Five Takeaways From the Supreme Court Decision on the Affordable Care Act The Supreme Court has ruled and the Affordable Care Act has survived, again. Specifically, the decision allows the federal government to continue to provide subsidies to individuals insured through the exchange created by the federal government. But what does that mean for the future of health care and American politics? David and Ruth Gottesman Associate Professor of Political Science Joseph Luders breaks it down into five crucial takeaways.

Dr. Joseph Luders is the David and Ruth Gottesman Associate Professor of Political Science at Yeshiva University

1.  This decision validates one of the most important pieces of social policy since the enactment of Medicare and Medicaid in 1965. So far, just two years after going in effect, the law has already expanded health care coverage to some 15 million Americans and the percentage of those without insurance has fallen sharply from 18 percent down to just over 10 percent, and even lower in states that have expanded Medicaid. Although public support for the law continues to be far weaker than other bulwarks of the social safety net, such as Social Security, at least some recent polling data suggests that a plurality of Americans now support the law for the first time. While partisanship overwhelmingly shapes opinion about the law, the Court’s decision may provide a further boost of support among independents. 2. The Affordable Care Act will endure, at least until the end of President Obama’s term in office, and probably beyond. Once fully in place, social policies are extraordinarily difficult to uproot. This is due in part to the fact that the arguments against the law are significantly weakened when the dire warnings of detractors do not materialize. The enactment of Medicare, for instance, did not inaugurate a socialist America, as some predicted. In this case, the sky likewise did not fall: the economy grew stronger, health care markets continued to function, and the government “takeover” of health care did not change things for most Americans. Indeed, for many, the impact of the law appears to have been strongly positive in lower premiums, slower health care cost inflation, and the sense of security that comes with health insurance coverage. Accordingly, the new law created a beneficiary population that might organize to resist wholesale repeal. Only the election of a Republican president will permit current congressional majorities to repeal or replace the ACA and, even then, there will be enormous pressure on Republicans to devise a replacement that does not simply pull the rug out from under the millions of Americans now benefiting from the law. 3. President Obama has secured his legacy by successfully defending his signature legislative achievement. Although it is always a bit premature to talk about the legacy of a president who is still in office, this decision is no doubt a massive relief for the Obama administration in part because it does appear to solidify the president’s legacy by achieving something that Democrats have sought since Truman. After all, the Affordable Care Act is more frequently referred to as “Obamacare” than by its actual statutory name and, accordingly, the fate of this law had become inextricably linked to the fate of the Obama presidency more generally. Although the history books have yet to be written, it appears likely that Obama will be regarded as the Democratic president who finally achieved what for so long seemed impossible. 4. There will be no "death spiral." The decision averts the collapse of the law from a possible “death spiral.” The ACA is sometimes compared to a stool with three legs: 1) Regulations that insurers cannot discriminate against individuals with pre-existing conditions, 2) an obligation that everyone must have health insurance (the individual mandate), and 3) the provision of subsidies to make insurance affordable to middle- and low-income individuals. If the subsidies were eliminated, effectively pulling out one of the legs of the stool, healthy individuals might opt out, despite the penalty. Premiums would then rise, which would cause more individuals to opt out, and so would begin the death spiral. 5. But it was a close call. The decentralization of United States politics creates multiple veto points that allow organized interests to block policy change. Although the ACA survived this challenge, it is striking how close the law was to being crippled even five years after its enactment, and this says something fundamental about American politics. The United States is relatively unique among developed democracies for the large number of veto points in the policymaking process. Veto points are the various stages in the policymaking process at which the advance of a measure can be blocked. With federalism, separation of powers, checks and balances, the Senate filibuster, the presidential veto, executive implementation, and judicial challenges, the policymaking process in the United States is a series of daunting hurdles that opponents can use to obstruct legislative initiatives. Although the ACA has survived this latest challenge, and may well yet become a durable fixture of the American social policy, this episode reminds us just how delicate are the gears of American governance. The opinions expressed above are solely those of the author and should not be attributed to Yeshiva University.