Supreme Court Upholds Obamacare

Gathering outside the Court; I wish I was there! (Reuters photo)

In a surprising move, Chief Justice Roberts sided with Sotomayor, Breyer, Ginsberg, and Kagan for the 5-4 decision upholding the individual mandate of the Affordable Care Act, dubbed “Obamacare” by opponents (and even used affectionately by supporters).  The ruling today ensured that millions of uninsured Americans will have access to affordable coverage, although the Medicaid expansion was determined to be relatively weak.

Chief Justice Roberts: The individual mandate “makes going without insurance just another thing the Government taxes, like buying gasoline or earning income. And if the mandate is in effect just a tax hike on certain taxpayers who do not have health insurance, it may be within Congress’s constitutional power to tax.”

The Medicaid limitation is perhaps one of the more significant aspects of the ruling. Essentially, the Court decided that Congress can indeed require that states expand their Medicaid funds, but that “Congress is not free…to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding.” This means that states can basically ‘opt-out’ of expanding their Medicaid funding without financial penalties from Congress. Almost 30 million more people would qualify for expanded Medicaid coverage under the ACA, but now individual states can choose to not allow it. I wonder what Kansas will do?

I work with state healthcare and Medicaid attorneys and the office is buzzing today! “Kennedy wrote the dissenting opinion!” “Justice Roberts sided with the liberals!” It’s been an interesting morning, full of calls to the Help Desk to allow access to the SCOTUSblog, loud phone calls, and overlapping excited conversations by the water cooler.

While certainly not my primary interest, thinking about the political implications of the decision is interesting. I mean, Mitt Romney did say on Tuesday:

“If Obamacare is not deemed constitutional, then the first three and a half years of this president’s term will have been wasted on something that has not helped the American people.”

I guess he wasn’t just twiddling his thumbs over there, huh? (The idea that the President of the United States of America, regardless of politcal party, EVER wastes their time is just completely ridiculous and disrespectful. But that’s for another time!)

The fact is that penalties for not having insurance do not take effect until 2014 and this ruling essentially puts off the final decision until we start to see the real effect of the mandate. For now, a tax is just a tax. Because every person will need to use healthcare at some point in their lives, there is no ‘choice’ about participating in the healthcare market and the individual mandate gets more people paying into the system which reduces costs to everyone overall.

Of course, Republicans have already decided that they will try to repeal the Act again. Eric Cantor (R-VA), House Majority Leader, said “the Supreme Court’s decision to uphold ObamaCare is a crushing blow to patients throughout the country.” Justice Kennedy, in his dissenting opinion said that “in our view, the entire Act before us is invalid in its entirety.” Whoa, heavy.

The fact is that this decision is huge, but at the same time, it’s a bit of a technicality. The individual mandate has been upheld as a constitutional “tax,”  finding that the Commerce Clause is not sufficient for the mandate to be held constitutional. Because the Constitution permits a penalty tax, which the insurance requirement can reasonably be assumed to be, it is “not our role to forbid it or to pass upon its wisdom or fairness” (National Federation of Independent Business v Sebelius, 567 U.S. _ 2012).  It doesn’t necessarily mean that this fight is over, although it does appear that a battle has been won for healthcare reform today (although listening to a few conservatives, somehow Chief Justice Roberts ‘tricked’ the liberal judges into something sneaky…not sure where they’re getting that idea, but I’m curious to hear!)

However, I do sort of like the idea of taxation paying for healthcare. From the Health Care Blog: “In any rational society health care ought to be a public good financed through taxation and distributed in some manner that makes rational sense. America has never officially believed that. Now it at least has affirmed the concept.”

It is important to note that the Chief Justice included his own additional comments after the Majority opinion and that the dissenting opinions were varied as well:

-Majority Opinion written by Chief Justice Robers

-Additional Comments by Chief Justice Roberts (not in the Majority opinion)

-Concurrence and Dissent in Part by Justices Ginsburg, Breyer, Sotomayor, and Kagan

-A dissenting opinion by Justices Scalia, Kennedy, Thomas, and Alito written by Justice Kennedy

-An additional dissent by Justice Thomas

This decision was not as simple as a 5-4 liberal/conservative split. This issue is complex, the ruling is complex, and the future of the ACA and American healthcare reform is not at all straightforward (ie. it’s complex!)

Tom Goldstein’s (SCOTUSblog) bottom line: “the entire ACA is upheld, with the exception that the federal government’s power to terminate states’ Medicaid funds is narrowly read.” What no one is really admitting yet is that this ruling was a massive victory for judicial restraint and conservatives really should be pleased in the long run. This decision was a nod of  respect to the actions of Congress and the will of the American people who elected them.

The full text of the decision is here.

The Health Care Blog’s take.

And an update on my life will certainly be forthcoming. I DID get married and stuff : )



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