Supremes Uphold the ACA

Update: here is the Supreme Court ruling.

The supreme court of the United States has upheld the Affordable Care Act. Per @scoutsblog, the “money quote” from Chief Justice Roberts’ opinion:

The money quote from the section on the mandate: Our precedent demonstrates that Congress had the power to impose the exaction in Section 5000A under the taxing power, and that Section 5000A need not be read to do more than impose a tax. This is sufficient to sustain it.

The court says you have a choice: buy insurance, or pay a penalty that amounts to a tax. And the federal government has the power to levy a tax. The court does say that a mandate to purchase health insurance is not allowable under the Commerce clause (4 of the 9 say it is allowable under commerce, but Roberts says no) of the Constitution, but 5 justices (Roberts as 5th vote; Kennedy was prepared to strike entire law) say the choice between buy insurance or pay a penalty is essentially a tax that is allowed.

The have also upheld the Medicaid expansion, but have limited the ability of the federal government to penalize states who do not expand Medicaid coverage up to 133% of the poverty level, as required in the ACA. Key from opinion, per @scotusblog on Medicaid

The key comment on salvaging the Medicaid expansion is this (from Roberts): “Nothing in our opinion precludes Congress from offering funds under the ACA to expand the availability of health care, and requiring that states accepting such funds comply with the conditions on their use. What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding.” (p. 55)

So, the federal government can offer extra funds for the Medicaid expansion as put forth in the ACA, but cannot take away other Medicaid funds from states that do not choose to undertake this expansion. So, they have limited the “stick” side of the Medicaid expansion. Update: as several have said, this seems to mean that a state can decide not to expand Medicaid coverage up to 133% of poverty, and not lose their basic Medicaid funding. What the ‘red states’ do will be a fascinating test of ideology v. financial self interest, since the ACA provides 100% federal funding for such expansions. Another update: TIE post with link throughs noting that if states do not expend Medicaid, the poor <100% poverty do not have to pay the uninsured tax.

A profound victory, first for the people who will now have insurance who otherwise would not have. Second, for the entire country, because the ACA is a good step that moves toward universal coverage; the next step needs to be identified, but the next step being back to nothing would have been disastrous. Third, a huge political victory for the President, and the Democratic party that spent huge amounts of political capital passing an imperfect bill–but that is the type of outcome our political system usually produces.

Note: @SCOTUSblog live bloggers are incredible, and they are the source of this legal analysis which I read and then restated in my words unless quoted; errors are mine alone.

About Don Taylor
Professor of Public Policy (with appointments in Business, Nursing, Community and Family Medicine, and the Duke Clinical Research Institute), and Chair of the Academic Council at Duke University . I am one of the founding faculty of the Margolis Center for Health Policy. My research focuses on improving care for persons who are dying, and I am co-PI of a CMMI award in Community Based Palliative Care. I teach both undergrads and grad students at Duke. On twitter @donaldhtaylorjr

5 Responses to Supremes Uphold the ACA

  1. remo says:

    So, instead of a tax outright, they make it a fine. I detect a slippery slope here. In fact, it looks a lot like an underhanded bit of trickery.

  2. David Schanzer says:

    Roberts placed the institutional legitimacy of the Court over ideology on this one — finding a narrow way to uphold the Act — the most substantial piece of social legislation in a half century — without expanding federal authority. This is the Roberts that many thought they would see more of when he was nominated; not the Roberts of Citizens United.

    • Don Taylor says:

      Yes, in fact he identified a limit to commerce clause, and found policy principle that was coercive, but let the law go forward. If the country wants it gone, they can get that outcome via the next election.

  3. Pingback: Clearly, not a lawyer | Irrational Tonics

  4. Pingback: ACA redistribution via Medicaid: what it means for future reform | freeforall

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