THURSDAY, March 22 (HealthDay News) -- The most ambitious
government health-care initiative since the Medicare and Medicaid
programs of the 1960s, and the legislative landmark of President
Barack Obama's presidency, is about to face its biggest
Starting Monday, the U.S. Supreme Court will hear an
unprecedented six hours of arguments over three days on the
constitutionality of the controversial and massive health-reform
initiative known as the Affordable Care Act.
The law -- the first national legislative effort to rein in
health-care costs -- aims to extend insurance coverage to more than
30 million Americans through an expansion of Medicaid and a
provision that people buy health insurance starting in 2014 or face
"There are 50 million people in this country who don't have health insurance. The Affordable Care Act will probably extend coverage to an estimated 30 to 32 million of those people," said Renee Landers, a professor at Suffolk University Law School in Boston.
The key sticking point in the legal showdown is whether Congress
exceeded its authority with the law's so-called "individual
mandate," which requires almost all adult Americans to maintain
health insurance or risk a penalty in the form of a tax.
The individual mandate -- scheduled to take effect in January
2014 -- is the pivotal piece of the law.
"The requirement that people purchase insurance is the key to having health insurance be there for everyone when they need it," said John Rother, president of the National Coalition on Health Care, which works to achieve reform of the U.S. health-care system.
Opponents call the mandate a stunning government intrusion into
the private lives of Americans and argue that Congress has no right
to tell an individual to buy a certain product.
Grace-Marie Turner, president of the Galen Institute, a
conservative public policy group, and a critic of the new law, is
thrilled that the High Court has agreed to hear challenges to the
"This case is before the Supreme Court in record time. Two years from the law being enacted to the case being heard is really remarkable," Turner said. "And you have 26 states -- the majority of states -- challenging the law."
The Supreme Court will also hear arguments on whether the law is
unconstitutional in requiring states to either comply with an
expansion of Medicaid to cover more lower-income people without
health insurance, or lose federal matching funding. At issue is the
concept of "federalism," the division of powers between the federal
and state governments.
Finally, the court will address "severability" -- that is,
whether the individual mandate can be struck down while leaving the
rest of the law intact.
In a recent
New England Journal of Medicine commentary, Landers described
arguments for and against severability.
Opponents have said that provisions of the legislation are too
intertwined for the law to stand without the individual mandate.
The Obama administration has said the law can still work without
the mandate, but provisions such as prohibiting insurance companies
from denying coverage to people with preexisting conditions would
be greatly compromised without the mandate.
Budget office sees savings; opponents skeptical
Here's how the health-reform law is designed to provide health
insurance to uninsured Americans:
- Individual mandate. It requires most adults to purchase health
insurance or pay a tax penalty. By 2016, the phased-in penalty will
reach either $695 or 2.5 percent of yearly taxable income,
whichever is greater. People with incomes below tax-filing
thresholds will be exempt from the provision. Up to 16 million
people are projected to join the rolls of the insured under the
- Medicaid expansion. This would increase eligibility to all
people under age 65 with annual incomes up to 133 percent of the
federal poverty level -- about $14,850 for a single adult and
$30,650 for a family of four in 2012. Non-disabled adults under 65
without dependent children were previously ineligible. Another 16
million people are estimated to gain insurance under the
- State-run insurance exchanges. They will be created to help
small businesses and individuals purchase insurance through a more
organized and competitive market.
In February 2011, the Congressional Budget Office estimated that
savings from the Affordable Care Act would cut the federal deficit
by $210 billion during the next decade.
But opponents say that the cost-cutting provisions probably
Devon Herrick, a health economist at the free-market National
Center for Policy Analysis, said the law sets up a "slippery slope"
that will increase costs, not lower them.
"If Congress and company have the legal authority to decide the minimum coverage you must have, all manner of lobbyists and special interests and providers for specific diseases will descend on Washington and state capitals, as they always have, to make sure that their respective services are covered by that mandate," Herrick said.
The law's supporters argue that without the requirement that
people have insurance coverage while they're healthy, there won't
be enough money in the risk pool to pay to take care of them when
the need for health care eventually -- and inevitably --
"If people don't feel like paying, then get sick and go to the emergency room or the hospital, those people's costs will be added on to our insurance bills as they are today, which makes it much more expensive," Rother said.
Lower courts, different interpretations
The legal trail of challenges leading up to the Supreme Court
has involved more than two dozen lawsuits and appeals.
Last June, the Cincinnati-based 6th Circuit Court of Appeals
ruled that the individual mandate was valid because of the
Constitution's Commerce Clause, which allows Congress to regulate
commerce that takes place among states.
In August, a district judge in Florida ruled that the individual
mandate was unconstitutional. However, the 11th Circuit Court of
Appeals, which reviewed his decision, rejected that argument and
found that the Affordable Care Act could stand even if the
individual mandate provision were removed, Landers said.
Then in November, the U.S. Court of Appeals for the District of
Columbia also upheld the individual mandate based on the Commerce
The U.S. Supreme Court chose to review the Florida case, which
now includes 25 other states as plaintiffs, along with the National
Federation of Independent Business.
The law has been controversial since it was passed by Congress
and signed by Obama in March 2010. Poll after poll has found that
Americans don't like the individual mandate. But a recent
Harris Interactive/HealthDay poll revealed that people are
starting to warm up to certain key provisions of the law -- such as
the ban on insurance companies turning away applicants with
preexisting health problems.
Some popular provisions -- including allowing children to stay
on their parents' health plans until age 26 -- are already in
Other provisions meant to help older Americans began in 2011,
with changes to continue through 2020.
Medicaid expansion a vital component of the law
States must comply with the Medicaid expansion no later than
2014. But some worry that a big influx of new enrollees could
strain medical specialties such as obstetrics/gynecology,
pediatrics and family practice.
Dr. Peter Carmel, president of the American Medical Association,
called the expansion "an important step in the right direction,"
even though many "physicians are currently unable to accept
Medicaid patients due to low reimbursement rates."
Added Dr. Glen Stream, president of the American Academy of
Family Physicians: "For the time being, [the new law] seems like
the best option to get everyone covered with health insurance.
Otherwise, people are carved out from good primary-care services,
good preventive care and wellness services, and care of their
chronic illnesses until sometimes it's too late."
The Supreme Court ruling is expected in June. The court could go
one of several ways:
- It could rule the individual mandate is unconstitutional and
the entire law invalid.
- It could rule the mandate is constitutional and the entire law
- It could reach a middle ground: that the individual mandate is
unconstitutional but the rest of the law can stand.
- It could decline to rule on the case and the health reforms
The decision may pivot on the vote of Justice Antonin Scalia, a
court conservative. Suffolk University's Landers said that in a
previous case that centered on the Commerce Clause, "Scalia wrote a
concurrence in which he took a very broad view of Congress'
authority. So I think he has a lot of work to do to get himself out
from under that concurrence."
She said it's also possible -- though unlikely -- that the court
could decide to delay ruling on the case altogether.
That would be a major setback for opponents, said Turner at the
Galen Institute. "By 2017, 'Obamacare' would have such deep roots
that it would be hard to overturn," she said.
Whatever the court decides, it will provide plenty of fodder for
the 2012 elections. And even if the Affordable Care Act survives
the legal challenge, Landers said, "with upcoming elections -- a
new Congress -- it doesn't mean that everything is set for all
American Bar Association website links to briefs
filed with the U.S. Supreme Court case on the Affordable Care
For legal experts' best guess on how the Supreme Court will rule
on the Affordable Care Act,
To learn more about the expansion of Medicaid under the
Affordable Care Act,
To learn more about the importance of the individual mandate to
the Affordable Care Act,