June 28--The Supreme Court on Thursday upheld the key provisions of President Barack Obama's health care overhaul, most notably the requirement that people have health insurance after 2014.

The so-called mandate, which would require people to have health insurance or pay a penalty, was considered most vulnerable to the legal challenges. It also became a focal point for opponents of the law -- a tangible and understandable example of the law's scope and reach.

The court's four liberal justices -- Stephen Breyer, Ruth Bader Ginsburg, Elena Kagan and Sonia Sotomayor -- joined Chief Justice John Roberts in upholding virtually all of the Affordable Care Act.

Justices Samuel Alito, Anthony Kennedy, Antonin Scalia and Clarence Thomas dissented.

The court's 5-4 decision means the huge overhaul, still taking effect, will proceed over the next several years, affecting the way that countless Americans receive and pay for their personal medical care.

President Barack Obama called the decision a "victory for people all over the country" that upholds the principle that in the wealthiest nation on earth, no one should fall into financial ruin because of an illness.

The president said the decision means that people with pre-existing medical conditions will not be discriminated against, and people will be able to afford quality health care.

The ruling hands Obama a campaign-season victory in rejecting arguments that Congress went too far in approving the plan.

However, Republicans quickly indicated they will try to use the decision to rally their supporters against what they call "Obamacare."

Wisconsin's opposition

Shortly after the election of Gov. Scott Walker, Wisconsin had joined other states that filed lawsuits challenging the law. Former Gov. Jim Doyle had blocked Attorney General J.B. Van Hollen from joining the legal challenges.

The Supreme Court's decision removes some of the uncertainty surrounding the law -- the most sweeping attempt to remake the U.S. health care system in nearly half a century and the first time the country moved to ensure almost every American had access to basic health insurance.

But the rulings are unlikely to lessen the strong divisions over the law, and with Republicans' vowing to repeal it, the real test could come in November.

Walker has said Wisconsin will not move forward on implementing the law until after the November elections.

For now, the court's ruling removes what would have been a significant setback to expanding coverage.

The law is projected to increase the number of people with health insurance nationally by roughly 30 million by 2019. The Congressional Budget Office had estimated that without the hotly debated mandate, 16 million fewer people would gain coverage.

In Wisconsin, an additional 340,000 people were projected to be insured by 2016 because of the law, based on a study done for the state. If the law had stood without the mandate, that number would have dropped to 62,000.

The court's ruling "provides some clarity for us moving forward," said Julie Swiderski, vice president of government relations for Wheaton Franciscan Healthcare. The health system supports the provisions in the law that would increase access to health insurance.

"We continue to believe that's the right direction for health care to be moving," she said.

Rick Abrams, chief executive officer of the Wisconsin Medical Society, took the same position and was pleased the mandate was upheld.

"The goal is to do what we can do to ensure access to high quality care for the most Wisconsinites as we can," he said.

If the court had rejected the mandate, Abrams said, other reforms, such as requiring health insurers to cover people with pre-existing health problems, would have been in jeopardy.

Costs remain a concern

The law would expand coverage by expanding the Medicaid program, by providing subsidies for people in low-to-middle-income households, and by requiring health insurers to cover people with pre-existing conditions.

The cost would be paid for primarily through smaller increases in Medicare spending in the future and through an array of taxes.

Opponents question the projected cost, and they believe that Congress over time may not follow through on the provisions to pay for the law, resulting in larger deficits.

The court's long-awaited decision opened a floodgate of statements from opponents, supporters and various stakeholders.

"If there is no political remedy from Washington and the law moves forward, it would require the majority of people in Wisconsin to pay more money for less health care," Walker said in a statement. "Additionally, it would increase the size and cost of government, decrease the quality of health care and, in our state, reduce access for those truly in need of assistance."

Dennis Smith, secretary of the state Department of Health Services and an opponent of the law, said the ruling weakened the law even as it upheld it because it would allow states more latitude to buck federal mandates within the law.

"Health care premiums are going up, taxes are going up and there will be less coverage than what the (Obama) administration and Congressional Budget Office said would happen," Smith said. "I think the law is collapsing and people will understand the court just gave it a big shove."

But Robert Kraig, executive director of Citizen Action of Wisconsin, called the ruling "historic" and said it "is a major step toward establishing the freedom of every American to make their own health care decisions.

"We are one step closer to every American having the peace of mind of knowing that health care will be there when they need it." Kraig said.

The Medicaid issue

In its rulings, the court found problems with the law's expansion of Medicaid, but even there said the expansion could proceed as long as the federal government does not threaten to withhold states' entire Medicaid allotment if they don't take part in the law's expansion of coverage.

People with household incomes below 133% of the federal poverty level -- about $15,000 for an individual -- would be eligible for Medicaid under the law, with the federal government initially paying the full cost, and 90% of the cost after 2016.

Of the 30 million people nationally who are projected to gain coverage under the law's provisions by 2019, about half would be covered by Medicaid. The rest would buy insurance on their own and most would be eligible for subsidies tied to their income.

Those eligible for subsidies would buy health insurance through online marketplaces, or exchanges, that would be set up in each state.

In Wisconsin, Walker halted work on the exchanges and returned a $38 million federal grant to help cover the cost of setting them up. States must show by early next year that they are making progress on the exchanges or the federal government will set up the exchanges for them.

The Walker administration's position frustrated advocates.

"The law has been passed. The court has ruled. Wisconsin should get going on implementing this," said David Riemer, a senior fellow at Community Advocates Public Policy Institute.

In a joint statement, the dissenting Supreme Court justices said the law "exceeds federal power both in mandating the purchase of health insurance and in denying non-consenting states all Medicaid funding."

Separately, GOP presidential candidate Mitt Romney has joined in calls for its complete repeal.

After the ruling, Republican campaign strategists said Romney will use it to continue attacking the president's signature health care program as a tax increase.

"Obama might have his law, but the GOP has a cause," said veteran campaign adviser Terry Holt. "This promises to galvanize Republican support around a repeal of what could well be called the largest tax increase in American history."

Democrats said Romney, who backed an individual health insurance mandate when he was Massachusetts governor, will have a hard time exploiting the ruling.

"Mitt Romney is the intellectual godfather of Obamacare," said Democratic consultant Jim Manley. "The bigger issue is the rising cost of health care, and this bill is designed to deal with it."

Justice Ginsburg said the court should have upheld the entire law as written without forcing any changes in the Medicaid provision. She said Congress' constitutional authority to regulate interstate commerce supports the individual mandate. She warned that the legal reasoning, even though the law was upheld, could cause trouble in future cases.

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