Vote in the Senate: Kickbacks, McCain Repeal, and Subsidies

The Senate passed the Affordable Care Act on Christmas Eve 2009 by a vote of 60 to 39, with every Democrat and independent voting yes and every Republican voting no. That was the decisive ACA vote in the Senate, but it is not the only one. The chamber has voted on the law again at two major inflection points: the 2017 repeal attempts that ended with John McCain’s thumbs-down, and the 2025 fight over the enhanced premium subsidies that ultimately expired at the end of that year.

The December 24, 2009 Passage Vote

After weeks of round-the-clock sessions, the Senate voted on the Patient Protection and Affordable Care Act on the morning of December 24, 2009. The tally was 60 yeas, 39 nays.¹ The cloture vote the day before, on December 23, produced the same 60-39 split, with Republican Jim Bunning of Kentucky not voting.²

All 58 Democrats voted yes. Both independents, Bernie Sanders of Vermont and Joe Lieberman of Connecticut, voted yes. Every Republican present voted no. It was one of the most partisan major legislative votes in modern Senate history, and it happened only because a set of unlikely events had briefly given Democrats the 60 votes needed to break a filibuster.

How Democrats Got to 60

When Barack Obama took office on January 20, 2009, the Democratic caucus held 58 seats. Two events pushed the count to 60. In April 2009, Pennsylvania Senator Arlen Specter switched from Republican to Democrat. On June 30, 2009, the Minnesota Supreme Court declared Al Franken the winner of his contested race, seating him after a seven-month delay.³⁴

The margin was fragile. Ted Kennedy’s death in August 2009 dropped the count back to 59, and Paul Kirk was appointed to fill the seat temporarily in September, restoring the supermajority as the bill entered its most critical phase.⁴ The window was closing. Republican Scott Brown won the Massachusetts special election and was sworn in on February 4, 2010, ending the supermajority. The Senate had to finish its work before Brown arrived, and every one of the 60 votes had leverage.³

The Deals Inside the 60 Votes

Because Democrats could not afford to lose a single senator, several moderates extracted concessions. Two became public symbols of the process.

The Cornhusker Kickback

Senator Ben Nelson of Nebraska withheld his support until leadership agreed to roughly $100 million in additional federal Medicaid funding for his state.⁵ Minority Leader Mitch McConnell called the provision a “smelly proposition,” and a dozen Republican state attorneys general argued it was unconstitutional.⁶ Nelson himself eventually advocated for its removal, and the reconciliation sidecar bill later stripped it out and applied Medicaid assistance equally across states.

The Louisiana Purchase

Senator Mary Landrieu of Louisiana secured about $300 million in extra Medicaid funding for her state, framed as disaster relief tied to Hurricane Katrina.⁷ Critics called it the “Louisiana Purchase.” Landrieu rejected the trade characterization as “an outright lie” and said the provision had been requested by state officials including Republican Governor Bobby Jindal.⁸

Lieberman Kills the Public Option

The single senator who most shaped the final text was Joe Lieberman. In late October 2009, he announced he would join a Republican filibuster against any bill containing a government-run public insurance option.⁹ Leaders tried a compromise that would have let people aged 55 to 64 buy into Medicare. Lieberman killed that too, and in December 2009 President Obama instructed congressional leaders to rewrite the bill to accommodate him.¹⁰ The public option and the Medicare buy-in were both removed.¹¹

Progressives were furious. Former DNC Chairman Howard Dean called it “the collapse of health care reform in the United States Senate” and urged killing the bill. Senator Roland Burris called the compromises “surrender.” Senator Sherrod Brown said he had personally appealed to Lieberman to preserve the Medicare buy-in and failed.¹¹ Critics also noted Lieberman had received over $1 million in campaign contributions from the medical insurance industry over his career, and his wife had worked as a health and pharmaceutical lobbyist.¹⁰

Finishing the Bill After Scott Brown

The House approved the Senate’s version on March 21, 2010, by a vote of 219 to 212. No Republicans voted yes, and 34 Democrats voted no. Passage depended in part on an agreement with abortion-rights opponents led by Representative Bart Stupak, who received a promise from Obama to issue an executive order barring federal funds from being used for abortion services.¹²

Because Brown had already ended the Democratic supermajority, a traditional conference committee was impossible. Any revised bill returning to the Senate would have been filibustered. Democrats instead used budget reconciliation, which requires only a simple majority, to pass a separate sidecar bill making adjustments.¹³

The Health Care and Education Reconciliation Act of 2010 (H.R. 4872) removed the Cornhusker Kickback, adjusted the individual mandate penalty structure, increased premium tax credits and cost-sharing subsidies for lower-income enrollees, and extended consumer protections such as the ban on lifetime coverage limits and the coverage of adult children up to age 26 to grandfathered health plans.¹⁴ The Senate passed the reconciliation bill on March 25, 2010, by a vote of 56 to 43.¹⁵ Obama signed the ACA on March 23, 2010, and the reconciliation bill on March 30.³

The 2017 Repeal Votes and McCain’s Thumbs-Down

After winning the presidency and both chambers in 2016, Republicans moved to repeal the ACA. In July 2017, the Senate considered a series of measures in rapid succession. A “repeal and replace” plan failed. A “straight repeal” bill, the same one Congress had passed in 2015 and Obama had vetoed, also failed.

The final attempt was the “skinny repeal,” officially the Health Care Freedom Act, which would have eliminated the individual and employer mandates, defunded Planned Parenthood for one year, and repealed the medical device tax. The Congressional Budget Office estimated it would have left 16 million more people uninsured in 2018 and raised premiums by 20 percent annually over the following decade.¹⁶

In the early hours of July 28, 2017, the skinny repeal failed 49 to 51. Three Republicans voted no: John McCain of Arizona, Susan Collins of Maine, and Lisa Murkowski of Alaska. McCain walked to the front of the chamber and turned his thumb down, producing audible gasps.¹⁶ In a statement, McCain said the skinny repeal offered “no replacement to actually reform our health care system” and urged the Senate to return to regular legislative order.¹⁷ Murkowski opposed every version of the repeal legislation that reached the floor.

Republicans secured a partial victory later that year. The Tax Cuts and Jobs Act, which passed the Senate on December 2, 2017, by a vote of 51 to 49, zeroed out the individual mandate penalty and effectively eliminated the enforcement mechanism for the ACA’s coverage requirement.¹⁸

The 2025 Vote on ACA Subsidies

The enhanced premium tax credits first established by the American Rescue Plan Act in 2021 and extended by the Inflation Reduction Act in 2022 capped Marketplace premiums at 8.5 percent of income for households above 400 percent of the federal poverty level. Marketplace enrollment climbed from 11.4 million in 2020 to 24.3 million by 2025 under those subsidies, which were set to expire at the end of 2025.¹⁹

On December 11, 2025, the Senate held votes on two competing proposals. The Democratic-led Lower Health Care Costs Act would have extended the enhanced subsidies for three years. A Republican alternative from Senators Bill Cassidy and Mike Crapo would have provided up to $1,500 annually in health savings account payments but not extended the ACA tax credits. Both measures failed 51 to 48, short of the 60-vote threshold to advance.²⁰

Four Republicans voted for the Democratic proposal: Susan Collins of Maine, Lisa Murkowski of Alaska, Dan Sullivan of Alaska, and Josh Hawley of Missouri. Hawley said he was “an all-of-the-above-approach kind of guy” on bringing down premiums, adding that “if you talk to people, what they’re going to say is their health care costs are out of control.”²¹

The subsidies expired on December 31, 2025. On January 8, 2026, the House passed its own three-year extension bill (H.R. 1834) by a vote of 230 to 196, with 17 Republicans joining all Democrats.²² The bill stalled in the Senate. Bipartisan negotiations over a compromise, the Consumer Affordability and Responsibility Enhancement (CARE) Act, were described as being on “shaky ground” by mid-January 2026, with disagreements over abortion-related funding and other issues blocking progress. President Trump’s health care framework, released on January 15, 2026, did not include a subsidy extension.²³ As of mid-2026, potential vehicles include upcoming appropriations bills or a reconciliation package, but no substantive action has been taken.²⁴

1
U.S. Senate. Roll Call Vote 396, 111th Congress
2
U.S. Senate. Roll Call Vote 395, 111th Congress
3
Harvard Journal on Legislation. The Extraordinary Path to 60 Votes
4
HuffPost. Debunking the Myth: Obama’s Two-Year Supermajority
5
NBC News. Cornhusker Kickback Dropped From Health Bill
6
Public Citizen. Corker Kickback vs. Cornhusker Kickback
7
The Christian Science Monitor. Healthcare’s Dealbreakers: Mary Landrieu Likes Her $300 Million
8
Roll Call. Landrieu Defends ‘Louisiana Purchase’ in Health Reform
9
CNN. Lieberman Threatens to Filibuster Public Option
10
The Guardian. Lieberman Forces Obama to Retreat on Healthcare
11
The Commonwealth Fund. Senate Democrats Drop Public Option, Woo Lieberman, and Liberals Howl
12
The New York Times. Obama Hails Vote on Health Care as Answering the Call of History
13
Citizens Against Government Waste. Why the Obamacare Reconciliation Bill Is So Important
14
Congressional Research Service. Health Care and Education Reconciliation Act Summary
15
Senate Committee on Finance. Health Care Reform Timeline
16
NBC News. Senate GOP Effort to Repeal Obamacare Fails
17
NPR. Senate Careens Toward High-Drama Midnight Health Care Vote
18
U.S. Senate. Roll Call Vote 303, 115th Congress
19
KFF. Inflation Reduction Act Health Insurance Subsidies
20
NPR. Senate ACA Premium Vote
21
The Hill. Republican Senators Vote for Democratic Obamacare Bill
22
American Journal of Managed Care. House Votes to Extend ACA Subsidies, Eyes Turn to Senate
23
Politico. The Senate’s Bipartisan Health Care Talks Are on Shaky Ground
24
Association of State and Territorial Health Officials. ACA Enhanced Premium Tax Credits Legislative Developments