The holdouts came down to Joe Lieberman of Connecticut, an independent who caucused with Democrats, and conservative Nebraska Democrat Ben Nelson. Lieberman’s demand that the bill not include a public option was met, although supporters won various concessions, including allowing state-based public options such as Vermont’s failed Green Mountain Care. Many voted against the bill that passed: it barely got through.

The White House and Reid addressed Nelson’s concerns during a 13-hour negotiation with 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”

On December 23, the Senate voted 60–39 to end debate on the bill: a cloture vote to end the filibuster. The bill then passed, also 60–39, on December 24, 2009, with all Democrats and two independents voting for it

They chose this approach after concluding that filibuster-proof support in the Senate was not present for more progressive plans such as single-payer.

Then at reconciliation of House & Senate bills for passage

The remaining obstacle was a pivotal group of pro-life Democrats led by Bart Stupak who were initially reluctant to support the bill.

The House passed the Senate bill with a 219–212 vote on March 21, 2010, with 34 Democrats and all 178 Republicans voting against it.