By ruling correctly that the individual mandate is constitutional, the U.S. Supreme Court preserved the life of Obamacare. Unfortunately, it also struck down a key provision that threatened the states with losing all federal Medicaid funding if they refuse to vastly expand eligibility. By that action, the court may have placed on life support roughly half of the Affordable Care Act's expansion of coverage to the uninsured.
In contrast, the four dissenters on the court would have struck down both the individual mandate and the Medicaid funding threat, and with those, the entire law. That may have been a better outcome, because it would have obliged Congress to start over and write a better law, preferably a single-payer plan that focused on cutting costs.
Trouble is, in the current political climate Congress would be unlikely to produce a better law. The Republicans don't have an alternative plan; they are focused entirely on repealing Obamacare. The Democrats don't have an alternative, either. They are focused entirely on defending and implementing Obamacare. Besides, they are exhausted from the ugly spectacle of enacting the Affordable Care Act two years ago, and they no longer control both houses of Congress.
The future of health care reform, then, lies in the November election. Given the widespread unpopularity of the law, especially among Republicans and independent voters, the Supreme Court ruling gives the GOP a stronger argument to defeat President Obama's bid for a second term. If Mitt Romney were to win the White House and the Republicans the Senate, they would have a mandate to repeal Obamacare and replace it.
If, on the other hand, Obama were to retain office and Democrats the Senate, they would have a green light to improve the Affordable Care Act, and Republicans would have at least some incentive to cooperate toward that end.
The other major consequence of the court's ruling is how Utah's governor and Legislature might react to the demise of Obamacare's federal Medicaid funding threat. Gov. Gary Herbert's cautious statement suggests that, for now, he would not seriously consider turning the state's back on billions of dollars of federal Medicaid money just so the state could avoid putting up hundreds of millions of its tax dollars at the end of this decade.
But all of the political and mathematical calculations have not yet been worked out. The court's Medicaid ruling was completely unexpected. We would hope that Utah leaders would take the federal money and cover more Utahns. But given the political volatility of Obamacare, there are no guarantees.