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Supporters of President Barack Obama's health care law celebrate Thursday outside the Supreme Court in Washington after the court's ruling was announced.

Health care overhaul upheld

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The U.S. Supreme Court on Thursday upheld nearly all of the landmark federal health law, affirming its mandate that most everyone carry insurance, but complicating the government's plan to extend coverage to the poorest Americans.

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Chief Justice John Roberts Jr. joined the court's four liberals in upholding the mandate, the best known and least popular part of the law. The court also upheld hundreds of other rules embedded in the law designed to help millions more Americans obtain insurance and to refashion the health care industry.

But a majority of the justices voted that the government could not compel states to expand Medicaid, the federal and state program for the poor, by threatening to withhold federal money to existing Medicaid programs.

That change creates unexpected challenges for the Obama administration's plan to extend insurance to 30 million more Americans. More than half of those -- mostly childless adults in poverty or slightly above it -- were to be covered by expanding Medicaid, but now states can opt out.

The ruling creates a new arena for political battles in the 26 states -- primarily Republican --that sued to overturn the law. Passing up the Medicaid expansion is a mixed bag, experts said, saving the states some money but also creating new pressures on health care providers that take care of the poor.

The court's decision also may have heightened the role of health care in the upcoming presidential and congressional elections, which may become the final arbiters on whether the law is fully phased or disassembled.

President Barack Obama welcomed the ruling, saying, "We will continue to implement this law. And we'll work together to improve on it where we can. But what we won't do -- what the country can't afford to do -- is refight the political battles of two years ago, or go back to the way things were."

However, initial reactions from Republicans indicated the law would be the subject of continued political dispute. "What the court did not do on its last day in session, I will do on my first day if elected president of the United States, and that is I will act to repel ObamaCare," said Mitt Romney, the presumptive GOP presidential nominee.

House Speaker John Boehner, R-Ohio, said: "Today's ruling underscores the urgency of repealing this harmful law in its entirety."

Creating an unusual majority coalition, Roberts joined the four liberals on the court in upholding the mandate, which had been viewed as the most legally tenuous part of the law.

Roberts concluded the penalty for not carrying insurance fell within Congress' taxing power, even though the administration's lawyers had justified the mandate as a reasonable regulation of interstate commerce.

Under the mandate, people who refuse to buy insurance will face a tax penalty. By the year 2016, that will amount to either $695 a year or 2.5 percent of income, whichever is greater. Roberts wrote that while the penalties were "plainly designed to ex­pand health insurance coverage ... taxes that seek to influence conduct are nothing new."

The decision leaves intact other major parts of the law that require insurers to accept all customers regardless of their health status and provide tax credits to those who need help to buy coverage. Those provisions go into effect in 2014.

The ruling eliminates one of the main justifications states have used to delay setting up new, online insurance markets called "exchanges," where small businesses and individuals not covered by employers can shop for coverage and insurers can't reject them for bad health.

While 14 states and the District of Columbia have authorized creation of these exchanges, another 33 have taken only initial steps or none at all, and three states have declared they won't do it at all. The law requires the federal government to run the exchanges if state officials are unwilling or unable to do so.

See today's edition of The Dickinson Press to read about North Dakota's take on the ruling.

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