Contraception ruling is a symbolic blow to the health care law

The Supreme Court struck a second blow against the health-care law Monday with its decision to narrow the so-called contraception mandate, an aspect of the federal program that was not central to its existence but was deeply cherished among liberal and many women's groups.

Unlike the court's decision two years ago that gutted the law's mandatory Medicaid expansion, severely limiting the law's reach, the effect here is more peripheral. The provision was not part of the main law but rather was laid out in regulatory language issued by the Obama administration. Millions of women who receive birth control at no cost through their company health plans are likely to keep it.

Still, women who work for closely held, for-profit companies whose owners have religious objections to contraceptives may feel an impact. And the ruling is a symbolic blow to the law, which has persevered through legal and political challenges since its enactment four years ago but today stands not entirely whole.

Shortly after the ruling was handed down, the Affordable Care Act's critics pointed to it as further evidence of the law's shortcomings.

'Obamacare is the single worst piece of legislation to pass in the last 50 years, and I was glad to see the Supreme Court agree that this particular Obamacare mandate violates the [law],' Senate Minority Leader Mitch McConnell (R-Ky.) said in a statement.

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Some supporters lamented the ruling, but insisted that the law remains strong and that Monday's decision will have a minimal impact on its core goal - reducing the number of the nation's uninsured.

They noted that the law itself only required company insurance plans to cover 'preventive' services. The Department of Health and Human Services then used guidelines established by the Institute of Medicine to label birth control, intrauterine devises and sterilization methods such as tubal ligation services that are integral to women's preventive health.

'Politically, of course, the case may be trumpeted as a major defeat for the ACA, but that is simply not true,' said Timothy S. Jost, a health law professor at Washington and Lee University and a supporter of the law. 'This case is not about the ACA. It is about religion, about employer and employee's rights, about corporate law, and I suppose about public health law, but it is not an existential challenge to the ACA.'

It is the latest turn in the tortured path taken by the Affordable Care Act, which was enacted in 2010 after a pitched political battle and has encountered obstacle after obstacle in the four years since.

The Supreme Court upheld the constitutionality of the law in June 2012, at the same time that it made the Medicaid expansion voluntary.

The contraception mandate was a prime example for the law's supporters as they sought to paint women as its prime beneficiaries. Women's health and liberal groups hailed the law as an antidote for years of inequality, with women routinely paying more than men for their health-care and health insurance.

But for critics of the law, the mandate became the most high-profile exhibit for what they viewed as an overreach into Americans' lives. The mandate applied not only to private companies but also religiously affiliated nonprofits that employ large numbers of workers from various backgrounds, such as Catholic hospitals.

A second wave of legal challenges to the contraception mandate, from those nonprofits, is also making its way through the courts. But a challenge striking more directly to the heart of the law looms: a wave of suits from citizens and employers who argue that the government is wrongly handing out tax credits in half of the states. If successful, this argument would cut at the heart of the law by making health insurance unaffordable for many people.