Obamacare now appears safe. The battle over its future continues.

“It is significant in that it allows all parties to move on, either build or tear down – but they must do so legally,” said health strategist Chris Jennings, who has advised the last three Democratic presidents. “The courts are basically saying, stop, go ahead, you have every option if you want to change this bill, but do it according to the books.”

The ruling will re-energize Democrats’ efforts to build on Obamacare through richer insurance subsidies and possibly a public option. And Republicans, who never agreed on the “replacement” portion of their anti-Obamacare pledge, condemned the high cost of the law following Thursday’s ruling and vowed to oppose Democrats’ proposals to expand government coverage.

“I suspect we will continue to work to make health care more accessible,” said Senator John Cornyn (R-Texas), whose home state led the ACA’s latest legal threat. “I think the Supreme Court upheld the Affordable Care Act three times and I think we have to move on.”

For the Democrats, the court ruling could also result in a long delayed reckoning of the party’s own vision for a health care system after the Court of Auditors’ recent legal challenge failed. Democrats generally agree that the ACA has its problems – high premiums, high deductibles, and a gaping coverage gap in the dozen mostly Republican-led states that refuse to join the Medicaid amendment to the law.

“For many years, one of the major obstacles to major progressive steps in healthcare has been the mantra we needed to get Obamacare into practice and then defend Obamacare,” said Adam Green, co-founder of the Progressive Change Campaign Committee. “It was a very existential block just to keep the law alive. Now that it seems pretty safe, there is more flexibility across the Democratic Party to take bold steps. “

But Democrats disagree on next steps, and Obamacare’s future could look very different depending on where party leaders are steering the ship.

President Joe Biden, who advocated further seismic changes to the ACA such as a public option and lowering the Medicare age to 60, has stepped back since taking office to focus on incremental policies that promote intra-party harmony or the powerful healthcare industry do not disturb disturb. The Democrats March’s Covid relief package temporarily increased Obamacare’s subsidies by nearly 30 percent to cut costs for low-income Americans and draw more middle-income families into the law’s insurance markets. Biden is pushing for these subsidies to become permanent in infrastructure legislation, prioritizing them over other Democratic health care proposals.

“How far will the Court of Auditors be expanded in all of its forms?” Said Tom Miller, Resident Fellow for Health Policy at the conservative American Enterprise Institute. That could turn into a longstanding argument between Democrats and Republicans as they swap control of Washington.

“That’s where The point of engagement is where it can go back and forth instead of saying, ‘I have another lawsuit for you,’ ”Miller added.

While Republicans largely oppose the expansion of insurance subsidies, they would be powerless to prevent it in this Congress if the Democrats included the aid in an infrastructure package that they pushed strictly according to party lines.

The prospects for other Democratic health care priorities are uncertain. Biden has stayed away from substantial debates on other campaign proposals, such as lowering the Medicare eligibility age, government-mandated drug price negotiations, and creating a state insurance option.

The White House even took a back seat on one of Biden’s broadest campaign priorities: devising a federal workaround for reporting in the dozen states that have turned down federal aid to expand Medicaid to approximately 2 million low-income adults. Democratic lawmakers have been trying to work out the details for months, hoping to find an approach that doesn’t upset the healthcare industry or states that have already joined the optional Obamacare program.

With wafer-thin margins in Congress, the Democrats only have a small window of time to implement their health plans before the 2022 midterm elections. The debate over the party’s health vision was already well underway this year and could now heat up now that Obamacare was secured by the Supreme Court.

Senator Bernie Sanders (I-Vt.), Who as chairman of the budget committee will have a strong influence on the Democrats’ infrastructure legislation, insisted Thursday that he will not give up on lowering the Medicare age in this Congress. He also calls for the program to be expanded to include vision, dental and hearing aids.

“There are millions of older workers who want Medicare who cannot today, so we must bring the age down, and there are millions more walking around who cannot hear, cannot afford glasses, and” cannot get dental work he added, according to a Capitol Hill press pool report.

Senate Health Committee Chair Patty Murray, D-Wash., And House Chairperson for Energy and Commerce Frank Pallone, DN.J., have begun gathering feedback on a public option and a potentially lengthy process to initiate the development of a policy that the Democrats could agree on. The idea has gained support during the drafting of the law since being dismissed from the Court of Auditors, but there are several ways in which a public option can be made.

“But it’s still going to be difficult because it’s a very important and big change in law and Congress isn’t acting very quickly,” said Henry Waxman, one of Obamacare’s lead writers in Congress, who now runs his own consultancy.

Rachel Roubein contributed to this report.

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