Five takeaways on the Supreme Court's Obamacare decision

In what has become something of a Washington tradition, the Supreme Court again upheld the Affordable Care Act on Thursday, in the third major case from Republican challengers to reach the high court. 

The margin this time was larger, 7-2, as the High Court appears less and less interested in revisiting the health care law through the judiciary. 

Democrats hailed the ruling as a boost to their signature law, and Republicans were left to figure out a path forward on health care amid another defeat. 

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Here are five takeaways:

This could be the last gasp of repeal efforts

It is impossible to ever fully rule out another lawsuit challenging the health law or another repeal push if Republicans win back Congress. 

But after more than 10 years of fighting the Affordable Care Act, GOP efforts at fighting the law are seriously deflated, as many Republicans themselves acknowledge. 

“It's been my public view for some time that the Affordable Care Act is largely baked into the health care system in a way that it's unlikely to change or be eliminated,” said Sen. Roy BluntRoy Dean BluntThe Hill's Morning Report - Presented by Facebook - Biden sets new vaccine mandate as COVID-19 cases surge Former Missouri Gov. Jay Nixon passes on Senate campaign The Hill's 12:30 Report - Presented by Facebook - US gymnast wins all-around gold as Simone Biles cheers from the stands MORE (Mo.), a member of Senate GOP leadership. 

Asked if he still wanted to repeal and replace the law, which was the GOP rallying cry for years, Sen. Chuck GrassleyChuck GrassleyThe Hill's 12:30 Report - Presented by Facebook - US gymnast wins all-around gold as Simone Biles cheers from the stands The Hill's Morning Report - Presented by Facebook - A huge win for Biden, centrist senators 'Blue wave' Democrats eye comebacks after losing reelection MORE (R-Iowa) said instead, “I think I want to make sure it works,” before attacking former President Obama’s promises about the law’s benefits. 

Even Sen. Josh HawleyJoshua (Josh) David Hawley228 Republican lawmakers urge Supreme Court to overrule Roe v. Wade Trio of Senate Republicans urges Supreme Court to overrule Roe v. Wade Atlanta-area spa shootings suspect set to be arraigned MORE (R-Mo.), who helped bring the lawsuit against the health law as attorney general of Missouri, said Thursday that the Supreme Court had made clear “they're not going to entertain a constitutional challenge to the ACA.”

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Supporters of the law said it is now even more entrenched, despite years of GOP attacks. 

“The war appears to be over and the Affordable Care Act has won,” said Stan Dorn, senior fellow at the health care advocacy group Families USA. 

Still, not all Republicans are throwing in the towel on at least verbally attacking the law. 

“The ruling does not change the fact that Obamacare failed to meet its promises and is hurting hard-working American families,” said House GOP leaders Kevin McCarthyKevin McCarthyAfter police rip Trump for Jan. 6, McCarthy again blames Pelosi Capitol Police asked to arrest the maskless 228 Republican lawmakers urge Supreme Court to overrule Roe v. Wade MORE (Calif.), Steve ScaliseStephen (Steve) Joseph ScaliseRepublican governors revolt against CDC mask guidance House to resume mask mandate after new CDC guidance What you need to know about the new COVID-19 surge MORE (La.) and Elise StefanikElise Marie StefanikStefanik calls Cheney 'Pelosi pawn' over Jan. 6 criticism GOP up in arms over Cheney, Kinzinger GOP's Banks burnishes brand with Pelosi veto MORE (N.Y.). 

And there is at least one ACA-related lawsuit still working its way through the lower courts. Kelley v. Becerra challenges provisions of the health law around insurance plans covering preventive care including birth control. 

The Supreme Court was fairly united 

The margin of victory for the health law was fairly large, with even more conservative justices such as Clarence ThomasClarence ThomasAn obscure Supreme Court ruling is a cautionary tale of federal power Overnight Health Care: St. Louis reimposes mask mandate | Florida asks Supreme Court to block CDC's limits on cruise ship industry Florida asks Supreme Court to block CDC's limits on cruise ship industry MORE, Amy Coney BarrettAmy Coney BarrettBill would honor Ginsburg, O'Connor with statues at Capitol Supreme Court's approval rating dips to 49 percent  The Hill's Morning Report - Presented by Facebook - Jan. 6 probe, infrastructure to dominate week MORE, Brett KavanaughBrett Michael KavanaughOn The Money: Biden asks Congress to extend eviction ban with days until expiration | Economic growth rose to 6.5 percent annual rate in second quarter Biden calls on Congress to extend eviction ban with days until expiration An obscure Supreme Court ruling is a cautionary tale of federal power MORE and John Roberts ruling to uphold the law, joining the opinion from liberal Justice Stephen BreyerStephen BreyerSenate panel votes to make women register for draft Biden's belated filibuster decision: A pretense of principle at work Klobuchar: If Breyer is going to retire from Supreme Court, it should be sooner rather than later MORE

The court’s other two liberals, Sonia SotomayorSonia SotomayorSenate panel votes to make women register for draft No reason to pack the court Supreme Court ruling opens door to more campaign finance challenges MORE and Elena KaganElena KaganNo reason to pack the court American freedom is on the line Supreme Court deals blow to Black Caucus voting rights efforts MORE, also joined the majority of seven. Two conservatives, Justices Samuel AlitoSamuel AlitoBill would honor Ginsburg, O'Connor with statues at Capitol No reason to pack the court Justice or just desserts? Trump, Cosby and Georgia cases show rising cost of political litigation MORE and Neil GorsuchNeil GorsuchNo reason to pack the court Democrats under new pressure to break voting rights stalemate Trump 'very disappointed' in Kavanaugh votes: 'Where would he be without me?' MORE, dissented and would have struck down the law. 

Through the three major Supreme Court cases on ObamaCare, the margin of victory has risen from 5-4 to 6-3 to 7-2. 

“There's a real message there about the Supreme Court's willingness to tolerate these kinds of lawsuits,” Andy Pincus, a visiting lecturer at Yale Law School, said of the growing margin of victory. 

The case was decided on fairly technical grounds. The Court ruled that the challengers did not have standing to sue, given that the penalty for not having health insurance at the center of the case had been reduced to zero, so it was not causing any actual harm that could be the basis for a lawsuit. 

Republicans did get some vindication in that Democrats had fiercely attacked Barrett during her confirmation hearings for being a vote to overturn the health law, when in fact she ended up voting to maintain the law. 

The ACA is stabilizing

The early years of the Affordable Care Act were marked with the turbulence of a website that failed at launch, premium increases, and major insurers dropping out of the markets given financial losses. 

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Now, though, the markets are far more stable. For example, 78 percent of ACA enrollees now have the choice of three or more insurers, up from 57 percent in 2017, according to the Kaiser Family Foundation. 

Democrats, now in control of the House, Senate and White House, were able to pass earlier this year expansions of the law’s financial assistance to help further bring down premium costs. 

The Biden administration announced earlier this month that a record 31 million people were covered under the ACA, including both the private insurance marketplaces and the expansion of Medicaid. 

“We are no longer in the Affordable Care Act, ‘How’s it going to go? Is it going to survive?’ mode,” said Frederick Isasi, executive director of Families USA. “We really are in a whole new phase. It really is: ‘How do we improve it?’”

Republicans face questions on their health care message

The Republican health care message for years was summed up with the simple slogan “repeal and replace.”

But now those efforts have failed in Congress, in 2017, and have failed for a third time in the courts. 

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That leaves uncertainty about what the Republican health care message is. The party has famously struggled to unite around an alternative to the ACA, so there is no consensus alternative for the party to turn to. 

The statement from McCarthy, Scalise, and Stefanik calling the ACA “failed,” shows that party leaders are not fully ready to accept the law. 

The leaders added that “House Republicans are committed to actually lowering health care costs,” which has been a possible area for the party to focus that is not simply about repealing the ACA. 

But any discussion of health care costs is fraught with complications. Republicans, for example, overwhelmingly oppose House Democrats’ legislation to allow the government to negotiate lower drug prices, arguing it would harm innovation from the pharmaceutical industry. 

Grassley reached a bipartisan deal on somewhat less sweeping drug pricing legislation with Sen. Ron WydenRonald (Ron) Lee WydenDemocrats warn shrinking Biden's spending plan could backfire Democrats release data showing increase in 'mega-IRA' accounts Senate Democrats press administration on human rights abuses in Philippines MORE (D-Ore.) in 2019, but that bill went too far for many Republicans as well. 

Democrats want to go farther, but face an uphill climb

With the ACA further entrenched, and control of the House, Senate and White House, Democrats are looking at ways to build on the health law. 

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The main health care proposal from the presidential campaign, a government-run “public option” for health insurance, has faded from the conversation and is not expected to be a part of a major legislative package on infrastructure and other priorities Democrats are pushing for this year. 

While the health care industry has largely made its peace with the ACA, pushing for a public option or lowering health care costs means taking on a fight with powerful industry groups. 

Progressives like Sen. Bernie SandersBernie SandersAngst grips America's most liberal city Democrats warn shrinking Biden's spending plan could backfire Democrats say they have the votes to advance .5T budget measure MORE (I-Vt.) have instead poured their energy into expanding Medicare benefits to include dental, vision, and hearing coverage, and lowering the eligibility age to 60. 

Allowing the government to negotiate lower drug prices also could make it into the package.

“Now, we’re going to try to make it bigger and better — establish, once and for all, affordable health care as a basic right of every American citizen,” said Senate Majority Leader Charles SchumerChuck SchumerAn August ultimatum: No recess until redistricting reform is done Biden to meet with 11 Democratic lawmakers on DACA: report Schumer's moment to transform transit and deepen democracy MORE (N.Y.). “What a day.”