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Obamacare now seems safe.  The battle for its future continues.

“This is important as it allows all parties to move forward, build or tear down – but they have to do it through legislation,” said health care strategist Chris Jennings, who advised the last three Democratic presidents. “The courts are basically saying, stop it, move on, you have all the capabilities if you want to change this bill, but do it properly. “

The move will inject new energy into Democratic efforts to build on Obamacare, through richer insurance subsidies and potentially a public option. And Republicans, who never stuck with the “replace” part of their anti-Obamacare pledge, condemned the high costs of the law in the wake of Thursday’s decision and vowed to fight Democratic proposals to expand. government coverage.

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

For Democrats, the court ruling could also result in a long delayed judgment on the party’s own vision for a healthcare system, now that the latest legal challenge against the ACA has collapsed. Democrats universally agree that the ACA has its problems – high premiums, large deductibles, and a yawning coverage gap in the dozen Republican-majority states refusing to join the Medicaid expansion of the law.

“For many years, one of the biggest obstacles to making great strides in healthcare was the mantra we needed to implement Obamacare and then defend Obamacare,” said Adam Green. , co-founder of the Campaign Committee for Progressive Change. “It was a very existential block to moving forward, just keeping the law alive. Now that it seems safe enough, there is more flexibility within the Democratic Party to take bold action. “

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

President Joe Biden, who has campaigned for more seismic changes to the ACA as a public option and lowering the Medicare age to 60, has stepped down since taking office to focus on more progressive policies that will not disrupt party harmony or the powerful health care sector. . Democrats The Covid relief program in March temporarily increased Obamacare subsidies by nearly 30%, in a bid to cut costs for low-income Americans and attract more middle-income families to markets in the world. assurance of the law. Biden is pushing to make these subsidies permanent in infrastructure legislation, prioritizing them over other Democratic healthcare proposals.

“How broad will CBA in all its forms be?” said Tom Miller, resident healthcare policy researcher at the conservative American Enterprise Institute. This could become a long-standing dispute between Democrats and Republicans as they swap control of Washington.

“It’s there that the point of engagement is, and where it can change back and forth, instead of “I’ve got another lawsuit for you,” Miller added.

While Republicans largely oppose the expansion of insurance subsidies, they would be powerless to prevent it from happening in Congress if Democrats included the aid in an infrastructure package that they are pushing along strictly lines. partisan.

The prospects for other democratic health care priorities are uncertain. Biden avoided substantive debate over other campaign proposals, like lowering the age of Medicare eligibility, government-mandated drug price negotiations, and creating an insurance option managed by the government.

The White House has even taken a back seat on one of Biden’s most important campaign priorities: refining a federal workaround for coverage in the dozen states that have rejected federal aid to expand Medicaid to about 2 million low-income adults. Democratic lawmakers have been trying to work out the details for months, hoping to take an approach that won’t anger the healthcare industry or states that have already joined the voluntary Obamacare program.

With very slim margins in Congress, Democrats only have a small window to implement their health plans ahead of the 2022 midterm election. Debate over the party’s vision for health care was beating down. already in full swing this year, and it could heat up now that Obamacare has been secured by the High Court.

Senator Bernie Sanders (I-Vt.), Who as chairman of the budget committee will have a strong influence on Democratic infrastructure legislation, insisted on Thursday that he would not abandon the lowering of the Medicare age at this Congress. He also called for expanding the program to cover vision, dental and hearing.

“There are millions of older workers who would like to benefit from Medicare who cannot today, which is why we need to lower the age, and there are millions more who do. walkers, who can’t hear, can’t afford glasses, and can’t afford dental care, ”he added, according to a report from the Capitol Hill Press Pool.

Senate Health Committee Chairman Patty Murray (D-Wash.) And House Energy and Commerce Chairman Frank Pallone (DN.J.) have started to gather comments on a public option, launching what could be a long process to craft a policy that Democrats could agree to at. The idea has gained support since being dumped from the ACA when the law was being drafted, but there are different ways to conceive of a public option.

“But it’s always going to be difficult because this is a very important and major change in the law, and Congress is not moving very quickly,” Henry Waxman, one of the main authors of Obamacare, told the Congress who now runs his own consulting firm. .

Rachel Roubein contributed to this report.

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