President Obama has won the latest round in the country's healthcare fight. The Supreme Court has ruled that his landmark health reform act, the Patient Protection and Affordable Care Act, can stand.
But it could still be a long time before the law goes into effect as Obama and his supporters envision.
Congressional Republicans have vowed to keep fighting the law, by repealing it or refusing to fund it. If Republicans continue to control the House of Representatives after the November elections, they may have the power to obstruct implementation of the law. If Congress wins both houses of Congress and Mitt Romney is elected president, then repeal becomes a legitimate possibility.
Even if Democracts prevail in the elections, the states, who are essential to getting the whole program up and running, could end up dragging their heels on the law. The main thing they have to do is establish health-insurance exchanges that will allow people without insurance to buy it from a competitive pool of plans.
Twenty-seven states joined the lawsuit against Obamacare or filed other suits objecting to the law in some way. Some of those states, which are mostly controlled by Republicans, may look for new ways to obstruct the law. The Kaiser Family Foundation says that just 16 states have formed an exchange or have started preparing one. The deadline for establishing exchanges is Jan. 1, 2014, which means states that haven't started could easily miss the deadline. Perhaps on purpose.
There's also the question of how readily businesses and individuals will comply with the law. While the Supreme Court ruling affirms the government's right to require people to buy health insurance, that doesn't mean they'll do so without a fight. The Congressional Budget Office estimates that the law would increase the number of insured Americans by somewhere between 30 and 33 million, with another 26 million or so remaining uninsured. That level of compliance is necessary to bring in new revenue, so the overall costs work out.
Yet the law remains deeply unpopular, with nearly half of all Americans saying they oppose it. Many business owners object to it, too. The Supreme Court decision seems unlikely to change that, and could even harden opposition among people who feel the government has become too assertive. If a tacit rebellion develops and a lot of people refuse to comply, it could wreck the economics of the program and disrupt its execution.
The Supreme Court ruling settles the matter of the law's constitutionality, but there could be a lot more litigation on the way, as the law begins to go into effect and individuals, businesses, and politicians react to it (or fail to). There may be many more rounds to this fight.
Rick Newman is the author of Rebounders: How Winners Pivot From Setback To Success. Follow him on Twitter: @rickjnewman.