audience. on june 15, 2009, the u.s. congressional budget office (cbo) issued a preliminary analysis of the major provisions of the affordable health choices act. the cbo estimated the ten-year cost to the federal government of the major insurance-related provisions of the bill at approximately $1.0 trillion. over the same ten-year period from 2010 to 2019, the cbo estimated that the bill would reduce the number of uninsured americans by approximately 16 million. at about the same time, the associated press reported that the cbo had given congressional officials an estimate of $1.6 trillion for the cost of a companion measure being developed by the senate finance committee. in response to these estimates, the senate finance committee delayed action on its bill and began work on reducing the cost of the proposal to $1.0 trillion, and the debate over the affordable health choices act became more acrimonious. congressional democrats were surprised by the magnitude of the estimates, and the uncertainty created by the estimates has increased the confidence of republicans who are critical of the obama administration's approach to health care. however, in a june new york times editorial, economist paul krugman argued that despite these estimates universal health coverage is still affordable. "the fundamental fact is that we can afford universal health insurance—even those high estimates were less than the $1.8 trillion cost of the bush tax cuts." in contrast to earlier advocacy of a publicly funded health care program, in august 2009 obama administration officials announced they would support a health insurance cooperative in response to deep political unrest amongst congressional republicans and amongst citizens in town hall meetings held across america. however, in a june 2009 nbc news/wall street journal survey, 76% said it was either "extremely" or "quite" important to "give people a choice of both a public plan administered by the federal government and a private plan for their health insurance." during the summer of 2009, members of the "tea party" protested against proposed health care reforms. former insurance pr executive wendell potter of the center for media and democracy- whose funding comes from groups such as the tides foundation- argue that the hyperbole generated by this phenomenon is a form of corporate astroturfing, which he says that he used to write for cigna. opponents of more government involvement, such as phil kerpen of americans for prosperity- whose funding comes mainly from the koch industries corporation counter-argue that those corporations oppose a public-plan, but some try to push for government actions that will unfairly benefit them, like employer mandates forcing private companies to buy health insurance. journalist ben smith has referred to mid-2009 as "the summer of astroturf" given the organizing and coordinating efforts made by various groups on both pro- and anti-reform sides. healthcare debate, 2008–2010 healthcare reform was a major topic of discussion during the 2008 democratic presidential primaries. as the race narrowed, attention focused on the plans presented by the two leading candidates, new york senator hillary clinton and the eventual nominee, illinois senator barack obama. each candidate proposed a plan to cover the approximately 45 million americans estimated to not have health insurance at some point each year. clinton's plan would have required all americans obtain coverage (in effect, an individual health insurance mandate), while obama's provided a subsidy but did not include a mandate. during the general election, obama said that fixing healthcare would be one of his top four priorities if he won the presidency. president obama addressing congress regarding healthcare reform, september 9, 2009. after his inauguration, obama announced to a joint session of congress in february 2009 his intent to work with congress to construct a plan for healthcare reform. by july, a series of bills were approved by committees within the house of representatives. on the senate side, from june through to september, the senate finance committee held a series of 31 meetings to develop of a healthcare reform bill. this group – in particular, senators max baucus (d-mt), chuck grassley (r-ia), kent conrad (d-nd), olympia snowe (r-me), jeff bingaman (d-nm), and mike enzi (r-wy) – met for more than 60 hours, and the principles that they discussed, in conjunction with the other committees, became the foundation of the senate's healthcare reform bill. with universal healthcare as one of the stated goals of the obama administration, congressional democrats and health policy experts like jonathan gruber and david cutler argued that guaranteed issue would require both a community rating and an individual mandate to prevent either adverse selection and/or free riding from creating an insurance death spiral; they convinced obama that this was necessary, persuading him to accept congressional proposals that included a mandate. this approach was preferred because the president and congressional leaders concluded that more liberal plans, such as medicare-for-all, could not win filibuster-proof support in the senate. by deliberately drawing on bipartisan ideas – the same basic outline was supported by former senate majority leaders howard baker (r-tn), bob dole (r-ks), tom daschle (d-sd) and george mitchell (d-me) – the bill's drafters hoped to increase the chances of getting the necessary votes for passage. however, following the adoption of an individual mandate as a central component of the proposed reforms by democrats, republicans began to oppose the mandate and threaten to filibuster any bills that contained it. senate minority leader mitch mcconnell (r-ky), who lead the republican congressional strategy in responding to the bill, calculated that republicans should not support the bill, and worked to keep party discipline and prevent defections:it was absolutely critical that everybody be together because if the proponents of the bill were able to say it was bipartisan, it tended to convey to the public that this is o.k., they must have figured it out. republican senators, including those who had supported previous bills with a similar mandate, began to describe the mandate as "unconstitutional". writing in the new yorker, ezra klein stated that "the end result was... a policy that once enjoyed broad support within the republican party suddenly faced unified opposition." the new york times subsequently noted: "it can be difficult to remember now, given the ferocity with which many republicans assail it as an attack on freedom, but the provision in president obama's healthcare law requiring all americans to buy health insurance has its roots in conservative thinking." tea party protesters at the taxpayer march on washington, september 12, 2009. the reform negotiations also attracted a great deal of attention from lobbyists, including deals among certain lobbies and the advocates of the law to win the support of groups who had opposed past reform efforts, such as in 1993. the sunlight foundation documented many of the reported ties between "the healthcare lobbyist complex" and politicians in both major parties. during the august 2009 summer congressional recess, many members went back to their districts and entertained town hall meetings to solicit public opinion on the proposals. over the recess, the tea party movement organized protests and many conservative groups and individuals targeted congressional town hall meetings to voice their opposition to the proposed reform bills. there were also many threats made against members of congress over the course of the congressional debate, and many were assigned extra protection. to maintain the progress of the legislative process, when congress returned from recess, in september 2009 president obama delivered a speech to a joint session of congress supporting the ongoing congressional negotiations, to re-emphasize his commitment to reform and again outline his proposals. in it he acknowledged the polarization of the debate, and quoted a letter from the late-senator ted kennedy urging on reform: "what we face is above all a moral issue; that at stake are not just the details of policy, but fundamental principles of social justice and the character of our country." on november 7, the house of representatives passed the affordable health care for america act on a 220–215 vote and forwarded it to the senate for passage. senate the senate began work on its own proposals while the house was still working on the affordable health care for america act. instead, the senate took up h.r. 3590, a bill regarding housing tax breaks for service members. as the united states constitution requires all revenue-related bills to originate in the house, the senate took up this bill since it was first passed by the house as a revenue-related modification to the internal revenue code. the bill was then used as the senate's vehicle for their healthcare reform proposal, completely revising the content of the bill. the bill as amended would ultimately incorporate elements of proposals that were reported favorably by the senate health and finance committees. with the republican minority in the senate vowing to filibuster any bill that they did not support, requiring a cloture vote to end debate, 60 votes would be necessary to get passage in the senate. at the start of the 111th congress, democrats had only 58 votes; the senate seat in minnesota that would be won by al franken was still undergoing a recount, and arlen specter was still a republican. to reach 60 votes, negotiations were undertaken to satisfy the demands of moderate democrats, and to try to bring aboard several republican senators; particular attention was given to bob bennett (r-ut), chuck grassley (r-ia), mike enzi (r-wy), and olympia snowe (r-me). negotiations continued even after july 7—when al franken was sworn into office, and by which time arlen specter had switched parties—because of disagreements over the substance of the bill, which was still being drafted in committee, and because moderate democrats hoped to win bipartisan support. however, on august 25, before the bill could come up for a vote, ted kennedy—a long-time advocate for healthcare reform—died, depriving democrats of their 60th vote. before the seat was filled, attention was drawn to senator snowe because of her vote in favor of the draft bill in the finance committee on october 15, however she explicitly stated that this did not mean she would support the final bill. paul kirk was appointed as senator kennedy's temporary replacement on september 24. following the finance committee vote, negotiations turned to the demands of moderate democrats to finalize their support, whose votes would be necessary to break the republican filibuster. majority leader harry reid focused on satisfying the centrist members of the democratic caucus until the hold-outs narrowed down to connecticut's joe lieberman, an independent who caucused with democrats, and nebraska's ben nelson. lieberman, despite intense negotiations in search of a compromise by reid, refused to support a public option; a concession granted only after lieberman agreed to commit to voting for the bill if the provision was not included, even though it had majority support in congress. there was debate among supporters of the bill about the importance of the public option, although the vast majority of supporters concluded that it was a minor part of the reform overall, and that congressional democrats' fight for it won various concessions; this included conditional waivers allowing states to set up state-based public options, for example vermont's green mountain care. senate vote by state. democratic yea independent yea republican nay republican not voting with every other democrat now in favor and every other republican now overtly opposed, the white house and reid moved on to addressing senator nelson's concerns in order to win filibuster-proof support for the bill; they had by this point concluded that "it was a waste of time dealing with " because, after her vote for the draft bill in the finance committee, snowe had come under intense pressure from the republican senate leadership who opposed reform. (snowe retired at the end of her term, citing partisanship and polarization). after a final 13-hour negotiation, nelson's support for the bill was won after two concessions: a compromise on abortion, modifying the language of the bill "to give states the right to prohibit coverage of abortion within their own insurance exchanges," which would require consumers to pay for the procedure out-of-pocket if the state so decided; and an amendment to offer a higher rate of medicaid reimbursement for nebraska. the latter half of the compromise was derisively referred to as the "cornhusker kickback" and was later repealed by the subsequent reconciliation amendment bill. on december 23, the senate voted 60–39 to end debate on