DISPUTES: Residents debate the ACA outside the Supreme Court in Washington, D.C. on March 28, the last day of hearings on the medical reform bill (FANG ZHE)

By now it seems difficult for many Americans to remember a time when health policy did not polarize. For much of the current presidential term, health care has been at, or near, the top of the political agenda, engendering strong opinions across the ideological spectrum, and fiercely further dividing Democrat from Republican. The recent headlines seem to suggest that, with the landmark ruling from the Supreme Court, the end of this battle is nigh. While the decision to uphold most of the legislation as constitutional gives its proponents some breathing room, however, the larger conflict over the shape of the nation's health care "system"—or lack thereof—will continue for years to come.

'ObamaRomneycare'

The "marquee" items of the Affordable Care Act (ACA)—today better known as Obamacare—derive from Republican precincts. The individual mandate requiring every American to obtain health insurance of some shape or form first appeared in a policy document from the right-leaning Heritage Foundation toward the end of the 1980s, and for many years enjoyed wide support from Republicans, and denunciation from Democrats. Over time, increasing numbers of Democrats warmed to the idea, while support slowly eroded among Republicans. Nonetheless, the concept of an individual mandate still enjoyed enough currency within the GOP that Republican Governor Mitt Romney signed on to a broader state health reform plan which included such a measure.

Indeed, perhaps one of the greatest ironies of the current position of the political constellations regarding the ACA is that a reform program today so closely associated with President Barack Obama nonetheless owes is inspiration to the Massachusetts plan endorsed by his current opponent in the 2012 campaign. During the primary race, the former governor's Republican rivals were hardly exaggerating when they dubbed the ACA "ObamaRomneycare" or, more simply, Romneycare. In the zero-sum game that American electoral politics has become, however, a measure adopted by the one party cannot possibly draw one iota of support from the other, and thus the Democratic adoption of the individual mandate and, along with it, insurance exchanges, made such measures radioactive to Republicans.

Republicans responded to the 2010 passage of the ACA along two tracks—one legislative, and the other judicial. Congressional Republicans immediately sought to repeal the legislation, a cause to which many remain rhetorically committed. It should be noted just how extraordinary this mission happens to be—the last repeal of a major piece of social legislation occurred in 1988, and that effort enjoyed broad, bipartisan support. In addition to these efforts, Republican state officials and representatives of small business and other groups collectively pursued lawsuits in an effort to get the ACA overturned by the courts.

The legal plaintiffs launched two major challenges against the legislation. On the one hand, they argued that the individual mandate was unconstitutional, asserting that the federal government did not possess the power to regulate "inactivity" by charging a penalty for a failure to obtain health insurance. On the other, plaintiffs argued that the Medicaid expansion included in the act, which requires states to cover all residents who fall within 133 percent of the federal poverty line or else lose all federal contributions to their Medicaid programs, constituted coercion.