Obamacare survives ‘epic trilogy’ of challenges, but new health battles loom

The era of existential fights over Obamacare has ended.

The Affordable Care Act survived its third major Supreme Court challenge — what Justice Samuel Alito described in his dissenting opinion as an “epic trilogy”. The law has gone from a five-four majority in its favour in the first case to yesterday’s seven-two split. The decision secures the health law as a major legacy of the Obama era — the largest expansion of health coverage in decades — after years of hard-fought and politically painful battles.

Obamacare enjoys higher-thanever public support, with most Americans now favouring the law. Enrolment in the health law’s programmes is at a record high. Democrats have moved from defending the

2010 law to expanding its benefits. While Obamacare remains a dirty word in some Republican circles, its repeal is no longer a focus for the Party, nor a galvanising issue among its voters.

For nearly a decade, Republicans ran and won many elections on the promise of ending Obamacare. But their failed bid to do so in 2017 changed their political priorities. That effort left them divided, bruised and on the wrong side of public opinion. Although President Donald Trump periodically threatened to return to repeal efforts, Mitch McConnell, the Senate Minority Leader, who once called to eliminate the law “root and branch”, said in

2019 that he had no interest in revisiting the law before the next presidential election.

The most recent lawsuit was a holdover from an earlier era of Obamacare politics. Filed by state attorneys general in 2018, it sought to eliminate Obamacare entirely and has taken years in the courts.

The Supreme Court did not dive into the merits of the case but instead found that the plaintiffs did not experience any harms that would give them standing to challenge the law.

The waning repeal effort has given Democrats their first chance in a decade to press forward on a new campaign: moving the country toward a system of universal health coverage. It seems the end of a period when Democrats played constant defence, fighting back against legislative and legal challenges.

Their recent expansion of health insurance subsidies had widespread support in the party. The stimulus package Democrats passed in January spent US$34 billion ($48b) to make coverage more affordable for nearly all Americans who purchase their own health plans. That change, however, was temporary and is set to expire at the end of 2022.

Fights about health policy are sure to remain heated, but they will be about what comes next. Democrats are still divided over many leading proposals, even if they remain united in their support of their past work.

“It’s our chance now to really build now that three strikes and the opponents of healthcare are out,” said Xavier Becerra, secretary of Health and Human Services, and the former attorney general of California, who stepped in with other Democratic-led states to defend the law when the Trump administration would not.

Efforts to move toward universal health coverage are complicated, with potentially high costs, difficult policy trade-offs and the risks of industry opposition.

Even policies with widespread support in Congress could face intense lobbying campaigns from opponents who fear additional government intervention and loss of revenue. One example is a proposal to eliminate surprise medical billing. It enjoyed bipartisan political support but faced an avalanche of industry opposition. Its success was not assured, but it passed in December.

The Affordable Care Act still has holes that have proved challenging to fix. The 2012 Supreme Court decision that upheld the individual mandate also made the law’s Medicaid expansion provisions optional. Twelve states do not participate in that programme, leaving millions of lowincome Americans without coverage. Generous incentive payments included in the most recent stimulus package have not been enough to convince holdout states to join.

Some political voices are still calling for the end of Obamacare, but they are growing rarer. In 2012, nearly every leading Republican politician expressed disappointment or anger at the first Supreme Court decision upholding the core of the law. Yesterday, few commented.

Republican Senator Ted Cruz, who once helped drive a government shutdown demanding an Obamacare repeal bill, issued a statement that reiterated his objections to the law.

Fellow GOP Senator Josh Hawley, who had helped bring the suit as his state’s attorney general, said in response to a reporter’s question that the Supreme Court had made its stance clear. (He did tweet about another Supreme Court case decided yesterday.)

Republican Representative Virginia Foxx, the ranking member of the House Education and Labour Committee, was among politicians to criticise the decision.

“It’s a shame the highest court in the country ruled today that Americans aren’t harmed by this broken law,” she said in a statement. She cited a need for “workable solutions that will bring down the cost of healthcare”.

Like Cruz and Hawley, she did not include a new call for Obamacare’s repeal.