It’s clear now that any overhaul of the Affordable Care Act will have to come through the political system, not the court. And repeal-minded Republicans face trouble generating a mandate for change.
Republicans were hoping the court would decide against this key part of the law -- and in turn give the party momentum as it argued for repeal during the 2016 election campaign.
Instead, Republicans now face huge hurdles.
Much of the public has had enough of this debate, now stretching into its seventh year. Since it was enacted, the Republican House of Representatives has voted more than 50 times to repeal it only to see its moves fall short; the court has ruled twice upholding the law; and President Barack Obama has won re-election over a GOP candidate who vowed to repeal and replace it.
A Kaiser Family Foundation survey earlier this month found 45 percent of Americans believe it’s time to move on, percentages generally uniform across party lines. A Pew Research Center survey in September found 54 percent of Americans said the law had not had an effect on them or their family.
“It’s died down as an issue,” said David Woodard, a Clemson, S.C.-based Republican consultant.
Republicans will continue to argue they’re tantalizingly close to having the power needed to repeal the law.
“It was never up to the Supreme Court to save us from Obamacare,” said former Texas Gov. Rick Perry, a candidate for the 2016 Republican presidential nomination. “We need leadership in the White House.”
“Today’s ruling makes it clear that if we want to fix our broken health care system, then we will need to elect a Republican president,” added Republican Party Chairman Reince Priebus.
Not everyone in the party -- including some presidential hopefuls -- agree that all of the law is a bad idea. Govs. John Kasich of Ohio and Chris Christie of New Jersey have accepted federal dollars to expand the Medicaid program, one of the law’s provisions, while Govs. Scott Walker of Wisconsin and Bobby Jindal of Louisiana have not.
Democrats are eager to exploit those divisions and dare Republicans to try to erase the law’s popular, now-ingrained features.
The instant reactions to the decision also made it clear that the health care debate is about more than health care. To Republicans, the 2010 law’s requirement that nearly everyone obtain coverage is a prime example of government gone wild.
“Hillary Clinton supports big government mandates and expanding the government’s reach into our health care system, maneuvers that have made our health care system worse off,” said Priebus.
Republicans put health care on a list with other examples of bloated government – regulation of businesses, efforts at gun control, requiring businesses to deal with people whose lifestyles offend their religious beliefs – and see a highly useful campaign issue.
“There’s too much power up here,” Sen. Rand Paul of Kentucky, a Republican presidential contender, told a cheering conservative gathering in Washington last week.
The ruling potentially raises the profile of the court itself in the coming election. The next president is likely to name Supreme Court justices, and in a court often divided 5-4 over the day’s most partisan issues, both parties will point out how much the election matters.
Neither party can assume that’s a winning issue, though.
A CBS News-New York Times survey earlier this month showed 22 percent thought the court was too conservative, 27 percent saw it as too liberal, and 35 percent said it was about right.
To most Democrats, the health care law is government at its most promising. Millions of previously uninsured people have obtained coverage. Rejecting coverage applicants for pre-existing conditions, which were particularly onerous to women, is gone. People under 26 can stay on their parents’ policies.
Democrats still have battles to fight, but the prospects are now brighter. With Barack Obama as president, the House couldn’t muster the votes that would be needed to override a certain veto of repeal. Republicans came closer this year, as they won control of the Senate, but Obama’s certain veto remained in the way.
That’s why 2016 matters so much in this crusade, since a Republican president would need only majorities in both chambers to rid the nation of the law.
“We cannot depend on the court to save us from Obamacare, and we must now turn our full attention to electing people who will help us repeal the law,” said Jenny Beth Martin, the CEO of Tea Party Patriots.
But Thursday’s decision, the second time the court has upheld part of the law, is going to make it hard for Republicans to claim 2016 as a mandate for health care change.