Why Obamacare Survived

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President Barack Obama delivers remarks on the fifth anniversary of the Affordable Care Act on March 25, 2015. Jonathan Ernst/Reuters

Obamacare survived yet again on Thursday—this time probably for good. The law has been on life support since the president signed it into law in 2010. The statute upended the American health care system, and conservatives have been trying to kill it ever since—both through Congress and the courts.

The latter is no longer an option. In a strongly worded 6-3 ruling written by Chief Justice John Roberts, the United States Supreme Court allowed millions of Americans receiving subsidies to buy health insurance under the Affordable Care Act to keep getting them.

At issue was a technical matter: Did the law allow subsidies to go to recipients in states that failed to create their own health care marketplace (or "exchange")?

Conservatives had a case. The wording of the statute seemed to prohibit that particular kind of subsidy. But the rest of the statute seemed to contradict that one section. What to do? Roberts, who sees himself as the steward of the court, said he looked at the whole law because focusing on one section would create chaos and "destroy" the marketplaces created by the legislation.

In their dissent, conservative justices responded with outrage. Justice Antonin Scalia, never one to mince words, used terms like "applesauce" and "SCOTUSCare"—a play on Supreme Court of the United States and Obamacare—to deride the court for supporting the bill. "Interpretive somersaults," Scalia called them.

It's the second time that Roberts—who was appointed by George W. Bush in 2005 and opposed by then Senators Hillary Clinton and Barack Obama—has saved the president's health care plan. The first came in 2012 when the Supreme Court, in an opinion also written by Roberts, upheld the requirement that people had to buy health insurance, the so-called individual mandate. And now this.

Can conservatives still turn to the judiciary to invalidate the law? That's unlikely, beyond a few smaller cases that are more pricks than death blows. The strongest challenges have already been launched and rejected by the high court and its conservative chief justice. For the first time since the law's proposal, the health care plan seems safe from legal challenge.

The drama of Obamacare was always whether it would live or die. Would it pass Congress, and if it passed would it be struck down? It was a struggle even when Democrats commanded 60 votes in the U.S. Senate, but it survived various attempts to kill it.

Conservatives hoped the courts would overturn the bill and issue a ruling like the one the Supreme Court did in 1935 when it struck down the National Industrial Recovery Act, a New Deal plan to regulate industry. That never happened. It's not entirely clear why. The Roberts court has had no compunction about overturning important legislation. It put the kibosh on an important section of the Voting Rights Act, and it's rewritten the rules of campaign finance, but in the case of Obamacare, Roberts has tread lightly, deferring to the legislature.

Technically, the Affordable Care Act can be repealed if Republicans win the White House next year and keep the House and Senate. But Democrats can still use their filibuster powers to prevent repeal even if their numbers in the chamber drop from the current 46 down to 40. Plus, the bill has to be replaced with something. Republicans would have a hard time selling the trade-offs that would come with overturning the legislation.

Can Republicans devise a non-Obama way of insuring millions, allowing kids to stay on their parents' insurance until they're 26, and never allowing pre-existing conditions to deny coverage? Maybe. They have various bills to make health insurance more available. But even if they worked, the measures in these bills lack the immediacy of the individual mandate or the exchange system.

Would big pharmaceutical firms and insurers and hospitals stand for scrapping a system in which they're profiting handsomely? Right now, business groups seem mostly focused on ancillary issues, like a medical device tax that's part of the Affordable Care Act, and less with scrapping the whole thing. Primary voters in Iowa may be fuming about Obamacare but not the chamber of commerce.

The court's ruling shows how ingrained the law has become. Roberts could have written a narrow decision, obviating just the Internal Revenue Service regulations that were central to the case. Instead, he offered a sweeping interpretation of the statute that'll make it impossible for, say, a President Marco Rubio to just rewrite a few regulations.

In one sense, conservatives were right. When government expands, it's hard to get it to contract—especially when it's giving people tangible benefits like health insurance. Social Security and Medicare are still with us. Obamacare is still more scaffold than edifice, a work in progress. But that doesn't mean it's going to fall.