WASHINGTON -- In a 5-4 decision that should shape the health and political landscape for decades, the Supreme Court has upheld almost all of President Barack Obama's signature health care overhaul, including the so-called "individual mandate" requiring Americans to obtain insurance coverage.
The decision, issued Thursday morning, is a policy victory for Mr. Obama in the midst of a re-election drive, but gives GOP presidential candidate Mitt Romney and other Republicans a divisive campaign issue to pursue through November and beyond. It also, potentially, limits Congress' ability to regulate commerce going forward.
Mr. Obama, in a brief televised speech, sought to recast the ruling as not a political triumph but a win for the uninsured and the rest of America's health consumers.
"Whatever the politics, today's decision was a victory for people all over this country," he said. Five years from now, or even 20 years from now, "we'll be better off because we had the courage to pass this law and keep moving forward," he said.
Mr. Obama acknowledged that the mandate wasn't politically popular, but that it was fundamentally fair to ask those who can afford it to "take the responsibility" to acquire health insurance.
That controversial provision survived because Chief Justice John G. Roberts Jr., a Republican appointee, viewed the statute as not so much a mandate to buy health insurance, but a tax upon those who do not.
"Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness," Justice Roberts said.
The other affirming justices, all appointed by Democrats, saw the legislation as a mandate and likewise saw that mandate as constitutional.
In a joint dissent, Justices Samuel Alito, Anthony Kennedy, Antonin Scalia and Clarence Thomas said "the act before us here exceeds federal power [in] mandating the purchase of health insurance."
The court also spoke to the Affordable Care Act's Medicaid expansion provision, which threatened to withhold federal funding for Medicaid -- the state-administered health insurance program for low-income individuals and families -- unless the states agree to loosen eligibility requirements for the program.
The majority said the expansion is constitutional, but that it would be unconstitutional for the federal government to withhold Medicaid funds from the states if they don't go along with the expansion.
Reaction to the decision, made public at 10:07 a.m. Thursday, came swiftly and cut mainly down party lines. Outside the Supreme Court building, news of the ruling spread as activists with smartphones relayed it to neighbors.
Simultaneous cheers and boos emanated from the crowd, which had divided itself by sorting health law supporters to the right side of the court building and opponents to the left.
Their celebrations and laments soon turned into a cacophony of screeches, drum beats, impromptu renditions of "Amazing Grace," chants and speeches shouted into microphones and bullhorns.
"I was worried, but this turned out to be a big victory," said John Keenan, 40, a Washington corporate government analyst who was among at least 1,000 who awaited the decision from the courthouse steps. "People shouldn't have to go bankrupt if they get sick, and now they won't. This is an important day."
Opponents, including Tea Party members and anti-abortion activists, said they'll take the fight to a new front: Congress, where they're hoping for a legislative appeal.
House Speaker Eric Cantor, R-Va., already has scheduled a repeal vote, and House Democrats are accusing him of being irresponsible for attempting to kill the law without having a plan to replace it.
The repeal vote is likely to pass the Republican-controlled House but stall in the Democratic-controlled Senate.
Republicans and many business groups said, as they have maintained all along, that the 2010 Patient Protection and Affordable Care Act -- commonly, and sometimes derisively, known as Obamacare -- will cost too much, and will hurt large and small businesses. The Supreme Court's narrow validation of the law, they said, underscores the urgency of the 2012 elections.
"If we're going to get rid of Obamacare, we've got to get rid of President Obama," Mr. Romney said Thursday, shortly after the ruling was issued. "That is my mission. That is our work."
Meanwhile, Democrats and many health advocates called the decision a victory for America's tens of millions of uninsured and low-income families who will soon become Medicaid-eligible.
"The Supreme Court made the correct decision. The reform provides access to health care for millions of Pennsylvanians, from college students, to those with pre-existing conditions, seniors who have high prescription costs and others," said state Sen. Jay Costa, D-Forest Hills.
Many legal and constitutional law scholars predicted the decision, and particularly the mandate, might live or die based on the justices' reading of the Constitution's "commerce clause," and whether that clause, which permits Congress to regulate interstate commercial activity, was applicable to an individual's decision to purchase -- or not purchase -- health care.
The court, via Justice Roberts' swing vote, said the mandate would not have survived the commerce clause test, concluding that "the individual mandate is not a valid exercise of Congress's power under the Commerce Clause [because] the power to regulate commerce presupposes the existence of commercial activity to be regulated."
But that point that was rendered moot by Congress's wide discretion when it comes to taxing individuals and collecting excises to "provide [for] the general welfare of the United States."
"Put simply," he wrote, "Congress may tax and spend."
Some foes of the statute also found a silver lining of sorts in Justice Roberts' characterization of the mandate as a tax.
They used the opportunity to call Mr. Obama and Democrats liars for denying that the mandate was a tax when the law was being debated -- and some said they would simply refuse to buy insurance or pay the "tax," to undercut the law.
Congressman Mike Doyle, D-Forest Hills, said it's a matter of semantics, not substance.
"The best part for Western Pennsylvanians -- where we have a very, very high number of senior citizens -- is that Medicare will no longer have a big donut hole with prescription drug coverage."
But one Western Pennsylvanian in the courthouse crowd, Samantha Smyers, said she finds little to like about the Affordable Care Act.
"I don't believe anybody is against health care, but mandating people to buy it isn't right. ... Congress is smarter than this. They can formulate a bill that can really help people without imposing mandates," said Ms. Smyers, 19, of Allison Park, who is a summer intern at the Washington lobbying firm Tech America.
Republican Pennsylvania Sen. Pat Toomey called the decision a "jarring blow to our 200-year-old tradition of constitutionally limited government and personal liability," while Congressman Mike Kelly, R-Butler, also derided the decision, saying "Americans should have the freedom to make their own health care decisions."
Democratic U.S. Sen. Bob Casey praised the ruling and the protections included in the act, but noted that "there is no doubt that we still confront significant challenges to reducing the cost of health care, and the only way to address these in the long-run is for Democrats and Republicans to work together."
Rep. Mark Critz, D-Johnstown, crossed party lines to support previous GOP repeal efforts because he disagreed with the mandate to buy health insurance.
Now that the law is in effect, Mr. Critz says it would be wrong "to go backwards and allow insurance companies to deny coverage [of] pre-existing conditions, to kick young adults off their parents' health insurance plans, or to reopen the donut hole, which will force seniors to pay more for medicine."