In the past three years, the ACA has survived a disastrous midterm election for the Democrats and a nail-biting Supreme Court decision last June, which also changed some key components of the law.

But in October, the ACA faces a daunting task, when as many as 24 million people will start to sign up for private health insurance exchanges run by the government, starting in January 2014.

The Congressional Budget Office said in February that it projects that 7 million people will enter the exchanges in 2014, with that number soaring to 24 million by 2017.

One of the key concepts behind the ACA was that states would be running the health insurances exchanges, with some help from the federal government. But in most cases, the federal government will run the exchanges until states decide to play a role in their operations.

The federal government will need to find the funds to manage the transition and organize a large operation that includes education, outreach, and complicated dealings with the insurance companies offering the policies, with all of this kicking off in six months.

Officially called The Health Insurance Marketplace, the exchanges provide a way for people without employer-sponsored insurance to get coverage and tax credits for health care.

On October 1, the government will start taking applications for coverage. The Washington Post recently obtained a draft of the application, which is 21 pages long. (There will also be a secure, online version of the application.)

The Health Insurance Marketplace is also the area where small business will try to figure out how they will insure workers, or just pay a penalty instead for not offering copaid insurance.

For now, the federal government will be running 26 of the exchanges outright and another seven in partnership with states. And in an interesting twist, President Barack Obama will be using the exchange system for part of his family’s health care, as will members of Congress.

Most of the states that passed on setting up their own exchanges are run by Republican governors.

The federal government didn’t expect to be that involved in running the exchanges when the October 2013 and January 2014 deadlines were set years ago.

Another important part of the whole health insurance exchange process is Medicaid. The Supreme Court ruling last June gave states the option to decline expanded Medicaid funds, which were tied to expanded coverage within states for lower-income citizens.

So far, 13 states have passed on taking federal money to expand Medicaid benefits. That would keep some lower-income residents from receiving Medicaid benefits, as well as hospitals from receiving Medicaid subsidies when they treat lower-income patients.

And since those low-income residents can’t get Medicaid, they could be caught in a situation where they would pay higher premiums if they buy private insurance in The Health Insurance Marketplace.

“States that do not move forward with the Medicaid expansion could see large gaps in coverage because individuals with incomes below 100 percent (of the federal poverty level) generally cannot receive subsidies to purchase coverage in the newly established health insurance exchanges and will not gain any new affordable coverage options,” said the Kaiser Family Foundation in a research paper.

The Kaiser Foundation also found that in its recent polling, most Americans are unsure about the major changes coming in October, and few know about how the changes will be handled on a state level.

About 48 percent of people acknowledge they knew nothing about their state’s plans for insurance exchanges and Medicaid, and 78 percent knew little about their governor’s stance on the Medicaid issue.

Kaiser also found that 57 percent of Americans said that they didn’t have enough information to understand how the ACA would affect them, and most importantly, more than two-thirds of people who are uninsured and in lower-income households didn’t understand the ACA.

The one thing that most people understood, at 74 percent, was the individual mandate that requires people to have insurance or pay a fine on their tax returns.

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Lyle Denniston looks at one company’s claim it has religious rights that exempt it from the Affordable Care Act’s requirement for free birth-control services.

The statements at issue:

“This Court has not previously addressed [religious freedom] or free exercise claims brought by closely held for-profit corporations and their controlling shareholders alleging that the mandatory provision of certain employee benefits substantially burdens their exercise of religion.”

—Supreme Court Justice Sonia Sotomayor, in an opinion on December 26, refusing a request to block the enforcement of the new federal health care law’s requirement that companies with more than 50 employees provide free health insurance coverage for birth control drugs and methods for their female workers.

“That Cyril and Jane Kortes operate their business in the corporate form is not dispositive of their claim…The contraception mandate applies to K&L Contractors as an employer of more than 50 employees, and the Kortes would have to violate their religious beliefs to operate their company in compliance with it.”

—Comment by a 2-1 majority of the Seventh U.S. Circuit Court of Appeals in Chicago, in an opinion on December 28, agreeing to block temporarily the mandate until the Kortes’ appeal can be decided.

We checked the Constitution, and…

One of the big issues not settled by the 2012 presidential campaign is whether “corporations are people” and, like people, have constitutional rights. The issue continues in a new form: does the First Amendment’s right to the free exercise of religion protect profit-making corporations? The courts are just beginning to provide answers, and the answers so far are mixed.

Last week, using different legal analyses, a Supreme Court justice on one day made it clear that the question remained open and unsettled, while a federal appeals court panel’s majority two days later gave at least a temporary answer: yes. Those were the most significant statements so far as federal courts work their way through more than 40 lawsuits challenging the new Affordable Care Act’s requirement for free birth-control services for millions of working women.

The Supreme Court, of course, has ruled that corporations do, indeed, have some constitutional rights that they share with real people. Most notably, the court ruled in 2010 in favor of corporations’ First Amendment right to spend money to express their political views in election campaigns. In fact, that decision in Citizens United v. Federal Election Commission was what caused the rights of corporations to become a campaign issue in 2012.

The Citizens United decision, of course, was based on the First Amendment’s Free Speech Clause, and said nothing at all about the amendment’s Religion Clauses. Still, it is noteworthy that, when the Seventh Circuit judges issued their order against the contraceptives mandate as it applied to an Illinois corporation, they cited the Citizens United decision as the basis for their remark that the corporate form shares its owners’ right to religious freedom.

That is both a new constitutional perspective, and likely to become a very controversial one if the idea spreads. Most corporations that engage in ordinary business activities are organized as secular firms; that is, they enter the marketplace to carry out commercial, not religious, endeavors. But what is perhaps more important is that business people who form corporations do so to keep themselves independent from it: one of the main advantages of the corporate form is that the owners are not targeted when their company gets sued.

Moreover, it sounds somewhat strange for a commercial entity that is considered to have an artificial legal personality, like a corporation, to “exercise” religion.

But to the family-run corporations that have sued to challenge the new contraceptives mandate, that is not strange at all. In fact, Cyril and Jane Korte in their lawsuit explicitly claimed that their construction company has its own right to exercise religion, and as its principal owners, they have insisted that they run its operations every day to reflect their personal religious convictions. The company’s business is, to them, another form of putting their Roman Catholic faith into daily practice.

The federal government challenged those claims in the Kortes’ lawsuit, noting that the family business was organized as a profit-making, secular business that makes no mention of a religious purpose in its incorporation papers, and that it sells no religious products or services. “The government is aware of no case in which a for-profit, secular employer with K&L’s characteristics prevailed” on a religious freedom claim, it said in a court document in the case.

The key dispute in this context thus appears to turn on whether the faith preferences of the owners of a profit-making corporation can be transferred to the business entity so that it is not an independent entity but rather, for constitutional purposes, an alter ego. The Kortes argue that, since the couple owns 88 percent of the construction company, they do treat it as an alter ego to express their faith. And it appears that, at least for the time being, that claim has prevailed in the courts in their case.

However, other judges on other federal courts have disagreed, and have concluded flatly that a secular corporation cannot exercise religion, and have warned that the contrary conclusion could raise the prospect of scuttling many laws that protect employees’ workplace rights.

Justice Sotomayor herself noted the conflicting results that have been emerging in the contraceptives mandate cases. And she also commented that the challengers, once they have had their day in the lower courts, will be free to bring the issue back to the Supreme Court. Given the intensity of the courthouse controversy over the mandate, such an appeal is all but certain, thus posing at some point a profound new twist on whether “corporations are people.”

Lyle Denniston is the National Constitution Center’s Adviser on Constitutional Literacy. He has reported on the Supreme Court for 54 years, currently covering it for SCOTUSblog, an online clearinghouse of information about the Supreme Court’s work.

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The administration of President Barack Obama said it didn’t object to the appeals court hearing the case of Liberty University v. Geithner.

Liberty University filed with the high court this summer, saying its previous claims should be looked at in a new light after the Supreme Court’s June 2012 decision. The evangelical school was founded by the late Reverend Jerry Falwell.

Liberty University is objecting to a mandate that most people buy health insurance or pay a tax penalty, and a requirement for most employers to offer health insurance to their workers, or pay a fine for each uninsured employee.

Liberty University claimed that the appeals court shouldn’t have used the Federal Anti-Injunction Act as a reason to deny hearing its original lawsuit.

The Fourth Circuit Court of Appeals will likely hear the case in the spring. Attorneys from Liberty University told Politico that they hope to bring their suit before the Supreme Court at some point.

On October 31, the Justice Department said it wouldn’t object if Liberty’s case were to be heard in the appeals court.

The court could also ask the Justice Department and the university to file new legal briefs.

The historic June 2012 Supreme Court decision on the Affordable Care Act ended three years of drama, for now, about President Obama’s wide-ranging overhaul of the health  care system.

Important parts of the reform effort, called Obamacare by its opponents, are already in place. But many parts of the law go into effect in 2014.

The court is under no obligation to hear the Liberty University case once the appeals court issues a decision.

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Ryan is leading the GOP effort to overhaul government spending in his role as a representative in the House from Wisconsin.

Medicare’s trustees currently say funding for the plan will start to run short in 2014.

The latest version of his plan, “Path To Prosperity,” was released in March 2012. The plan is a blueprint for government spending controls, with Medicare as a key component.

Link: Read the full Ryan plan

The Ryan plan doesn’t end Medicare, but it is a huge reform effort.

The proposed plan seeks to lower costs to taxpayers by using a system of payments given indirectly to seniors, who would in turn use the money to buy health insurance.

The Ryan plan calls them premium-support payments. Opponents call them vouchers.

The free market would then force insurance prices lower, according to the theory, through competition among insurers, while cutting costs to the federal government.

Factcheck.org and the Kaiser Family Foundation have breakdowns of the Ryan’s “Path To Prosperity” plan from March 2012.

Under Ryan’s plan, seniors currently in Medicare stay in the existing system. But in 2023, people over 65 would pick an insurance plan in a new Medicare exchange system, with Medicare competing with other insurers for their business.

The government would send money, called a premium-support payment, directly to the insurer picked by the consumer.

If the consumer picks a plan more expensive than the government premium payment they receive, the consumer must pay the difference out of pocket. If the consumer picks a cheaper plan, they pocket the difference in the form of a rebate check.

The Ryan plan set the premium payment to consumers at the cost of the second-least expensive government-approved plan.

The federal government will determine the minimum level of benefits that all plans must offer. The premium-support payment is capped at the growth of GDP, plus 0.5 percent. The subsidy will be adjusted based on the income level of the consumer.

After 2022, seniors are guaranteed they can enroll in any plan offered by the new exchanges and Medicare despite their health status or age.

In Ryan’s March 2012 plan, there is no limit of out-of-pocket costs incurred by seniors, and the plan doesn’t address prescription drug costs.

A key part of the plan is killing off the Obama administration’s Affordable Care Act.

The plan picks up out-of-pocket costs for seniors who qualify for both Medicare and Medicaid. Other seniors who don’t qualify for Medicaid also will have their out-of-pocket costs covered, based on their income level.

The Ryan plan also would gradually raise the eligibility age to 67 by 2034 and return the Medicaid program to the control of states, through the administration of block grants.

A sticking point with the health care industry will be the scenario where annual costs exceed the cap on premium payments based on GDP.

Some health care providers fear that doctors, insurance companies, and hospitals will pay the difference if Congress doesn’t authorize additional subsidies.

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The statements at issue:

“His job is not to finesse the place of the Supreme Court in the political world, in which he and most justices are rank amateurs, but to get the Constitution right first and then defend the institution second.”

– John Yoo, law professor at the University of California-Berkeley, in an email message published July 3 by The New York Times. He was commenting on leaks to the news media that Chief Justice John G. Roberts, Jr., had switched positions from striking down the new federal health care law to upholding it.

“There is speculation in conservative circles that Roberts had intended to strike down Obamacare but flipped his position at the last minute. We don’t know if he was suddenly convinced by his liberal colleagues or simply had a failure of nerve.”

– Marc A. Thiessen, fellow of the American Enterprise Institute in Washington, in an op-ed column July 7 in The Washington Post, commenting on the same news reports.

We checked the Constitution, and…

The Chief Justice of the United States–that is the correct title–is one of the few top federal officials whose job was created explicitly in the Constitution. By tradition, the Chief is also the head of the judicial branch and is its dominant administrator. And, if the federal courts’ reputation is suffering, or those courts are under political siege, it is to the Chief that the other justices–and perhaps the nation’s people–look for restoration of its stature, and maybe its power, too.

After seven terms as Chief Justice, John G. Roberts, Jr., probably has not had his leadership tested as much as now. When he returns from a two-week teaching assignment in Malta, and retreats to his summer home in Maine, he almost certainly will start thinking about that challenge, and whether he needs to do something about it.

He can have no doubt that many conservative politicians, pundits, and academics are thoroughly displeased with his votes in the health care case. (When those tempers cool, though, they will discover on closely reading his opinion that Chief Justice Roberts has not abandoned any of his conservative philosophy, and, indeed, has given a strong push to the limited government sentiment that now runs so deeply in conservative circles.)

But the Chief Justice’s problem, if he has one right now, is not solely with conservative critics outside the Court. It now appears that the internal deliberations of the Court were the subject of very substantial leaks from inside, and those leaks were framed in a way that challenged his leadership in fashioning a majority to resolve the Affordable Care Act controversy. Mr. Thiessen’s comment in The Post that the Chief Justice may have suffered “a failure of nerve” is an echo of what the leaks had indicated was an internal complaint, too.

It is almost certainly not in Roberts’ power to stop such leaks altogether. But, as the Chief, he does have the prestige and the rank–and perhaps the obligation–to lead the Court back toward renewed collegiality and common purpose.  He is known to want to keep the Court above politics, as much as possible, and that may very well account for the way he voted on health care. He almost surely is fully aware of the criticism that the Roberts Court is a partisan bastion, but now, the sniping from inside might just reinforce such an image–unless the Chief moves to ease the tension.

But dealing with that is an internal task; Roberts also faces a task that involves the world outside the Court, and not just to woo back America’s conservatives.

Although Professor Yoo sought to lecture the Chief Justice on his priorities, that critique suffered from two flaws.  First, there was no “right” way to decide the health care case; that the Court was deeply divided on almost all parts of the ruling showed that mature minds can differ on basic questions of constitutionality. The Court is not “wrong” just because it displeases some of the public.

Second, because the Chief Justice is the public face of the court, he must have a highly developed sensitivity to when it is getting into political trouble. A Chief Justice must be constantly aware of that in the digital age, when a negative response to the court can go viral instantly.

As a student of the court’s history, Roberts surely is aware of what may have been the finest moment in the career of one of his predecessors. And, despite Professor Yoo, this previous Chief Justice did not consider his external obligations to be secondary.

That Chief, of course, was Charles Evans Hughes. In 1937, with the Court in the midst of the constitutional crisis over its independence of the White House, it was Hughes’ public and private maneuvering that helped seal the doom of President Franklin Roosevelt’s Court-packing plan. Had that plan succeeded, it might well have destroyed the Court.

In a column in The Nation magazine in May 1937, when the Roosevelt plan was going down to defeat, columnist Robert S. Allen wrote: “Few realize how important a part Mr. Hughes has played in the fight against the court bill. He has conducted his operations with consummate deftness and finesse–and tremendous effectiveness.”

Hughes did it, though, with the support of his colleagues.  The leaks from within the Roberts Court do raise some doubt about whether this Chief can count on solidarity from within.

Lyle Denniston is the National Constitution Center’s Adviser on Constitutional Literacy. He has reported on the Supreme Court for 54 years, currently covering it for SCOTUSblog, an online clearinghouse of information about the Supreme Court’s work.

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The Treasury Department issued a proposed rule change on June 22 involving the Affordable Care Act, just six days before the Supreme Court health care decision.

The change restricts how debt collectors can approach patients within nonprofit hospitals –before, during and after treatment–and how long they have to pay ER bills.

In some cases, hospitals would need to wait 240 days before trying to collect a debt from you.

But the proposed rules change could also drive up costs at hospitals, and they could be extended to all hospitals, if a well-known politician can get another health care act passed.

The battle in Minnesota

The proposed rules seem spurred by a battle in Minnesota between Lori Swanson, the state’s attorney general, and Accretive Health, a Chicago-based company that works with hospitals to process and collect payments.

In a complaint, Swanson claims Accretive Health used a “high-pressure boiler-room-style sales atmosphere” to collect payments from patients at nonprofit hospitals in Minnesota.

The alleged tactics included approaching patients in the emergency room, at their bedsides and on exit from the hospital for bill payments.

Accretive Health was hired by Fairview Health Services and North Memorial Health Care, to help with administrative tasks. (Since Swanson’s filing, Fairview Health Services ended its contract with Accretive Health.)

Accretive Health has repeatedly denied any wrongdoing in its battle with Swanson, and it is offering to help set industry-wide standards for collecting medical payments.

Accretive Health also says it mostly works with patients and hospitals to make sure people are insured and aware of their financial help options, and that medical facilities get reimbursed from different sources.

“The state’s proposed amended complaint contains no new causes of action and no additional requested relief. The state has merely added selected allegations from its initial compliance review, which contain numerous mischaracterizations and distortions of documents and facts,” the company said in late June.

Accretive Health has filed with a federal court to have the complaint dismissed.

ER debt collection rules

The collection of debt payments could be a significant issue as President Barack Obama’s health reform program heads toward its full implementation in 2014.

The Treasury Department didn’t say directly if the proposed national rule changes were related to the Accretive Health case.

“In recent months, we have heard concerns about aggressive hospital debt collection activities, including allowing debt collectors to pursue collections in emergency rooms. These practices jeopardize patient care, and our proposed rules will help ensure they don’t happen in charitable hospitals. These rules also require charitable hospitals to establish and publicize financial assistance policies, and give hospitals the flexibility to establish programs that meet the needs of their communities,” said Acting Assistant Secretary for Tax Policy Emily McMahon.

The changes allow could drive down out-of-pocket costs for patients who need financial assistance to pay their hospital bills.

“A hospital may not charge individuals eligible for its financial assistance more for medically necessary care than the amounts generally billed to insured individuals,” says one proposed rule change.

The Treasury Department changes are now in a 90-day public review stage. They only apply to nonprofit hospitals, which would be barred from putting financial representatives in emergency departments and other wards to collect payments from patients.

If nonprofit hospitals don’t comply with the rules, they face losing their nonprofit tax status. About half of the hospitals in the U.S. would be affected by the decision.

Unpaid bills a drain on health care

Hospitals and other medical providers use a variety of methods to collect payments. By one estimate, about $40 billion a year is lost by health care providers in uncollected payments.

A report from Kaiser Health News from February 2012 detailed upfront bill collection efforts at for-profit hospitals, as operators tried to contain emergency room costs.

The Kaiser story also discussed how some nonprofit ERs were asking for upfront co-payments (for the insured) or cash payments (from the uninsured) for dealing with non-emergency treatments. The upfront cash payments for the uninsured were $350.

The Supreme Court’s decision to allow states to opt out of Medicaid expansion also complicates matters.

In 2010, health care providers agreed to accept lower government reimbursements, in the expectation that more people would have health insurance to pay for expenses like emergency room visits.

As many as 18 million additional people had been expected to join Medicaid if the ACA had passed in its original form. Now, states have the choice to decline Medicaid expansion.

And some states have already started restricting emergency room payments to hospitals under Medicaid.

ER visits and politics

U.S. Senator Al Franken from Minnesota wants to take the Treasury Department changes further, and apply debt collection and privacy restrictions to for-profit hospitals.

Franken says he will introduce the End Debt Collector Abuse Act of 2012. While Franken doesn’t name Accretive Health in his proposed law, he held a hearing in Minnesota in May during which an Accretive Health representative testified.

One of the public supporters of Accretive Health is Chicago Mayor Rahm Emanuel. In a letter in May, Emanuel asked Swanson to first try to settle the matter privately.

Swanson later claimed that Accretive Health “has retained or contacted numerous heavyweights in the national Democratic Party.”

Both Emanuel and Swanson are Democrats.

Accretive Health then retained Leavitt Partners, a consulting firm run by Mike Leavitt, the former Utah governor, to set up a project to research national debt collection standards.

The project’s board includes former Clinton cabinet member Donna Shalala, and former Senators Tom Daschle and Bill Frist.

Leavitt also later selected by Mitt Romney in June to lead his presidential transition team, if Romney defeats President Barack Obama in November.

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The polls were done independently by the Pew Research Center and the Kaiser Family Foundation, but they have similar results that show a big chunk of the electorate disengaged from the health care reform issue.

Both polls were done after the Supreme Court upheld most of President Barack Obama’s health reform plan on Thursday.

The Pew study showed that despite widespread publicity about the case, just 55 percent of the public knew the Supreme Court upheld most of the health care law. The other 45 percent said they thought the court rejected most of the law (15 percent) or they didn’t know what the court did (30 percent).

Only 37 percent of people under 30 years of age knew what the health care decision was, even though the story was four days old when the survey ended.

That poll was conducted from June 28 to July 1.

The Kaiser study was conducted for three days, from Thursday through Saturday, and it found that only 59 percent of those polled knew that the Supreme Court had issued a ruling upholding the law.

Another 18 percent thought the court hadn’t acted yet, while 17 percent just didn’t know about the case.

Both polls found the public equally divided on the issue, based on party affiliation. The Kaiser study found independent voters equally split.

One telling sign was also in the Kaiser study, where 56 percent wanted opponents of the Affordable Care Act to stop trying to block it and move on to other national problems.

The Pew survey also said despite a large number of people seemingly disengaged from the issue, health care was still the biggest news story in June, and the second biggest so far in 2012. (The biggest news story of 2012 was soaring gasoline prices in March.)

The poll also showed little public interest or awareness in the Eric Holder case.

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“The U.S. Constitution died today.  The underlying hope and belief that our nation’s founding document protected individual freedoms from an ever-encroaching government is a thing of the past based upon this ruling.”

– Bill Wilson, president of Americans for Limited Government, an advocacy group based in Fairfax, Va., in a press release June 28 commenting on the Supreme Court decision upholding almost all of the new federal health care law.

We checked the Constitution, and…

To paraphrase Mark Twain, the death of the Constitution may well be “greatly exaggerated.”  Our “founding document” was still alive and well when we checked, and it does not appear to be approaching a terminal condition.   The Supreme Court left Washington for the summer yesterday, and the Justices – though deeply divided on their last day on the bench this term –  seemed confident that the Constitution would be in good health when they return in October.

Whatever hopes the opponents of the new Affordable Care Act had that the Constitution would provide the means to kill that law, they surely were disappointed.  But the survival of the Act was not at the Constitution’s expense.  Even so, it is entirely true that the Constitution does have a different meaning today than it had two days ago, due to this new decision.

Here are some of the characteristics of what might well be termed a new constitutional order:

– Congress is clearly on notice that its vaunted power to regulate interstate commerce, which seemed to have no limits, may well have reached its outer limits.   People’s private lives and private economic choices cannot be regulated, by Congress, if the people do not voluntarily move into a branch of commerce that runs across state lines.    The Court’s 1942 decision in Wickard v. Filburn, allowing Congress to control how much wheat a farmer can grow on his own acres, for his own use, now looks like a relic of the constitutional past.

– Congress, however, has learned that it definitely had the authority to try – for the first time in history – to arrange for nearly universal health care for Americans, provided it finds a means to enforce such a goal by using its taxing power to induce people to become customers of the health insurers.   In the process, Congress can take creative and bold steps to hold down not only the cost of health insurance premiums, but the cost of health care itself.

– And Congress also has been told that it can push through massive reforms of the way a single industry operates – in this instance, the health insurance industry – if it is careful about the specific authority in the Constitution that it puts to work.

– If Congress wants to encourage states to adopt a broad new social welfare program, and puts up most of the money for it, it cannot force the states to take part by threatening to take away the money they already were entitled to receive.   A state’s participation in such a government-funded program has to be purely – and demonstrably – a matter of free choice.

– And, for the first time in history, the Court has embraced in an actual case, to challenge a major piece of federal legislation, a theory that the states retain a degree of sovereign dignity that can be severely compromised by a federal law that attaches too tough conditions on their receipt of federal money for a federal-state program.  (In a Court otherwise divided 5 to 4, that proposition had a healthy 7-2 margin.)

There were other consequences of Thursday’s decision, but not least was that Chief Justice John G. Roberts, Jr., took a giant step toward crushing the popular myth that “the Roberts Court” is a conservative wrecking crew bent on hell-bent promotion of Republican causes.

Some pundits have been saying that Roberts and President Obama have been on a collision course for the past two years, and one of them would have to yield to avoid a constitutional crisis.

In fact, the President’s most-prized domestic policy initiative survived in the Roberts Court – and, in the process, the Chief Justice did not forfeit one sliver of his conservative constitutional philosophy; in fact, he solidified the five-Justice conservative majority, at least on the severe retrenchment of Congress’s power over commercial activity.    To do that without dismantling entirely the modern “welfare state” was really quite creative.

As an incidental benefit to the Supreme Court, which genuinely believes it has no place in politics, it will be a lot harder for President Obama to run against the Supreme Court in the balance of this year’s election campaign.

Lyle Denniston is the National Constitution Center’s Adviser on Constitutional Literacy. He has reported on the Supreme Court for 54 years, currently covering it for SCOTUSblog, an online clearinghouse of information about the Supreme Court’s work.

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In a 5-4 decision, the Supreme Court said the Obama health care plan is constitutional, mostly because its health insurance mandate survived on a legal technicality.

But it could be that legal technicality that boosts Mitt Romney’s campaign, given a court ruling that mandatory health insurance for some Americans is a tax.

Chief Justice John Roberts agreed to a secondary argument made in March court hearings that the mandate was allowed as a tax, even though it violates the Commerce Clause of the Constitution.

Few observers saw that coming. But it was enough to save the Affordable Care Act.

And in the hours after the Supreme Court decision, the GOP was on the offensive, saying the court just affirmed that President Obama lied in 2009 when he said the Affordable Care Act wasn’t a tax hike.

During nearly six hours of health care hearings in March 2012, the administration’s secondary argument about the mandate as a tax drew laughs in the courtroom.

U.S. Solicitor General Donald Verrilli was chided for using the term “tax penalty” by Justice Samuel Alito.

“Today you are arguing that the penalty is not a tax. Tomorrow you are going to be back and you will be arguing that the penalty is a tax,” said Justice Alito, to loud laughter.

It was that obscure argument, which many saw as Verrilli’s low point, that saved the ACA.

But on Thursday, Republicans seized on the idea that Obama and the liberal part of the Supreme Court pushed a huge tax hike on the American people.

“Obamacare raises taxes on the American people by approximately $500 billion. Obamacare cuts Medicare, cuts Medicare, by approximately $500 billion. And even with those cuts, and tax increases, Obamacare adds trillions to our deficits and to our national debt and pushes those obligations on to coming generations,” said Romney.

Other statements from GOP leaders called the individual mandate the biggest tax hike in U.S. history.

Commentator Rush Limbaugh quickly jumped out in front with his own message, saying it was a “massive, regressive tax on all Americans.”

And just as quickly, Democratic websites like Media Matters for America were out with a counter-message, saying that individual mandate only applied to between 2 and 5 percent of Americans.

It also pointed out a more problematic issue for Romney: His health care plan in Massachusetts included an individual insurance mandate.

Another left-leaning web site, Think Progess, was out with statements from 42 Republicans on Thursday bashing “the ACA tax hike,” with a companion video from 2006 showing Romney discussing about how he used taxes as governor to mandate health insurance.

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Barack Obama

President Obama stated: “Whatever the politics, today’s decision was a victory for people all over this country whose lives will be more secure because of this law and the Supreme Court’s decision to uphold it.”

Obama’s staff also tweeted a picture stating “Obamacare UPHELD.”

Mitt Romney

GOP candidate Mitt Romney tweeted: “If we want to get rid of Obamacare, we’re going to have to replace @BarackObama.”

In addition, Romney made a statement and used the ruling in an online appeal for donations:

“Today, the Supreme Court upheld Obamacare. But regardless of what the Court said about the constitutionality of the law, Obamacare is bad medicine, it is bad policy, and when Mitt Romney is president, the bad news of Obamacare will be over.”

Harry Reid

In a statement for the Senate floor, Senate Majority Leader Harry Reid said:

“Passing the Affordable Care Act was the greatest single step in generations toward ensuring access to affordable, quality healthcare for every American–regardless of where they live or how much money they make.”

John Boehner

Speaker of the House John Boehner stated:

“The president’s health care law is hurting our economy by driving up health costs and making it harder for small businesses to hire.  Today’s ruling underscores the urgency of repealing this harmful law in its entirety.”

Nancy Pelosi

Democratic Leader Nancy Pelosi announced:

“This decision is a victory for the American people.  With this ruling, Americans will benefit from critical patient protections, lower costs for the middle class, more coverage for families, and greater accountability for the insurance industry.”

Eric Cantor

House Majority Leader Eric Cantor said in a statement:

“The Supreme Court’s decision to uphold ObamaCare is a crushing blow to patients throughout the country.”

Cantor committed to a House vote on July 11 to attempt once more a repeal of the health care reform law.

Rand Paul

In a statement, Senator Rand Paul said:

“Just because a couple people on the Supreme Court declare something to be ‘constitutional’ does not make it so. The whole thing remains unconstitutional. While the court may have erroneously come to the conclusion that the law is allowable, it certainly does nothing to make this mandate or government takeover of our health care right.”

Mitch McConnell

In a statement, Senate Republican Leader Mitch McConnell said:

“Today’s decision makes one thing clear: Congress must act to repeal this misguided law. Obamacare has not only limited choices and increased health-care costs for American families, it has made it harder for American businesses to hire.”

Patrick Gaspard

After hearing the news, DNC Committee Executive Director Patrick Gaspard tweeted: “it’s constitutional. B******.” Later, he updated: “I let my scotus excitement get the better of me. In all seriousness, this is an important moment in improving the lives of all Americans.”