Obamacare survives but not yet immortal

The decision on the healthcare law was a decision for common sense. The ACA requires virtually all Americans to carry health insurance and provides tax credits to help them afford it. The Supreme Court decided that when Congress enacted the law it fully intended, despite what Justice John Roberts called "inartful" language, that tax credits should be available to all eligible people, regardless of whether they were using federally – or state-operated health insurance exchanges.

The court's ruling means that low and middle-income people in all 50 states will remain eligible for federal subsidies to help pay for the cost of health insurance. Importantly, future administrations cannot interpret this aspect of the law differently or delegate decisions on this issue to the executive branch.

Had the legal challenge been successful, it was estimated that 6.4 million people now enrolled in federal exchanges and receiving tax credits would lose their insurance. Knock-on effects were predicted, including an undermining of the mandate requiring health insurance cover, rapid rises in premiums and the possible collapse of health insurance markets.

Republican efforts to undo the ACA are not at an end. They will continue in the political sphere. This was highlighted by the raft of scathing responses from the ever-growing cadre of Republican presidential candidates; to them, the Supreme Court decision changed nothing about the law they detest and highlighted what Mike Huckabee termed "an out-of-control act of judicial tyranny".

"This fatally-flawed law imposes job-killing mandates, causes spending in Washington to skyrocket by $1.7 trillion, raises taxes by $1 trillion and drives up healthcare costs," claimed Jeb Bush, ignoring all the evidence to the contrary. "This decision is not the end of the fight against Obamacare."

Needless to say, Republicans' ire was further inflamed by the decision on gay marriage, released a day later. These Supreme Court decisions give Republicans a twin-barrelled weapon with which to galvanise conservative voters into action.

Opponents of Obamacare realise that the only chance they now have to roll back the law is to win the White House and keep control of the Congress in 2016. And the presidency also offers the chance to play a key role in shaping the future focus of the Supreme Court, with the possibility of replacing as many as three justices.

But even these victories might not be enough. It would take until well into 2017 before legislation to abolish or curb the ACA could be drafted and enacted and more months before a new law of any magnitude could take effect. By then some 30 million Americans not previously covered would have health insurance and all the benefits that come with that. Moreover, the independent Congressional Budget Office estimates that the total budget gap between 2016 and 2025 would rise by $US353 billion if the ACA was eliminated.

In celebrating the Supreme Court's decision, Obama mused over why public support for Obamacare is still mediocre. On many measures the law is actually working better than projected. A major reason is that the ACA's supporters have never owned the dialogue around it; the law's critics have consistently presented a much louder and more certain attack and it is their scare stories and anecdotes Americans have heard rather than the facts. Prejudice means that many people repudiate Obamacare while saying they support the Affordable Care Act.

Perhaps Obama himself has best summarised his healthcare reform legacy five years on from the law's enactment: "The point is this is not an abstract thing anymore. This is not a set of political talking points. For all the misinformation campaigns, all the doomsday predictions, all the talk of death panels and job destruction, for all the repeal attempts – this law is now helping millions of Americans."

Dr Lesley Russell is an adjunct associate professor at the Menzies Centre for Health Policy at the University of Sydney.