In eliminating the last major legal challenge to the Affordable Care Act's insurance subsidies, the U.S. Supreme Court on Thursday raised significant new hurdles for Republicans who continue to make repealing and replacing the law the centerpiece of this year's legislative and next year's political campaign strategies.
The decision likely ends any chance that the courts will dismantle the law, political observers said. The 6-3 decision also ruled out any possible reinterpretation by a future administration that could reverse the court's ruling.
For Republicans, that narrows options to override the law to the crowded campaign trail and Congress, where the Republican-controlled chambers face an assured veto from the president.
“It is such a clear judgment,” said Joseph Antos, a healthcare economist at the American Enterprise Institute, a center-right think tank in Washington. “That's it. This is a clear message to Republicans if you want to change anything about the ACA, you really do have to repeal it and start all over again.”
Any Republican plan will likely retain the more popular elements of the ACA, which have widespread public support such as the guarantee that people can't be denied coverage because of pre-existing conditions. “It's political reality that we're not going to go back to the old days where people can be refused coverage,” Antos said.
But Republican alternatives offered to date scrap mandates for employer and individual coverage, which insurers insist are necessary to make guaranteed issue work. If only people with high healthcare needs buy insurance, rates become unaffordable.
Leading think tanks on the right still aren't offering specific alternatives. A Republican alternative will take shape during the campaign, said Dan Holler, a spokesman with the conservative Heritage Action for America. “There is going to be a robust debate about what America's healthcare looks like post-Obamacare,” he said.
Hollar said the court decision “reset the debate” on the law to its repeal. “The Supreme Court is making a habit of saving Obamacare,” he said. “If Republicans ever expect to get rid of this law, it's going to have to be done by Congress. They can't continue to rely on the court to save them.”
A renewed debate over healthcare reform in the run up to next year's election could sway public opinion, which remains bitterly divided over the law. Half disapproved of the law in the latest Gallup poll compared with 44% in favor, although favorable opinion has climbed in recent months.
“It's going to be hotly rhetorical,” said Dan Mendelson, the CEO of healthcare consulting company Avalere Health.
Democratic presidential hopefuls, meanwhile, may seek to expand the law's reach to address high health plan deductibles, which are common in subsidized coverage but leave households will potentially large bills when they seek care, said Robert Blendon, a professor of health policy and political analysis at Harvard University. Democrats may also seek greater patient choice of physicians to counter the proliferation of narrow health plan networks, which insurers are increasingly using in their exchange-offered plans to hold down costs.
Republican presidential hopefuls lost no time deriding the decision and calling for repeal. Scott Walker, who is expected to formally enter the race next month, urged Republicans via Twitter to “redouble their efforts to repeal and replace this destructive & costly law.” Sen. Marco Rubio, a Florida Republican, quickly sent out a barrage of Tweets endorsing repeal of the law and its replacement.
Former Florida Gov. Jeb Bush, who leads Republicans on the fundraising front, joined the Twitter chorus with a call to repeal the law. "I am disappointed in the Burwell decision, but this is not the end of the fight against ObamaCare," he said.
Democrats, in praising the ruling, tried to put the politics of Obamacare in the rear view mirror. Many are declaring the high court's decision Thursday as the final act in the nation's long-running debate over the law.
“Five years in, this in no longer about a law, this is not about the Affordable Care Act as legislation, or Obamacare as a political football, this is healthcare in America,” President Barack Obama said in his Rose Garden speech shortly after the decision was announced.
“What we are not going to do is unravel what has now been woven into the fabric of America,” Obama said.
Senate Democratic leader Harry Reid used Twitter to tell Republicans to move on. “Obamacare is the law of the nation," he wrote. "Republicans should stop wasting the time of the American people by trying to repeal it.”