"I may not have gone where I intended to go, but I think I have ended up where I intended to be." ~Douglas Adams
The United States Supreme Court has upheld the constitutionality of the Patient Protection and Affordable Care Act (ACA), almost in its entirety. The centerpiece of the ACA and the focus of the legal challenge - the mandate that individuals purchase health insurance or pay a tax penalty – was affirmed. The Court in essence determined that Congress can't force someone to buy health insurance against their will, but Congress can impose a tax on that person if they don't buy the insurance, which is exactly what the ACA does. The only portion of the law that the Court struck down was the provision that would have penalized states that chose not to participate in the Medicaid expansions contained in the act.
As it turns out, the deciding vote on the nine-member Court was the Chief Justice, John Roberts, who at least until yesterday was the darling of conservatives across the country. He sided with the four more liberal members of the Court to uphold the law. Some call his decision Solomonesque; others say he knuckled under to the threat of the President criticizing his court as being "activist." His deftly crafted opinion turned on whether the penalty for not purchasing health insurance was in reality a tax. He said it was, and as such, Congress was perfectly within its power to levy a tax on someone who doesn't buy the prescribed insurance policy. Although proponents of the law had gone to great lengths to say that the penalty wasn't a tax, the Chief Justice said that it most certainly was, and his opinion is the one that matters.
While the political debate about the ACA will undoubtedly continue, and could influence the current presidential election, the decision by the Court makes it pretty clear that the vast majority of the law is likely to remain in effect for the foreseeable future. Although congressional Republicans are already vowing to pass legislation to repeal the law, the chance of that happening is a long shot. If the President is re-elected, he will certainly veto any attempts to repeal the law. If his re-election bid fails, the presumptive GOP nominee, Mitt Romney, has stated his intentions to repeal and replace the law. In order to do so, however, the Republicans would have to regain control of the Senate, and have enough votes–it takes 60–to overcome an almost certain filibuster by Democrats, which appears to be improbable if not impossible.
The public appears to remain pretty divided over the law, but regardless of how one feels about the signature legislative achievement of President Obama, the Court's decision makes it clear that it is the law of the land. It is a safe bet that as its provisions are implemented over the next several years, there will be continuous efforts to amend and reshape it. In other words, health reform is going to continue to be a long journey, not a destination.