the bill: a cloture vote to end the filibuster by opponents. the bill then passed by a vote of 60–39 on december 24, 2009, with all democrats and two independents voting for, and all republicans voting against except one (jim bunning (r-ky), not voting). the bill was endorsed by the ama and aarp. several weeks after the vote, on january 19, 2010, massachusetts republican scott brown was elected to the senate in a special election to replace the late ted kennedy, having campaigned on giving the republican minority the 41st vote needed to sustain filibusters, even signing autographs as "scott 41." the special election had become significant to the reform debate because of its effects on the legislative process. the first was a psychological one: the symbolic importance of losing the traditionally democratic (‘blue’) massachusetts seat formerly held by ted kennedy, a staunch support of reform, made many congressional democrats concerned about the political cost of passing a bill. the second effect was more practical: the loss of the democrat's supermajority complicated the legislative strategy of reform proponents. house house vote by congressional district. democratic yea democratic nay republican nay no representative seated president obama signing the patient protection and affordable care act on march 23, 2010. the election of scott brown meant democrats could no longer break a filibuster in the senate. in response, white house chief of staff rahm emanuel argued the democrats should scale-back for a less ambitious bill; house speaker nancy pelosi pushed back, dismissing emanuel's scaled-down approach as "kiddie care." obama also remained insistent on comprehensive reform, and the news that anthem in california intended to raise premium rates for its patients by as much as 39% gave him a new line of argument to reassure nervous democrats after scott brown's win. on february 22 obama laid out a "senate-leaning" proposal to consolidate the bills. he also held a meeting, on february 25, with leaders of both parties urging passage of a reform bill. the summit proved successful in shifting the political narrative away from the massachusetts loss back to healthcare policy. with democrats having lost a filibuster-proof supermajority in the senate, but having already passed the senate bill with 60 votes on december 24, the most viable option for the proponents of comprehensive reform was for the house to abandon its own health reform bill, the affordable health care for america act, and pass the senate's bill, the patient protection and affordable care act, instead. various health policy experts encouraged the house to pass the senate version of the bill. however, house democrats were not happy with the content of the senate bill, and had expected to be able to negotiate changes in a house–senate conference before passing a final bill. with that option off the table, as any bill that emerged from conference that differed from the senate bill would have to be passed in the senate over another republican filibuster; most house democrats agreed to pass the senate bill on condition that it be amended by a subsequent bill. they drafted the health care and education reconciliation act, which could be passed via the reconciliation process. unlike rules under regular order, as per the congressional budget act of 1974 reconciliation cannot be subject to a filibuster, which requires 60 votes to break, but the process is limited to budget changes; this is why the procedure was never able to be used to pass a comprehensive reform bill in the first place, such as the aca, due to inherently non-budgetary regulations. whereas the already passed senate bill could not have been put through reconciliation, most of house democrats' demands were budgetary: "these changes – higher subsidy levels, different kinds of taxes to pay for them, nixing the nebraska medicaid deal – mainly involve taxes and spending. in other words, they're exactly the kinds of policies that are well-suited for reconciliation." the remaining obstacle was a pivotal group of anti-abortion democrats, initially reluctant to support the bill, led by congressman bart stupak. the group found the possibility of federal funding for abortion would be substantive enough to warrant opposition. the senate bill had not included language that satisfied their abortion concerns, but they could not include additional such language in the reconciliation bill, as it would be outside the scope of the process with its budgetary limits. instead, president obama issued executive order 13535, reaffirming the principles in the hyde amendment. this concession won the support of stupak and members of his group and assured passage of the bill. the house passed the senate bill with a vote of 219 to 212 on march 21, 2010, with 34 democrats and all 178 republicans voting against it. the following day, republicans introduced legislation to repeal the bill. obama signed the aca into law on march 23, 2010. the amendment bill, the health care and education reconciliation act, was also passed by the house on march 21, then by the senate via reconciliation on march 25, and finally signed by president obama on march 30. state and city reform efforts a few states have taken steps toward universal health care coverage, most notably minnesota, massachusetts and connecticut. examples include the massachusetts 2006 health reform statute and connecticut's sustinet plan to provide health care to state residents. the influx of more than a quarter of a million newly insured residents has led to overcrowded waiting rooms and overworked primary-care physicians who were already in short supply in massachusetts. other states, while not attempting to insure all of their residents, cover large numbers of people by reimbursing hospitals and other health care providers using what is generally characterized as a charity care scheme; new jersey is an example of a state that employs the latter strategy. several single payer referendums have been proposed at the state level, but so far all have failed to pass: california in 1994, massachusetts in 2000, and oregon in 2002. the state legislature of california twice passed sb 840, the health care for all californians act, a single-payer health care system. both times, governor arnold schwarzenegger (r) vetoed the bill, once in 2006 and again in 2008. the percentage of residents that are uninsured varies from state to state. in 2008 texas had the highest percentage of residents without health insurance, 24%. new mexico had the second highest percentage of uninsured that year at 22%. states play a variety of roles in the health care system including purchasers of health care and regulators of providers and health plans, which give them multiple opportunities to try to improve how it functions. while states are actively working to improve the system in a variety of ways, there remains room for them to do more. one municipality, san francisco, california, has established a program to provide health care to all uninsured residents (healthy san francisco). in july 2009, connecticut passed into law a plan called sustinet, with the goal of achieving health care coverage of 98% of its residents by 2014. the sustinet law establishes a nine-member board to recommend to the legislature, by january 1, 2011, the details of and implementation process for a self-insured health care plan called sustinet. the recommendations must address (1) the phased-in offering of the sustinet plan to state employees and retirees, husky a and b beneficiaries, people without employer-sponsored insurance (esi) or with unaffordable esi, small and large employers, and others; (2) establishing an entity that can contract with insurers and health care providers, set reimbursement rates, develop medical homes for patients, and encourage the use of health information technology; (3) a model benefits package; and (4) public outreach and ways to identify uninsured citizens. the board must establish committees to make recommendations to it about health information technology, medical homes, clinical care and safety guidelines, and preventive care and improved health outcomes. the act also establishes an independent information clearinghouse to inform employers, consumers, and the public about sustinet and private health care plans and creates task forces to address obesity, tobacco usage, and health care workforce issues. the effective date of the sustinet law was july 1, 2009, for most provisions. in may 2011, the state of vermont became the first state to pass legislation establishing a single-payer health care system. the legislation, known as act 48, establishes health care in the state as a "human right" and lays the responsibility on the state to provide a health care system which best meets the needs of the citizens of vermont. in december 2014, the governor of the state of vermont suspended plans to implement this single-payer system because of its cost.