The Supreme Court voted 6-3 in favor to uphold the Affordable Care Act, aka Obamacare.

"With the uncertainty of the ruling behind us, we think this will be the last significant challenge to the Affordable Care Act," Citi's Murali Ganti said.

Immediately, hospital and health insurance stocks spiked.

"We think this ruling calms those fears and believe positive sector conviction will follow, allowing investors to once again focus on fundamentals," Ganti noted. "Predictably, hospital and managed care stocks have been rallying this morning given that they were the most at risk."

And now that this is behind us, everyone including the folks in Washington can move on.

"The ruling represents the best possible outcome for Democrats, but more importantly for Republicans, who remain more focused on capturing the White House than having to defend their position on why 6.4 million individuals could potentially become uninsured."

SEE ALSO: SUPREME COURT SAVES OBAMACARE

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President Barack Obama did not waste the opportunity to celebrate the Supreme Court's decision to uphold his signature health care law.

In a 6-3 ruling on Thursday, the Supreme Court ruled that the Obama administration was within its rights to grant subsidies to individuals living in states that had not set up exchanges under the Affordable Care Act.

The decision was met with relief within the Obama administration.

"That's when America soars. When we look out for one another. When we take care of each other. When we root for one another's success. When we strive to do better and be better than the generation that came before us and try to build something better for generations to come," Obama said.

Following the decision, White House photographer Peter Souza tweeted out a picture of Obama and Vice President Joe Biden hugging White House Chief of Staff Denis McDonough and Deputy Chief of Staff Kristie Canegallo in the Oval Office.

Several other photographers captured signs of relief as the White House celebrated the ruling as well as the trade bill's passage on Thursday.

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The Supreme Court handed the Obama administration a significant victory on Thursday, when it upheld a key provision of the Affordable Care Act that allows the federal government to keep distributing subsidies to help low-income Americans buy health insurance.

But the decision's ramifications could be felt in the 2016 election and beyond, especially if a Republican wins the White House next year.

That's because the Supreme Court not only ruled the federal subsidies are legal under the Affordable Care Act, but it also did not leave any ambiguity that would allow a future administration to interpret the law differently.

"The court focused definitively and said, this is what the law means," said MaryBeth Musumeci, an associate director at the Kaiser Commission on Medicaid and the Uninsured.

The challengers in the case argued the way the law was written does not allow for subsidized insurance in states where the federal government had set up insurance exchanges. Instead, the challengers argued, insurance subsidies are allowed only in states that have set up their own exchanges. They pointed to a clause that they argued meant exchanges should be "established by the state."

A brief history: In 2011, the IRS issued a regulation that interpreted a part of the law in question to mean that the federal government could issue the subsidies. But in its opinion Thursday, the Supreme Court majority said that decision should not be left up to a government agency to interpret, since Congress did not make that explicit in the Affordable Care Act.

Instead, the high court disregarded the agency's interpretation and ruled on the statute on its own. It said the decision should not be left up to the agency, which means a future administration cannot change that interpretation.

"If the court had left in question about whether there should have been deference to the agency, that would have left the door open potentially for another administration running that agency to say, ‘OK, this is ambiguous language, and we have a different legal interpretation,'" Musumeci said.

Practically, this means that a theoretical future Republican president could not come in and say that the federal government cannot hand out subsidies.

That might not be a practical solution: After all, by the time a Republican president could enter into office, millions of additional people would benefit from subsidies handed out under the law. But there's no longer even an option: The Supreme Court has definitively determined that the federal government can provide subsidies under the law.

"Because the Court has provided its own, definitive interpretation of the ambiguous statute — and held that it will not defer to the agency’s interpretation — a subsequent presidential administration (say, a Republican Administration) cannot reinterpret the statutory provision to prohibit tax subsidies in exchanges established by the Federal Government," Chris Walker, an assistant professor at the Michael E. Moritz College of Law who clerked for Justice Anthony Kennedy, wrote Thursday.

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WASHINGTON (AP)— The Supreme Court's resounding rejection of a conservative attempt to gut President Barack Obama's health care overhaul won't stop Republicans from attacking the law they detest. But now, their efforts will be chiefly about teeing up the issue for the 2016 presidential and congressional elections.

The court's decision left GOP lawmakers stunned and uncertain about some of their next steps. Most agreed they would continue trying to annul the entire law and erase individual pieces of it, like its taxes on medical devices. Yet many also conceded they have little leverage to force Obama to scale back — let alone kill — one of his most treasured legislative achievements.

"Obamacare is fundamentally broken," said House Speaker John Boehner, R-Ohio, who said repeal efforts would continue. But he declined to guarantee a vote on a replacement plan this year and said, "It's very difficult to deal with it when you have a president that fundamentally disagrees with us. And so the struggle will continue."

"We'll continue to pick away at the law," said Sen. John Barrasso, R-Wyo., a leader of Senate GOP efforts to craft a bill responding to a court victory that never came. "But ultimately our goal is to repeal and replace, and that's not going to be possible until after the 2016 elections," when Republicans hope for a GOP president.

That leaves Republicans mostly using efforts to void or dramatically weaken the health care overhaul to contrast their views with Obama's for voters.

"It's going to be one of the most important, if not the most important, debating points for 2016," said Rep. John Fleming, R-La.

Yet though few would admit it, the court's ruling caused many Republicans to exhale with relief.

By leaving intact federal subsidies that help millions afford health care, the ruling lets Republicans bash Obama's law in their 2016 campaigns without having to quickly help those who would have lost assistance. Taking away those benefits could have created many angry voters.

"There isn't some sort of, that sword of Damocles hanging over our heads that people are going to lose their care in 30 days or something," said Rep. Greg Walden, R-Ore., who heads House GOP campaign efforts.

Republicans have promised to repeal and replace Obama's law since its 2010 enactment, but have yet to rally behind a plan doing that. A bill temporarily continuing the subsidies this year would have faced a difficult path to passage, thanks to conservative reluctance to abet Obama's health law in any way.

Had the GOP-backed lawsuit by conservatives succeeded, the 34 states likeliest to lose subsidies included many that will be pivotal in next year's elections. That included Florida, a key presidential state where a national high of 1.3 million people could have lost assistance, plus Pennsylvania, Illinois, Ohio, Wisconsin and New Hampshire, where GOP senators could face tight re-election battles and worried about constituents losing aid.

"The court has saved Republicans from themselves," said former Rep. Tom Davis of Virginia, who once led the House Republican political organization.

Underscoring that the court decision left intact the issue's high-wattage political appeal, it took just minutes for both sides to use the ruling for political fundraising. GOP hopeful Jeb Bush, the former Florida governor, emailed for money to stop "the overreaches of the last six years," while Senate Democrats warned that Republicans have "pledged to destroy Obamacare."

The decision was a relief to the health care industry, which feared chaos in the insurance market, and business groups hoping Congress would now turn to making specific changes in the law to ease employers' costs.

In Thursday's ruling, the justices by 6-3 left intact subsidies that help 8.7 million people buy health insurance — most of whom analysts say couldn't otherwise afford coverage.

Conservative plaintiffs said the law's wording limited that aid to states running their own insurance marketplaces — not the three-dozen states using the federal website HealthCare.org. The law's defenders said killing those subsidies would destabilize health insurance by increasingly leaving only sicker, costlier people with coverage — raising everyone's rates.

"Congress passed the Affordable Care Act to improve health insurance markets, not to destroy them," Chief Justice John Roberts wrote in the majority opinion, using the law's formal name. Roberts' deciding vote found the law constitutional in 2012.

"We should start calling this law SCOTUScare," said dissenting Justice Antonin Scalia, using the court's acronym.

Savoring his triumph at the White House, Obama noted that his law has had five years to take hold and said: "This is not about the Affordable Care Act as legislation, or Obamacare as a political football. This is health care in America."

Even so, Republicans had little reason to back off, especially those concerned about primaries from conservative challengers. An April Associated Press-GfK Poll showed that 71 percent of Republicans oppose the law, compared to 33 percent of independents and 14 percent of Democrats.

"We've got to put something on the president's desk, not just a repeal but what are we going to do, what's our alternative," said Rep. Tim Huelskamp, R-Kan.

In the latest potential wedge between conservatives and Boehner, the speaker said he had not decided whether to use streamlined procedures that could avoid a Senate filibuster. Conservatives want to use those rules, but that device can be used only rarely and some Republicans want to save it for something Obama might sign, like deficit reduction.

___

Associated Press writer Erica Werner contributed to this report.

Copyright 2015 The Associated Press. All rights reserved. This material may not be published, broadcast, rewritten or redistributed.

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Former Arkansas Gov. Mike Huckabee's (R) presidential campaign used his grandson to argue that Obamacare is terrible.

In a short video sent to his supporters on Friday, a woman who appears to be his daughter and campaign manager, Sarah Huckabee, introduces the two-week-old George. 

She says George has smelly diapers, but the Supreme Court's Thursday ruling upholding a key part of the Affordable Care Act smells worse.

"Boy can he stink up the joint," she says as George lies there and squirms. "But even George's worst do not stink nearly as bad as what's been coming out of Obama and the Supreme Court."

Huckabee had a far harsher reaction immediately after the ruling, which found that President Barack Obama's signature healthcare law could provide subsidies to millions of people insured through federal exchanges. The dissenting justices said the healthcare law indicated that only people insured through state-based exchanges should be eligible for the subsidies.

Huckabee argued Thursday that the decision was "an out-of-control act of judicial tyranny."

Watch his campaign's video about George below:

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The Affordable Care Act (ACA) survived another review at the Supreme Court on Thursday. But Obamacare isn't out of the woods yet. There will be a new president in January 2017, and if that president has a tall "R" next to his or her name, the pressure to undermine the ACA will be high.

Republicans wouldn't have any great options. But here are several things they might try, in order of least to most likely to happen.

Full repeal

To make good on the GOP mantra of "repeal and replace," Republicans would have to hold Congress, then do what they've been unable to do since 2009 — unite behind an alternative health-care proposal. There is at least one real GOP replacement plan on the table, from Sens. Richard Burr (N.C.), Tom Coburn (Okla.) and Orrin Hatch (Utah), but it probably wouldn't attract enough support among hard-right conservatives.

Even if Republicans coalesced around a replacement plan, Senate Majority Leader Mitch McConnell (R-Ky.) would have to find a procedural way around an inevitable Democratic filibuster. That could conceivably involve ending the filibuster altogether, a move that former Senate majority leader Harry Reid teed up when he ended the filibuster on presidential nominees in 2013.

In other words, a lot of things would have to go right for the GOP to pull off a full repeal and replace.

Partial repeal

There are many things Republicans could do short of a full repeal that would nevertheless undermine the law. Electing a GOP president and a GOP Congress next year would almost guarantee the death of Obamacare's medical device tax, a source of revenue for the health-care expansion that Republicans may or may not make up with something else. Cutting the tax would represent raw interest group pandering, but conservatives would be attracted to anything that's hostile to Obamacare, and losing the revenue could bolster GOP claims that the policy is unaffordable.

It's also likely Republicans would push to relax insurance coverage requirements, allowing people to buy skimpier plans. Though some people would end up paying less, they would also get less protection. ACA backers argue that the least generous health-care plans currently allowed are already pretty basic. Moreover, any tinkering with what people have to pay into the system would risk throwing it out of financial balance. But these considerations still might not stop Republicans committed to rollback, and this sort of change might not seem as threatening to Democrats seeking to protect the law.

Meanwhile, rolling back the ACA's individual mandate, which requires people to carry health-care insurance, seems to be a mainstream GOP position, even though it would send insurance markets spiraling. Unless Republicans want to be blamed for a policy disaster, they would have to replace the mandate with some other incentive for people to buy insurance or pass a much broader Obamacare replacement package. Either would probably be easier than passing a comprehensive replacement plan, but not by much.

In other words, any ambitious legislative change to the ACA would have to account for Democratic opposition and the predicted 24 million people the law will cover by 2017, both of which would leave GOP lawmakers with some, but not ample, room to maneuver.

Presidential action

Remember when Mitt Romney promised to issue Obamacare "waivers" to every state on his first day in office? The ACA gives the executive branch a fair amount of leeway in implementing pieces of the law, and a Republican president could rely on these authorities to undercut the policy. Timothy Jost, a Washington and Lee law professor and ACA specialist, maps out several paths.

Formal rules that the Department of Health and Human Services or other agencies have already established could be redrawn, though that would invite legal challenges. Yet, Jost wrote in an e-mail, "a great deal of the ACA implementation has been through informal guidance, and this could be more easily revised." Also, "a future administration could delay implementation of various requirements, as has the current administration, perhaps indefinitely."

Finally, "perhaps the easiest thing for a president hostile to the ACA to do would be to liberally grant 1332 waivers to the states," Jost wrote. 1332 waivers exempt states from many ACA requirements, allowing them to experiment with health-care policy models, as long as those experiments result in affordable coverage options, cover a comparable number of people as standard Obamacare would have and don't add to the debt.

These stipulations seem to limit the opportunity for mischief. But the affordability and comparability requirements could both be interpreted loosely. A GOP Congress could also ease these restrictions, conceivably allowing conservative states to hack away at Obamacare on their own.

Now that the Supreme Court has ruled, the ACA is on sure footing for the next year and a half, and it is unlikely that it will go away after that. Republicans will try to please the base as best they can, and they could do some damage. But their hardest task might be placating conservatives who demand a spectacular policy reversal.

SEE ALSO: SUPREME COURT SAVES OBAMACARE

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It's safe to say Sen. Ted Cruz (R-Texas) was horrified by this week's landmark Supreme Court rulings on Obamacare and gay marriage. 

In an appearance on Sean Hannity's radio show on Friday, Cruz, who is running for president, made it clear he thought the rulings represented a sad moment for America.

"Today is some of the darkest 24 hours in our nation's history," Cruz said after Hannity asked how he was doing, according to audio posted by Mediaite.

Cruz went on to describe both rulings as "naked and shameless judicial activism." 

The first of the two decisions Cruz blasted on the radio came Thursday when the Supreme Court upheld a provision of the Affordable Care Act. In that ruling, the justices rejected an argument that the way the so-called Obamacare legislation was written prevents subsidized insurance in states where the federal government has set up healthcare exchanges.

According to Cruz, this decision amounted to the judges "rewriting" the law in support of President Barack Obama's agenda.

"The decision yesterday rewriting Obamacare ... for the second time six justices joined the Obama administration," Cruz said. "You now have Barack Obama, [former United States Secretary of Health and Human Services] Kathleen Sebelius, and six justices responsible for forcing this failed disaster of a law on millions of Americans and simply rewriting the law in a way that is fundamentally contrary to their judicial oaths." 

Cruz has made repealing Obamacare one of the cornerstones of his presidential campaign. 

After discussing the Obamacare case, Cruz attacked Friday's Supreme Court ruling that legalized same-sex marriage in all 50 states. He characterized it as an attack on existing state-based marriage laws.

"This radical decision purporting to strike down the marriage laws of every state, it has no connection to the United States Constitution," Cruz said. "They are simply making it up. It is lawless and in doing so they have undermined the fundamental legitimacy of the United States Supreme Court."

The audio can be listened to below — via the Democratic group American Bridge:

Last updated 5:44 p.m. with audio.

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The White House's official photographer captured the exact moment that President Barack Obama found out that the Supreme Court saved a crucial component of Obamacare.

Peter Souza, the photographer, explained what happened in a Friday post on Medium.

"The President was in the middle of his daily briefing on Thursday when Brian Mosteller, the director of Oval Office operations, abruptly opened the door at 10:10AM," he wrote. "Knowing a series of Supreme Court decisions were pending, I instinctively switched to my camera with a telephoto lens to zoom in on the President."

As Obama heard the news that his signature Affordable Care Act survived its second major legal challenge, he paused. 

"For one split second, the President’s face was blank as if he was trying to comprehend the news," Souza wrote.

Here's the photo:

And then Obama reacted with 'jubilation.' Here's Souza's incredible photo of that moment:

Obama then walked around to celebrate with the various members of his administration:

Click here to view Souza's full post on Medium. 

SEE ALSO: Obama just took a victory lap on Obamacare

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The Supreme Court handed the Obama administration a significant victory on Thursday, when it upheld a key provision of the Affordable Care Act that allows the federal government to keep distributing subsidies to help low-income Americans buy health insurance.

But the decision's ramifications go far beyond an immediate win for President Barack Obama and the law. The Supreme Court's ruling firmly entrenches the Affordable Care Act as the law of the land, leaving no room for a theoretical future Republican president to undo major pillars of the law in an executive fashion.

"The decision leaves no wiggle room for a future administration that might have wanted to end the ACA’s subsidies," Larry Levitt, senior vice president at the Kaiser Family Foundation, told Business Insider after the ruling.

That's because the Supreme Court not only ruled the federal subsidies are legal under the Affordable Care Act, but it also did not leave any ambiguity that would allow a future administration to interpret the law differently.

"The court focused definitively and said, this is what the law means," said MaryBeth Musumeci, an associate director at the Kaiser Commission on Medicaid and the Uninsured.

The challengers in the case, King v. Burwell, argued the way the law was written does not allow for the federal government to distribute subsidies to individuals in states that had not set up their own exchanges. They pointed to four words in the law that they argued meant exchanges should be "established by the state."

A brief history: In 2011, the IRS issued a regulation that interpreted a part of the law in question to mean that the federal government could issue the subsidies. But in its opinion Thursday, the Supreme Court's majority said that decision should not be left up to a government agency to interpret, since Congress did not make that explicit in the Affordable Care Act.

Instead, the high court disregarded the agency's interpretation and ruled on the statute on its own. The IRS ruling, in effect, is null. The court said the decision should not be left up to the agency, which means a future administration cannot change that interpretation and alter the way subsidies are handed out under the Affordable Care Act.

"If the court had left in question about whether there should have been deference to the agency, that would have left the door open potentially for another administration running that agency to say, ‘OK, this is ambiguous language, and we have a different legal interpretation,'" Musumeci said.

Practically, this means that a theoretical future Republican president could not come in and say that the federal government cannot hand out subsidies.

That might not be a practical solution anyway: After all, by the time a Republican president could enter into office, millions of additional people would likely have access to subsidies as more people enroll in plans under the federal exchange. But there's no longer even an option. The Supreme Court has definitively determined that the federal government can provide subsidies under the law.

"Because the Court has provided its own, definitive interpretation of the ambiguous statute — and held that it will not defer to the agency’s interpretation — a subsequent presidential administration (say, a Republican Administration) cannot reinterpret the statutory provision to prohibit tax subsidies in exchanges established by the Federal Government," Chris Walker, an assistant professor at the Michael E. Moritz College of Law who clerked for Justice Anthony Kennedy, wrote on his blog Thursday.

Rick Hasen, a professor of law and political science at the University of California, Irvine, said the "biggest favor" Chief Justice John Roberts did for Obama was protecting the law's legal entrenchment well into the future.

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Justice Antonin Scalia penned a fiery dissent to the Supreme Court’s ruling upholding the legality of nationwide subsidies for insurance plans purchased through the federal health care exchange.

Scalia blasts the majority decision written by Chief Justice John Roberts as a “defense of the indefensible” and criticizes it for its “interpretive jiggery-pokery” and “somersaults of statutory interpretation.” He calls some of the arguments in the majority decision “pure applesauce.”

Here are some other highlights from Scalia’s withering critique:

• “Words no longer have meaning if an Exchange that is not established by a State is ‘established by the State.’ It is hard to come up with a clearer way to limit tax credits to state Exchanges than to use the words ‘established by the State.’ And it is hard to come up with a reason to include the words ‘by the State’ other than the purpose of limiting credits to state Exchanges.”
• “Yet the [majority] opinion continues, with no semblance of shame, that ‘it is also possible that the phrase refers to all Exchanges—both State and Federal.’ … (Impossible possibility, thy name is an opinion on the Affordable Care Act!)”
• “The Court holds that when the Patient Protection and Affordable Care Act says ‘Exchange established by the State’ it means ‘Exchange established by the State or the Federal Government.’ That is of course quite absurd, and the Court’s 21 pages of explanation make it no less so.”
• “This case requires us to decide whether someone who buys insurance on an Exchange established by the Secretary gets tax credits. You would think the answer would be obvious—so obvious there would hardly be a need for the Supreme Court to hear a case about it.”
• “Under all the usual rules of interpretation, in short, the Government should lose this case. But normal rules of interpretation seem always to yield to the overriding principle of the present Court: The Affordable Care Act must be saved.”
• “Much less is it our place to make everything come out right when Congress does not do its job properly. It is up to Congress to design its laws with care, and it is up to the people to hold them to account if they fail to carry out that responsibility. Rather than rewriting the law under the pretense of interpreting it, the Court should have left it to Congress to decide what to do about the Act’s limitation of tax credits to state Exchanges….The Court’s insistence on making a choice that should be made by Congress both aggrandizes judicial power and encourages congressional lassitude.”
• “Having transformed two major parts of the law, the Court today has turned its attention to a third. The Act that Congress passed makes tax credits available only on an “Exchange established by the State.” This Court, however, concludes that this limitation would prevent the rest of the Act from working as well as hoped. So it rewrites the law to make tax credits available everywhere. We should start calling this law SCOTUScare.”

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John Oliver is celebrating the end of other people celebrating the "end" of Obamacare.

Since President Obama signed the Affordable Care Act in 2010, many lawmakers and pundits have predicted the demise of the the president's signature healthcare law, citing various legal and legislative challenges to the law.

In a montage on Sunday's show, Oliver weaved together the numerous doomsday predictions for the law, which began in earnest only seven minutes after Obama signed the Affordable Care Act. 

But even following the Supreme Court's second ruling upholding the law, it's unlikely that Republican lawmakers in Congress will give up their fight, particularly considering that the law remains hugely unpopular among conservative voters. 

As Oliver's video points out, some Republican lawmakers are already fighting back.

Almost all of the Republican presidential candidates have promised to repeal the Affordable Care Act if elected, and as The Hill notes, some GOP lawmakers in Congress are hoping to use a budgetary process called reconciliation to force a standoff with Obama. 

Watch the clip below, via HBO:

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With the Supreme Court’s decision last week, the last serious challenge to the legitimacy of the Affordable Care Act seems to have been pushed aside. For the foreseeable future, Obamacare is the law of the land.

That ruling has left Republicans with two options, economist Stuart Butler, a staunch Republican who spent 35 years at the Heritage Foundation before decamping to the Brookings Institution last year, wrote recently:

“They can choose to adopt ‘repeal’ as simply an election battle cry for 2016, using the ACA as a ‘messaging’ issue much as they did with the Clinton health plan after its collapse in 1994. Or they can engage in a more focused and deliberate strategy to change the direction of an established program, as they did successfully in accomplishing welfare reform in 1996.”

Two years from now, Butler pointed out, even if a Republican takes the White House, the prospects of wholesale repeal of Obamacare will still be slim, if only because citizens will have become accustomed to it and the health care sector will have invested huge amounts of money into adapting to the new reality of how insurance is provided.

“If Republicans choose the first alternative, there may be some short-term election gains – although that is far from clear – but they will probably lose the long-term health reform war…. But if they choose the second alternative, and focus on the redesign of core elements of the law that could win bipartisan support, they could well change the structure and evolution of the ACA.”

So, which will Republican candidates for the presidency choose, the dubious promise of short-term gain? Or the long-term commitment needed to bring about actual reform?

Former Florida Gov. Jeb Bush, currently the leading GOP candidate, set the tone Monday in a mass email to supporters with the all-caps subject line: THIS IS NOT THE END OF THE FIGHT AGAINST OBAMACARE.

“As President of the United States, I would make fixing our broken health care system one of my top priorities,” he wrote. “I will work with Congress to repeal and replace this flawed law with conservative reforms that empower consumers with more choices and control over their health care decisions.”

Wisconsin Gov. Scott Walker, currently running second to Bush in the Real Clear Politics average of polls over the last month, said last weekend that he didn’t just support repealing and replacing Obamacare, but that he would support changing the rules of the United States Senate to do away with the filibuster if it would allow a Republican majority to overturn the ACA. Bush has also said he would support such a move. (When he led the Senate in 2014, Nevada Democrat Harry Reid engineered what was called the “nuclear option” by changing Senate rules to do away with the filibuster on certain presidential nominations. Eliminating the filibuster for regular legislation would be a much more dramatic change.)

Right down the line of high-profile GOP candidates, the promise to repeal the law remains front and center.

“Despite the court's decision, Obamacare is still a bad law that is having a negative impact on our country and on millions of Americans,” Florida Sen. Marco Rubio said last week. “I remain committed to repealing this bad law and replacing it with my consumer-centered plan that puts patients and families back in control of their health care decisions.”

Texas Sen. Ted Cruz reiterated his promise to do away with the law completely. “Mark my words, following the election in 2016… [the Senate] will return and we will repeal every word of Obamacare,” he said.

If a Republican nominee should choose to back away from the repeal pledge, though, Butler of Brookings has a few areas where he thinks conservatives could press for changes to the law that would make it less offensive to their political sensibilities.

He suggests the creation of an “off-ramp” for states that would take advantage of provisions in the law for state-by-state discretion on how to implement the act via waivers. One section, he noted “explicitly allows these waivers to include such things as an end to the individual and employer mandates, a fundamental redesign of the subsidy system and a substantial modification of the benefits package. Even with no change in the law, Republican governors — especially if there is a Republican in the White House in 2017 — could use Section 1332 to achieve the broad goals of the ACA in quite different ways.”

Similarly, he points out, the Obama administration has suggested that it is open to alternatives to the controversial expansion of Medicaid, including the use of federal money that would be spent on Medicaid expansion to enroll the uninsured in private insurance plans.

“If Republicans focus on structural reform of the ACA rather than a repeal-only strategy, they have an opportunity to covert at least the Medicaid expansion provisions of the ACA, and potentially much of Medicaid and the Children’s Health Insurance Program (CHIP), into direct subsidies for private coverage,” Butler wrote.

Finally, there is an opportunity for conservatives in the looming battle over the ACA’s so-called “Cadillac tax,” which will be imposed on high-cost, employer-provided health care plans. “The tax provides an opening to completely change the tax treatment of employer-provided health care – a long-time conservative goal,” he said.

“This will be a test case for Republicans. Those focused only on short-term politics will line up with calls simply to eliminate the Cadillac Tax. Those committed to an overhaul of the tax system as well as achieving an efficient health system will seek to modify the Cadillac Tax as a first step towards replacing the exclusion with tax credits for coverage,” Butler said.

Butler may be hopeful that members of his party will see the logic in his approach, and ease up on calls for repeal in favor of calls for reform. But judging from the line taken by the GOP’s top presidential candidates, he’s likely to be disappointed.

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"Daily Show" host Jon Stewart took aim at Supreme Court Justice Antonin Scalia on Monday night over Scalia's recent dissents on Supreme Court rulings on the Affordable Care Act and same-sex marriage.

"The crankiness of Scalia's insults run inverse to his intellectual consistency," Stewart said, mocking Scalia's use of the phrases "pure applesauce" and "jiggery-pokery"before calling him a hypocrite over his gay-marriage dissent.

"The judges should never overturn the will of the voters; it's a core Scalia principle," Stewart said, referring to Scalia's comments that the same-sex-marriage ruling was decided by a "highly unrepresentative panel of nine."

"Unless the voters' will was for Obamacare, which [Scalia] was glad to try to destroy the day before. Or if the voters wanted to limit campaign-finance spending, then he had no problem telling the people to f--- off at that time," Stewart said, a reference to the landmark Citizens United ruling in 2010.

But Stewart acknowledged he felt bad for Scalia. And in a "gesture of empathy," he treated viewers to a short cartoon titled "Justice Antonin Scalia and his terrible, horrible, no-good, very bad day."

Watch the full video below:

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The Affordable Care Act has altered competition and operates under a purely digital business model.

While the U.S. Supreme Court has removed much of the uncertainty surrounding the future of the Affordable Care Act (ACA), the impact of this far-reaching change in U.S. health care financing and delivery will be a complex story unfolding gradually for years to come.

The ACA is a huge “disruptive innovation,” to borrow a popular term from the business school literature. Like other disruptive innovations, it will generate winners and losers and have a slew of unforeseen consequences. Health policy analysts will be preoccupied for years with monitoring the effects of the ACA and proposing ways of building on it to ensure that more Americans receive effective health care at sustainable costs.

“A disruptive innovation,” Wikipedia informs us, “in an innovation that helps create a new market and value network, and eventually disrupts an existing market and value network (over a few years or decades)…” Turmoil, or “creative destruction,” as noted economist Joseph Schumpeter put it, defines how market economies grow and prosper.

First, it profoundly alters the nature of competition in health insurance markets: it forces insurers away from competing with each other through trying to attract the healthiest, least costly to insure toward competing for a larger pool of customers by offering lower premiums and better service.

As long as insurers were permitted to charge sicker people higher premiums, refuse coverage to customers with pre-existing conditions, and impose life-time spending limits, companies had to compete by attracting customers least likely to incur high medical expenses.

The ACA put this form of competition out of bounds, but kept the insurers in the game by mandating that most people have adequate health insurance (not just a bare bones policy that wouldn’t help them much if they needed it) and providing taxpayer subsidies to make the higher-standard coverage affordable to lower-income persons.

The contours of these new markets are only beginning to be visible. Both buyers and sellers are feeling their way in unfamiliar territory. Some health plans are responding by cutting deals with narrow networks of providers in order to attract customers seeking low premiums, and those narrow networks may force customers to pay more to keep a preferred provider.

The disruption of familiar patterns has also accelerated defensive consolidations in both the insurer and provider markets, including many hospital acquisitions of physician practices. These consolidations threaten to limit the very competition needed to fulfill the promises of market-based reform.

In its second disruptive innovation, the ACA took advantage of the on-going revolution in information technology to create new electronic market places where consumers, armed with federal subsidies, can choose among health plans.

Electronic marketplaces, which are also cropping up in the employer-sponsored health insurance markets, may soon become the normal venue for acquiring health insurance — if the glitches can be worked out and service improved. Major advances are needed in the quality and reliability of information displayed about alternative plans, user-friendliness of websites, and availability of well-trained assistants to help consumers navigate the sites and make appropriate choices.

Third, the ACA launched a flood of demonstrations and experiments involving new ways of reimbursing health providers. Some of these may be successful in moving the whole health system away from rewarding higher volume of services toward rewarding improved health and quality of care, which is what the incentives should be, but it will take time to sort out which ones work and how they fit together.

Fourth, and perhaps ultimately most important, the ACA introduced new challenges into the already complex interactions between state and federal government with respect to health care. The ACA is described by its opponents as federal over-reach, but it actually gives the states enormous control over how the implementation of the act plays out.

Since insurance regulation is a state function, the ACA gave the states control over such vital matters as defining the geographic areas within which plans compete and determining if the plan offers adequate access to physicians and hospitals.

Over the next several years, the states will have increasing opportunities to experiment with different approaches and to learn from experience—their own and each other’s. Many states have obtained waivers in order to exercise more control over their Medicaid spending, and a new waiver process coming into effect in 2017 will give states far more latitude in designing their own health delivery systems than they had before the ACA.

Analyzing how all this disruptive innovation plays out in the market place will not only be challenging for economists and market analysts; the ACA may up-end challenging the standard political analysis as well. The going-in notion that blue states would embrace the ACA and implement it skillfully, while red states would sabotage it, is already proving at least partially wrong.

After last week’s Supreme Court decision, red state politicians may conclude that the ACA is part of the permanent landscape and start turning it to their advantage. If governors and legislators—red, blue, and purple—seize the ACA’s challenge of shaping health care to their own states’ needs and desires, the results of this disruptive innovation could be a health system with far greater state-to-state diversity than we have now.

How will this all shake out? Stay tuned! But, don’t expect this big, dynamic sector of our economy—18 % of the U.S. economy — to stand still any time soon.

SEE ALSO: Obamacare isn't out of the woods yet

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NOW WATCH: KRUGMAN: The Latest Legal Challenge To Obamacare Is 'Ridiculous'

NASHVILLE, Tenn. (Reuters) - Fresh from another Supreme Court validation of his landmark healthcare law, President Barack Obama visited healthcare hub Nashville, Tennessee on Wednesday to push state governments to expand the Medicaid health program for the poor.

Obamacare, as the president's law is known, envisions a major expansion of the program, but nearly half of all U.S. states, mostly Republican-controlled, have rejected that part of the law and opted out of a Medicaid expansion.

The Tennessee legislature voted against an expansion in February and a total of 22 states have made such a stand.

Without expansion, 6.9 million low-income Americans will not get Medicaid assistance, said the Kaiser Family Foundation.

White House spokesman Josh Earnest told reporters traveling to Nashville on Air Force One that Obama’s visit was meant to send a message to Tennessee and the other opt-out states.

“The hope is that we will put pressure on those individuals, and it’s been almost all Republicans, who have put political interests ahead of the health of their citizens,” Earnest said.

Nashville rode the 1990s healthcare boom to become a major industry center, with 50-percent growth in clinical provider jobs between 1995 and 2008, according to the Nashville Health Care Council. The sector accounts for 250 businesses in Nashville and more than $70 billion in revenue.

Shares in Nashville-based HCA, which accounts for 4 percent to 5 percent of all in-patient care in the United States, rose 10.6 percent on the Supreme Court decision on Thursday that upheld Obamacare's insurance premium tax subsidy system.

HCA spokesman Ed Fishbough said the company was pleased with the ruling and has backed efforts to expand Medicaid in Tennessee.

Sheryl Skolnick, a hospital industry analyst for Mizuho Securities, said hospitals welcome expanded Medicaid because it covers the uninsured poor who often go to the hospital for routine health ailments, increasing costs for everyone.

For the hospitals, "it is a burden. The hospital becomes the insurer of last resort,” said Skolnick.

But the conservative Beacon Center of Tennessee, one of the loudest voices of opposition when the state considered expansion, said Obama is selling a program that is “unaffordable and immoral.”

“While we thank the president for visiting our beautiful capital city, giving a speech on bad policy and shaking a few hands is not going to solve our healthcare problems here in Tennessee,” said spokesman Mark Cunningham.

(Editing by Kevin Drawbaugh and Tom Brown)

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Having lost their latest war against President Barack Obama's healthcare overhaul, Republicans must decide how to wage battles that could fan the issue for the 2016 elections.

Last month's Supreme Court decision upholding the statute's federal subsidies, which help millions of Americans afford health care, shattered the GOP's best chance of forcing Obama to accept a weakening of his prized law.

Without that leverage, Obama would likely veto any major changes they'd send him.

They could, however, try sending him veto-bait legislation designed to show voters how they'd reshape the nation's health care system — if only Republicans could agree on what to do.

With the GOP-run Congress back from a July 4 break, here's a look at their problematic path:

Q: Republicans say they want to repeal and replace the health care law, but how would they revamp it?

A: The House has voted over 50 times to repeal all or part of the law. Yet five years after enactment, Republicans have yet to rally behind a replacement plan.

Several GOP lawmakers have introduced bills or vaguely described what they'd prefer. Details vary, but Republicans generally want to weaken federal coverage requirements, such as which procedures must be insured, and give more flexibility to the states.

Many also want to cancel the law's requirements that people get policies and that many employers offer coverage to workers — moves Democrats say would wreak havoc on insurance markets and leave millions without coverage.

Q: What's preventing Republicans from coalescing behind one plan?

A: Republican lawmakers face varying political imperatives back home.

Some from strong GOP areas need to worry about satisfying deeply conservative voters, who despise Obama's law. Others from closely divided states don't want to abolish parts of the statute — like its subsidies and other consumer safeguards — that help millions of voters.

And that's just the congressional races. The campaign for the GOP presidential nomination adds more complications.

Several hopefuls are senators and might use the health care issue to distinguish themselves from competitors — perhaps making them less inclined to heed party leaders and back a consensus plan. And the eventual GOP presidential candidate will likely offer his or her own plan, leaving some congressional Republicans wondering why they'd push a proposal their own nominee's would overshadow.

Republicans also face thorny decisions about their proposals. How far would the measure go? How much would it cost, and crucially, how would they pay for it?

Q: Can Republicans even get a replacement to Obama's desk?

A: That's unclear. House Speaker John Boehner, R-Ohio, would not commit recently to holding a House vote this year on a GOP alternative.

The Senate presents an additional problem. Republicans have 54 of the chamber's 100 seats, and Democrats might kill any GOP plan by filibuster — procedural delays that can derail legislation lacking 60 votes.

Q: Can Republicans get around that?

A: Potentially.

The Senate can use a streamlined process called reconciliation that prevents filibusters. It would let Republicans pass something with a simple majority of Senate votes.

So far, they've not decided whether to use the accelerated process for a broad health overhaul that Obama would definitely veto, or a narrower bill drawing some bipartisan support that he might sign, like repealing the law's taxes on high-cost insurance and medical devices.

Or they might use it for a different issue, like deficit reduction or a tax overhaul.

Q: Why not use it to repeal the entire health law?

A: This procedure comes with show-stopping restrictions.

Most significantly, bills using the process must reduce the deficit.

Unfortunately for Republicans, the nonpartisan Congressional Budget Office last month projected that repealing Obama's law would increase deficits by at least $137 billion over the coming decade.

That's because the law's subsidies for lower-earning people, expanded Medicaid coverage and other spending increases are outweighed by its savings. Those include cutting Medicare payments to providers, collecting fees from the pharmaceutical and other health-care industries and raising taxes on higher-income people and others.

That means that to repeal the entire law using the reconciliation process, Republicans would have to find over $137 billion in savings — a major challenge.

Q: Can't they use this streamlined process to simply repeal pieces of the law they oppose?

A: Yes, but that's also problematic.

Republicans could eliminate the law's subsidies and expansion of Medicaid. That would save money, but also throw millions of Americans off insurance unless the bill also offered alternative aid.

Repealing the mandates for individual and employer-provided coverage — a favorite GOP goal — would cost money because the government collects fines from people and companies who disobey those requirements. Once again, these rules require the bill to reduce the deficit, not increase it.

Do Republicans repeal the law's tax increases? Most would want to, but that would make it harder for their bill to reduce the deficit.

The reconciliation process also forbids provisions not directly aimed at deficit reduction. That could preclude language sought by many Republicans restricting abortion coverage or allowing health insurance sales across state lines. 

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WASHINGTON (AP) — Phony applicants that investigators signed up last year under President Barack Obama's health care law got automatically re-enrolled for 2015. Some were rewarded with even bigger taxpayer subsidies for their insurance premiums, a congressional probe has found.

The nonpartisan Government Accountability Office says 11 counterfeit characters that its investigators created last year were automatically re-enrolled by HealthCare.gov, even though most had unresolved documentation issues. In Obama's terms, they got to keep the coverage they had.

Six of those later were flagged and sent termination notices. But GAO said it was able to get five of them reinstated by calling HealthCare.gov's consumer service center. That seemed to be a weak link in the system.

The five bogus beneficiaries who were reinstated even got their monthly subsidies bumped up a bit, although GAO did not ask for it. The case of the sixth fake enrollee who appealed was under review.

HealthCare.gov does not appear to be set up to detect fraud, GAO audits and investigations chief Seto Bagdoyan said in prepared testimony for a Senate Finance Committee hearing Thursday. A copy was provided to The Associated Press.

HealthCare.gov's document-processing contractor "is not required to seek to detect fraud," said Bagdoyan. "The contractor personnel involved in the document-verification process are not trained as fraud experts and do not perform antifraud duties."

Administration officials told GAO there has been "no indication of a meaningful level of fraud" in the program, Bagdoyan said.

Federal health care subsidies go directly to insurers, so the money does not end up in the bank accounts of individual enrollees. But health insurance is a valuable product in and of itself, with the cost of family coverage averaging close to $17,000 a year.

Finance Committee chairman Orrin Hatch, R-Utah, said the GAO's investigation reveals "negligence" by the Obama administration, which "calls into question the legitimacy of the health law's enrollment numbers and challenges the integrity of the website's security checks."

Last year, when GAO first disclosed that it had succeeded in signing up fake beneficiaries, the administration said it would work to strengthen HealthCare.gov's verification checks.

Late Wednesday, the administration said it looks forward to working with GAO to improve safeguards for health insurance sign-ups. It noted that the online system had initially flagged applications from the undercover investigators.

HealthCare.gov is an online insurance marketplace used by residents of 37 states to get subsidized private coverage under the health care law.

Although the administration has terminated coverage for more than 200,000 people who could not prove their citizenship or legal immigrant status, and some 300,000 have had their subsidies changed because of discrepancies over reported income, GAO's bogus beneficiaries largely evaded that dragnet.

It's unclear whether the fictitious enrollees would have been kicked out of the program eventually. For example, no tax returns were filed on behalf of any of them. Since health insurance subsidies are income-based, tax returns are one of the main ways the government checks applicants.

GAO's investigation also uncovered a problem that bedevils millions of real people dealing with the program's new bureaucracy: confusing and inaccurate communication.

Investigators said their bogus enrollees received unclear correspondence that failed to identify the problems with their applications.

"Rather than stating a message directly, correspondence instead was conditional or nonspecific, stating the applicant may be affected by something, and then leaving it to the applicant to parse through details to see if they were indeed affected," said Bagdoyan.

The fake enrollees also got some perplexing instructions from HealthCare.gov. Eight of the 11 were asked to submit additional documentation to prove their citizenship and identity. But the list of suitable paperwork detailed documents for verifying income instead.

The 11 bogus beneficiaries were part of a larger group of 18 that GAO tried to sign up last year. They're the ones who got through and were automatically re-enrolled for 2015.

Overall, about 10 million people are getting coverage this year through HealthCare.gov and state health insurance markets. GAO said the results of its undercover testing, while illustrative, cannot be generalized to the full population of applicants and enrollees.

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The Supreme Court has fallen out of favor with Republicans.

According to a new Gallup survey, the court's approval rating among GOP voters has fallen to a record-low 18%.

At the same time, more than three-quarters of Democrats who were surveyed viewed the Supreme Court favorably (76%).

It's the court's widest approval margin in 15 years.

Reasons for the disparity can be deduced from some of the latest historic rulings to come down from the bench.

In one of its most consequential sessions in recent memory, the high court first upheld a key provision in the Affordable Care Act in a 6-3 vote.

The ruling arguably ensured the law's survival and cemented a win for the Obama administration — thanks in part to Chief Justice John Roberts, who joined the court's liberals in writing the majority opinion.

Shortly after, the court issued a ruling that legalized same-sex marriage nationwide, scoring a cornerstone victory for gay-rights advocates and, by extension, the Obama administration, which had become increasingly vocal in its support of gay marriage in recent years.

Though Roberts panned that ruling in his dissenting opinion, he said his view was not about his personal opinion of same-sex marriage but instead about how he viewed the court's capacity to decide the matter.

Gallup notes that over the past 15 years, the Supreme Court's approval swings tended to follow judicial rulings on topics that fundamentally divide Republicans and Democrats.

In 2012, in the midst of a presidential campaign, a Supreme Court ruling affirmed Congress' ability to fine some Americans who failed to purchase health insurance. A Gallup poll at the time placed GOP approval of the Court at 29% and that of Democrats at 68%.

And in 2000, after the court handed a decisive election victory to George W. Bush after a dispute with Al Gore over the vote count in Florida, the Supreme Court's Republican approval rocketed to 80%. Only 42% of Democrats approved at the time.

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TORONTO – It is cool here. A welcome change from Athens, Madrid, and Paris.

The markets were cool yesterday, too. The Dow rose 70 points. Nothing to get excited about.

Today, we report on a new front in the Great Zombie War – the U.S. health care sector… and why costs there are set to rise. (More on that below…)

For now, we are sitting in the bar at The Hazelton Hotel. We always thought of Canadians as being a bit more reserved and conservative (socially, not necessarily politically) than their neighbors to the south.

Well, not in this hotel!

It is more like Dallas than what we recall from our summers in Nova Scotia. People dressed in the latest gaudy fashions… loud hipster music… trendy decor… women who appear to have had extensive body work done.

And on the TV above the hotel bar is a recurring ad from a zombie law firm advertising for personal injury cases!

Is Spain the Next Greece?

We floated our way through Europe’s wine country, foggily trying to keep track of what we are seeing.

We surveyed the Greek front with a pitcher of red wine on a blue paper tablecloth. Greek wine is as mysterious to us as Greek finance – both make you a little light-headed.

The wine served in the street restaurants of Athens is cheap and plentiful. In Madrid, our host insisted on a classic Rioja… a rich, complex wine.

Madrid is a cleaner, more modern, and more sophisticated city than Athens. The wine is similarly more advanced and reliable.

And in France, a Bordeaux… a Saint-Émilion… or a Saint-Estèphe… usually anchors our red-checkered tablecloth. After the Rioja, the perplexing Greek wine, and months of drinking Malbec in Argentina, the French wines seem to lack character.

They are like the French people: subtle and clever.

In Greece, we were there to witness a financial system meltdown. It didn’t oblige. The scheduled breakdown didn’t happen when it was supposed to; Greece and its creditors booted the can down the road yet again.

Even after two weeks of closed banks… and widespread expectations of a financial crack-up… we saw no sign of panic.

Instead, the Greeks were prepared. Bloomberg, interviewing a local restaurateur, sheds some light on how:

My son is a fisherman. Today I took two kilograms of my son’s fish to the butcher. He gave me two kilograms of meat in return.

We don’t take money to the bank. The money we earn is spent on supplies and expenses to eat and drink.

Meanwhile, our sources in Madrid explained…

There is a big political movement here to throw out the baby and the bathwater. There’s a whole new political party, called Podemos (which translates as “We Can”).

It came out of nowhere. It was organized on the social media. I’ve never seen anything like it. I don’t know what these people want… but I don’t think they’re going to be as predictable and as flexible as the traditional parties.

Our guess is Podemos wants to slip Spain’s debts.

Zombie Math

Most people will be zombies – if they can get away with it.

Everyone wants wealth, power, and status. And they want to get it in the easiest way possible. So, it really only makes sense for them to support the political party that promises to give them more than they can get on their own.

Or, to put it differently, in a modern democracy, politicians must promise to give voters back more than they take from them in taxes.

If a party gives back only what it takes in from taxes, the zombies get no net gain. And when the politicians promise to run a budget surplus to pay down debts from past spending, the zombie math no longer works.

The voters must pay more in taxes than they get in redistributions.

That’s when the logic of modern popular democracy breaks down. And when that happens, watch out!

Now, back in the New World, we turn our lips to a California wine and our attention to the North American front of the Great Zombie War.

From the New York Times comes news of a big zombie push in the health insurance sector.

You’ll recall the lay of the land. Crony lobbyists for insurance companies, Big Pharma, and the medical industry got together with the Obama administration and created “Obamacare.”

The law was so complex and so long-winded that politicians voting for it admitted they didn’t know what was in it. Only the cronies knew what was in this pudding; they had put the sugarplums in themselves.

The rest of us would just have to wait until we choked on the seeds: Reports the New York Times:

Health insurance companies around the country are seeking rate increases of 20% to 40% or more, saying their new customers under the Affordable Care Act turned out to be sicker than expected. Federal officials say they are determined to see that the requests are scaled back.

“As a result, millions of people will face Obamacare sticker shock,” said Senator John Barrasso, Republican of Wyoming.

Yes… the medical industry is a battleground, too. The zombies are fighting hard – by hook, crook, regulation, and legislation – to get even more of your money.

Stay tuned for the next dispatches from the front lines…

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