In largely symbolic ballot measures, five states allowed voters on Election Day the opportunity to show their disapproval of the 2010 Patient Protection and Affordable Care Act, dubbed Obamacare.

The measures were symbolic because the U.S. Supreme Court already ruled this past summer that the federal health-care law is constitutional, thus making moot any state-level efforts to nullify the federal law.

On Nov. 6, similar health-care amendments were on the ballot in Alabama, Florida, Wyoming and Montana. The amendments allowed residents in those states the option to purchase health insurance or not, which the Affordable Care Act compels all Americans to do in what is called the individual mandate.

In Missouri, a ballot question sought to prevent the Show-Me State from having to set up its own health-insurance exchange, which all states are required to do by Nov. 16.

The Alabama Health Care Amendment — Amendment 6 on the state ballot — passed by a 58% margin, with 738,905 voters approving it and 543,946 voting against. The amendment is supposed to prohibit mandatory participation in any health-care system, which would block the Affordable Care Act from taking effect in that state.

Alabama Gov. Robert Bentley told reporters in Huntsville on Nov. 6 that he favored the effort to amend the Alabama Constitution to prevent the federal health-care law from being implemented in his state.

"The worst piece of legislation that has ever been passed in my lifetime by Congress is this ‘Affordable Health Care Act,’" the governor said, according to AL.com.

"It is not affordable, and it is not health care. It is the worst — ah, I said that. I don’t have to say it twice," Bentley said.

AL.com also reported that Bentley said he did not know if his state will set up its health-insurance exchange by Nov. 16. Alabama missed a deadline last month to submit a list of health-care benefits that would be offered on its exchange to the U.S. Department of Health and Human Services.

In Florida, a similar health-care ballot question failed, with 52% of people voting against the amendment. The measure would have required 60% of voters approving it in order to amend the Florida Constitution.

The Republican-controlled state Legislature in Florida pushed the amendment as a way to send a strong political message against Obamacare. The Florida Health Care Amendment aimed to prevent laws or rules from compelling any person or employer to purchase, obtain or provide health insurance.

Florida state lawmakers tried to get a similar measure on the ballot in 2010, but that state’s Supreme Court prevented those efforts, ruling that the proposed ballot question’s summary was inaccurate and misleading. The Sunshine State’s former attorney general, shortly after President Barack Obama signed his health-care reform into law in 2010, filed a lawsuit against the law.

Meanwhile, in Montana, a similar health-care amendment passed on Nov. 6, with 47,920 people (64.58%) casting votes in favor and 26,281 votes against (35%).

The Montana Health Care Amendment allows residents in that state the choice to decide if they want health insurance or not and which health insurance to buy if they choose to do so.

Voters in Wyoming approved essentially the same amendment to the Wyoming Constitution, with 124,987 people voting for the measure and 36,022 against. The Wyoming amendment says: "No federal or state law, rule or administrative decision shall compel, directly or indirectly, any person, employer or health-care provider to participate in any health-care system."

Wyoming, Alabama and Montana join Arizona and Oklahoma as states that have amended their constitutions in attempts to prevent the implementation of the Affordable Care Act.

The so-called Obamacare federal law was controversial from the start. Not a single Republican lawmaker voted for it. Republican leaders in the U.S. House of Representatives have tried unsuccessfully to repeal the law, while 28 states filed joint or individual lawsuits to overturn its individual mandate that compels all Americans to obtain health insurance.

The Affordable Care Act also empowered Health and Human Services Secretary Kathleen Sebelius to issue a mandate that employers must provide coverage in their employee health-insurance plans — without deductibles or co-pays — for all government-approved forms of birth control, including abortion-inducing drugs and sterilization.

On June 28, the U.S. Supreme Court, after having heard three days of oral arguments in March, upheld the Affordable Care Act by a 5-4 margin — Chief Justice John Roberts, one of six Catholics on the court, was the decisive vote — on the grounds that the law’s financial penalty for individuals who don’t obtain health insurance is a tax, which the Constitution allows Congress to collect.

The Supreme Court’s upholding of the Affordable Care Act in essence regulates the state amendments to mere symbolic status because the Constitution’s Supremacy Clause guarantees that federal law trumps state law.

That holds true, as well, for a Missouri ballot amendment that 63% of voters approved to prevent their state from being forced to institute its own health-insurance exchange. The amendment — Proposition E — symbolically grants the authority to make decisions about the exchange to the state Legislature and voters.

However, the Affordable Care Act already empowers the federal government to set up "federally facilitated exchanges" in 2014 for states that choose not to create their own exchanges.

Brian Fraga writes from

Fall River, Massachusetts.