WASHINGTON - By a single vote, President Barack Obama's health care overhaul survived a painstaking Supreme Court review that consumed thousands of pages in legal filings and an extraordinary six hours-plus of oral argument time back in March.
In the end, the court upheld the law, with a minor change, and dashed Republican hopes of bringing down what conservatives deride as "Obamacare" on constitutional grounds. The outcome surprised many who thought tough questions from the conservative justices during the arguments foreshadowed the demise of the far-reaching legislation.
The decision leaves a trail of winners and losers, from Main Street, USA, to the very steps of the Supreme Court. For some, it's a mixed bag. Here's a look:
Casey Quinlan, a 59-year-old breast cancer survivor who lives near Richmond, Va., and millions of other uninsured people. Starting in October 2013, the uninsured will be able to sign up for taxpayer subsidized coverage either through private insurance plans or the Medicaid health care program. Coverage commences on Jan. 1, 2014. The law eventually is expected to provide health insurance to about 30 million of the estimated 50 million uninsured Americans. Insurers will not be able to turn away people with a history or medical problems, or charge them more. "What's at stake is whether or not the insurance market will be encouraged to recognize our presence and create products that are affordable for people with pre-existing conditions," Quinlan said.
Hospitals. Their stock zoomed Thursday after the Supreme Court ruling guaranteed them millions more paying customers. Some analysts expect the law to reduce uncompensated care losses borne by hospitals by about half. Currently about one-fourth of the care provided by hospitals is never paid for, either because debts can't be collected or the patient is uninsured. Stocks of big laboratories also rose. But insurance companies had a see-saw day, down sharply at first but recovering some lost ground. They'll get millions of new customers also, but they face new federal regulation and taxes they fear will drive up costs.
Family practice doctors. The law provides a pay boost for those treating Medicare patients, and takes other steps that could make general practitioners the new gatekeepers of a more efficient health care system.
Democrats. President Barack Obama and former House Speaker Nancy Pelosi devoted a vast amount of his first term to passing a health care law that has divided the nation. Democrats lost the House in the 2010 midterm elections partly on public displeasure with Medicare cuts embedded in the health care overhaul. By winning at the court, Obama and his party preserve historic legislation that liberals have been pining for over more than 50 years.
Solicitor General Donald Verrilli Jr. Obama's top Supreme Court lawyer was maligned for his performance in both the health care and Arizona immigration cases. His argument in defense of the insurance requirement got off to a bad start when Verrilli appeared to choke on his words and had to take a drink of water. Turns out, he largely prevailed in both cases, in which he also was in charge of producing the administration's written legal briefs. That's perhaps just the latest indication one shouldn't hang too much on oral arguments.
Chief Justice John Roberts - The darling of conservatives, Roberts finds himself in the unusual position of being praised by the left and criticized by the right following the health care ruling, and to a lesser extent, the Arizona immigration case in which he also sided with the court's liberals. On one level, these demonstrations of a willingness to break with conservatives could burnish Roberts' reputation as the neutral umpire he told his confirmation hearings he sought to be. On the other hand, the conservative Roberts may be very much in evidence when the court takes up affirmative action in the fall.
The National Federation of Independent Business. The powerhouse small business lobbying group played a pivotal role in derailing former President Bill Clinton's health care bill and was lead plaintiff in the case against Obama's overhaul. NFIB President Dan Danner said Thursday the group will continue to push for repeal, but odds of completely overturning the law seem slimmer now. The law imposes fines on employers that do not offer coverage, but companies with fewer than 50 workers are exempt, and that means most small businesses will not have to worry about the mandate. Moreover, most companies with 50 or more employees already provide coverage. Nonetheless, business groups generally see the health care law as an encroachment.
Republicans. From presidential candidate Mitt Romney, to congressional leaders like House Speaker John Boehner, R-Ohio, and Senate Minority Leader Mitch McConnell, R-Ky., it will get harder for Republicans to argue that the law should be wiped from the books. However, Republicans could regain the upper hand by targeting unpopular provisions for repeal, like tax increases on industry, cost controls and cuts to service providers.
States that didn't prepare. About half the states now find themselves in the position of the little piggy that built his house out of straw. Many Republican-led states held back on carrying out the law's plan to set up new insurance markets, confident the Supreme Court would toss out the whole thing. They're now in the position of watching Health and Human Services Secretary Kathleen Sebelius' federal bureaucrats come in and run the markets for them. Sebelius says she wants to play nice and will partner with any interested states. But you can bet it will be on her terms.
Justice Antonin Scalia. He sat glumly and silently as other justices read their takes on the health care law. Scalia was more vocal than any justice in his distaste for the law when the court heard arguments in March.