In a landmark ruling Thursday, the Supreme Court upheld President Barack Obama 2010 Affordable Care Act (ACA), ruling both the individual mandate and the Medicaid expansion were constitutional. Chief Justice John Roberts, appointed by President George W. Bush in 2005, uncharacteristically sided with the left side, upholding the law in a 5-4 vote.
Specifically, the court ruled on three questions: Can the ACA be considered an unpaid tax? If not, is the mandate constitutional? and Is the Medicaid expansion constitutional?
Question 1: Is the ACA a tax or a penalty?
On the first question, the court ruled the ACA could not be considered an unpaid tax under the Anti-Injunction Act of 1867. Under this Act, the Supreme Court cannot rule on the constitutionality of a tax until it is levied. Since the ACA will not be enforced until 2014, this would bar the court from making a ruling on the law's constitutionality until 2015.
However, since the court ruled the ACA is not an unpaid tax, they were able to move onto their final ruling on the law's provisions today.
Question 2: Is the individual mandate constitutional?
On the second question, the court ruled the individual mandate, requiring U.S. citizens to purchase health insurance if not otherwise provided by their employer, parent or other, is constitutional, but only as a tax and not under the Commerce Clause.
"Chief Justice Roberts delivered the opinion of the Court with respect to [the individual mandate's constitutionality], concluding that the individual mandate may be upheld as within Congress's power under the Taxing Clause," the court's ruling read.
Roberts was joined by liberal justices Sonia Sotomayor, Gerald Breyer and Elena Kagan in this ruling. However, Justice Ruth Bader Ginsburg dissented, stating she believed the Commerce Clause does in fact authorize Congress to enact the minimum coverage provision.
"Our precedent has recognized Congress large authority to set the Nation's course in the economic and social welfare realm," Ginsberg's opinion read. The burden of the unpaid bills of uninsured Americans end up on the shoulders of doctors and the government. This thereafter ends up burdening insured Americans when these doctors raise premiums.
Being uninsured, therefore, is an impediment to commerce, which empowers Congress to remedy the situation by enforcing mandatory health care coverage.
"Medical-care providers deliver significant amounts of care to the uninsured for which the providers receive no payment - [$43 billion worth of the $116 billion in care they administered to those without insurance]. Health-care providers do not absorb these bad debts," Associate Justice Gimsberg wrote in her opinion.
These debts then lead to increasing premiums from companies and then to higher bills for the insured, she wrote, adding, "the net result: Those with health insurance subsidize the medical care of those without it...Higher premiums, in turn, render health insurance less affordable, forcing more people to go without insurance and leading to further cost-shifting."
"The Chief Justice's crabbed reading of the Commerce Clause harks back to the era in which the Court routinely thwarted Congress' efforts to regulate the national economy inthe interest of those who labor to sustain it...It is a reading that should not have staying power."
Question 3: Is the Medicaid expansion program constitutional?
The court also ruled the Medicaid expansion provided for under the law is also constitutional. The expansion requires states to provide Medicaid to a larger group of people, encompassing those making 133 percent of the poverty line, including childless adults.
However, the court also ruled Congress would not be able to withhold individual state's Medicaid funds if they opted not to enroll to receive funds under this expansion plan.
"Chief Justice Roberts, joined by Justice Breyer and Justice Kagan, concluded in Part IV that the Medicaid expansion violates the Constitution by threatening States with the loss of their existing Medicaid funding if they decline to comply with the expansion."
However, "this constitutional violation is fully remedied" by not allowing the Secretary of Health Katherine Sebelius to withdraw existing Medicaid funds from states for failure to comply with the expansion's requirements, the decision read.
On this point, Ginsberg and Sotomayor dissented, saying they believe the federal government should be able to withhold all Medicaid funding from a state who violates the expansion program's requirements even if they opt to not receive the additional funds.
Conclusion: Dissenting Opinions
The court's four remaining justices, Samuel Alito, Antonin Scalia, Anthony Kennedy and Clarence Thomas, all dissented on the total ruling of the five majority justices. Although as the minority their ruling does not have the force of law, constitutional scholars and pundits will look closely at the reasoning behind their opinions.
In their dissenting remarks, the four men questioned the constitutionality of both of the law's provisions under judgment and also the efficacy of the law as good policy for the American people.
"The question in this case...is whether the complex structures and provisions of the Patient Protection and Affordable Care Act (Affordable Care Act or ACA) go beyond [Congress' powers under the Constitution]. We conclude that they do," the four wrote in their dissenting opinion.
The four justices recommended that Congress might protect the health care industry from rising costs by prohibiting low-cost competition, according companies preferential tax treatment, or granting the industry as a whole a direct subsidy. Any other option vindicating the ACA would be an affront to our individual freedoms, they wrote.
"The fragmentation of power produced by the structure of our Government is central to liberty, and when we destroy it, we place liberty at peril," they wrote.
"Today's decision should have vindicated, should have taught, this truth; instead, our judgment today has disregarded it. For the reasons here stated, we would find the Act invalid in its entirety. We respectfully dissent."
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