The stakes are high, a "wrecking operation," according to Justice Ruth Bader Ginsburg, who noted that "the more conservative approach would be salvage rather than throwing out everything."
After three days of historic debates in the highest court in the land this week, the conservative justices who hold a narrow 5-4 majority seemed inclined to relegate the Democratic president's signature reform to the scrap heap of history.
A decision from the nine justices is due in June. But, in light of their exchanges, the conservatives appeared set to rule as unconstitutional the law's linchpin requirement mandating that nearly every American must be insured.
The remainder of the reform, all 2,700 pages of it, could also go down with it -- greater medical coverage for the poorest, insurance for all Americans regardless of health condition and insurance for 32 million Americans who lack coverage.
But a decision to strike down the Affordable Health Care for America Act would be "even more radical" than the court's 5-4 split decision in the 2010 Citizens United case that paved the way for unlimited corporate funding of election campaigns, said Thomas Mann of The Brookings Institution.
"The prospect is so breathtaking in its audacity that it may lead (Chief Justice John) Roberts to pull back and write a narrow decision upholding the law," Mann told AFP, adding that a repeal of the reform would "call into question much of what the federal government does routinely."
The fate of the law may rest in the hands of Justice Anthony Kennedy, who plays the role of swing vote in many major Supreme Court cases.
"Now the big question is: will the court go backward, would it rule three-quarters of a century of jurisprudence and go back to the pre-New Deal era" of economic programs in the 1930s, asked American University historian Allan Lichtman.
The court would then replicate the profoundly ideological maneuver of a conservative court under president Franklin Roosevelt in 1935, when it nullified the National Industrial Recovery Act intended to help stimulate economic recovery through a public works program.
In 1936, the Supreme Court also declared a farming subsidy law known as the Agricultural Adjustment Act unconstitutional.
"I think there are number of justices that would like to go back to the 20s when the Supreme Court rigidly held the federal government," Lichtman said.
He said a repeal of so-called Obamacare "would be a signal that this court is interested in turning back the New Deal revolution in constitutional interpretation and much more rigidly control what the federal government can do, in regulation and in welfare."
For lawyer Simon Lazarus of the National Senior Citizens Law Center, "these five conservative justices have to decide clearly if they want to go back to that kind of a cliff."
Kennedy will probably see his decision followed by Roberts, the conservative chief justice who is seeking a true majority on the key ruling.
"Roberts and Kennedy seemed to be aware of the enormity of taking such a political step," Lazarus said, who has backed the Obama administration on the health reform.
Constitutional law expert Elizabeth Papez, a litigation partner at Winston & Strawn, noted that "if they strike the whole law, they would affirm very clear limits on the federal government's commerce power."
Critics have charged that the so-called individual mandate of the law is a violation of the US Constitution's Commerce Clause, which gives Congress the power to regulate interstate commerce.
"It was a very, very, very partisan bill that has created a partisan controversy in the US," said Randy Barnett, professor at Georgetown Law and lawyer for the National Federation of Independent Business, a plaintiff in the case.
He said the text was passed by a "solely party vote" in Congress when Obama's fellow Democrats held a majority in both chambers.
Conservative Justice Antonin Scalia admitted during the hearings that the 26 states suing the federal government have Republican governors.
"It came as a Republican proposal to cover the uninsured," recalled George Washington University law professor Jonathan Siegel.
"Now it's embraced by a Democrat president, the Republicans have turned against it. That's just politics; the Supreme Court is supposed to be above that kind of thing."
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