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Health care reform

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Once the stimulus bill was enacted in February 2009, health care reform became Obama's top domestic priority, and the 111th Congress passed a major bill that eventually became widely known as "Obamacare." Health care reform had long been a top priority of the Democratic Party, and Democrats were eager to implement a new plan that would lower costs and increase coverage. In contrast to Bill Clinton's 1993 plan to reform health care, Obama adopted a strategy of letting Congress drive the process, with the House and Senate writing their own bills. In the Senate, a bipartisan group of Senators on the Finance Committee known as the Gang of Six began meeting with the hope of creating a bipartisan healthcare reform bill, though the Republican Senators involved with the crafting of the bill ultimately came to oppose it. In November 2009, the House passed the Affordable Health Care for America Act on a 220-215 vote, with only one Republican voting for the bill. In December 2009, the Senate passed its own health care reform bill, the Patient Protection and Affordable Care Act (PPACA or ACA), on a party-line, 60-39 vote.  Both bills expanded Medicaid and provided health care subsidies, while establishing an individual mandate, health insurance exchanges, and a ban on denying coverage based on pre-existing conditions. However, the House bill included a tax increase on families making more than $1 million per year and a public health insurance option, while the Senate plan included an excise tax on high-cost health plans.

The 2010 Massachusetts Senate special election victory of Scott Brown seriously imperiled the prospects of a health care reform bill, as Democrats lost their 60-seat Senate super-majority. The White House and Speaker Nancy Pelosi engaged in an extensive campaign to convince both centrists and liberals in the House to pass the Senate's health care bill, the Patient Protection and Affordable Care Act. In March 2010, after Obama announced an executive order reinforcing the current law against spending federal funds for elective abortion services, the House passed the Patient Protection and Affordable Care Act. The bill, which had passed the Senate in December 2009, did not receive a single Republican vote in either house. On March 23, 2010, President Obama signed the PPACA into law. The New York Times described the PPACA as "the most expansive social legislation enacted in decades," while the Washington Post noted that it was the biggest expansion of health insurance coverage since the creation of Medicare and Medicaid in 1965. Both houses of Congress also passed a reconciliation measure to make significant changes and corrections to the PPACA; this second bill was signed into law on March 30, 2010. The Patient Protection and Affordable Care Act became widely known as the Affordable Care Act (ACA) or "Obamacare."

The Affordable Care Act faced considerable challenges and opposition after its passage, and Republicans continually attempted to repeal the law. The law also survived two major challenges that went to the Supreme Court. In National Federation of Independent Business v. Sebelius, a 5-4 majority upheld the constitutionality of the Affordable Care Act, though it made state Medicaid expansion voluntary. In King v. Burwell, a 6-3 majority allowed the use of tax credits in state-operated exchanges. The October 2013 launch of HealthCare.gov, a health insurance exchange website created under the provisions of the ACA, was widely criticized, though many of the problems were fixed by the end of the year. The number of uninsured Americans dropped from 20.2% of the population in 2010 to 13.3% of the population in 2015, though Republicans continued to oppose Obamacare as an unwelcome expansion of government.  Many liberals continued to push for a single-payer healthcare system or a public option, and Obama endorsed the latter proposal, as well as an expansion of health insurance tax credits, in 2016.



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