In a 5-4 vote, the U.S. Supreme Court upheld the Patient Protection and Affordable Care Act today, including the controversial individual mandate that requires all Americans to buy health insurance beginning in 2014. However, the ruling limited the federal government’s power to punish states for not expanding Medicaid coverage, as the ACA required.
“The Court did not sustain it as a command for Americans to buy insurance, but as a tax if they don’t. That is the way Chief Justice John G. Roberts, Jr., was willing to vote for it, and his view prevailed. The other Justices split 4-4, with four wanting to uphold it as a mandate, and four opposed to it in any form,” Lyle Denniston, the 81-year-old reporter, wrote on SCOTUS blog today.
The immediate sense is that this is a major victory for President Barack Obama and the signature legislation from his first term in office. “Whatever the politics,” the president said after the ruling, “today’s decision was a victory for people all over this country whose lives will be more secure because of this law and the Supreme Court’s decision to uphold it.”
But the decision also was an indication that the Supreme Court perhaps isn’t as predictably partisan as many believed prior to the announcement. Breaking with the court’s other conservative justices, Chief Justice Roberts announced the judgment that allows the law to go forward with its mission of covering more than 30 million uninsured Americans. Many observers speculate that Roberts’s ruling reflected his attempt to avoid going down in history as an activist chief justice on what might be the most important decision of his tenure.
UrbanFaith spoke to a variety of legal and medical experts about what the implications of today’s decision may be.
Bernard James, professor of law at Pepperdine University in Malibu, California, along with three other sources UrbanFaith talked to earlier this week, expected the individual mandate to be struck down, but said the ruling has the potential to answer “an extraordinarily important substantive issue about the power of Congress under the Commerce Clause.”
The Commerce Clause refers to Article 1, Section 8, Clause 3 of the U.S. Constitution. It gives Congress the power to regulate commerce with foreign nations and among the states.
“Once it’s clear what the Commerce Clause permits and what it requires, not just health care, but all other subjects on the current agenda for this Congress will be more easily pondered and legislated,” said James.
“There were not five votes to uphold [the individual mandate] on the ground that Congress could use its power to regulate commerce between the states to require everyone to buy health insurance. However, five Justices agreed that the penalty that someone must pay if he refuses to buy insurance is a kind of tax that Congress can impose using its taxing power,” editor Amy Howe wrote on the SCOTUS blog. “Because the mandate survives, the Court did not need to decide what other parts of the statute were constitutional, except for a provision that required states to comply with new eligibility requirements for Medicaid or risk losing their funding. On that question, the Court held that the provision is constitutional as long as states would only lose,” she wrote in her summary of the ruling.
James A. Davids, former president of the Christian Legal Society and a joint professor at the Robertson School of Government and the School of Law at Regent University in Virginia Beach, Virginia, said that ever since the New Deal was implemented in the 1930s, the Supreme Court has viewed federal power “expansively.” That vision of federal power was “tweaked” under the Renquist court, Davids said, in its rulings on two bills, the Violence Against Women Act of 1994 and the Gun-Free School Zones Act of 1990. As with today’s ruling, the court said then that there may be good reasons to enact these laws, but not under the Commerce Clause. “There were exceptions going into the power of the government under the Renquist court, under federalism issues, and this is like federalism on steroids,” said Davids.
Davids also said the Rehnquist court ruled that it was constitutional for the federal government to withhold highway funding from South Dakota when the state refused to comply with the National Minimum Drinking Age Act. In this case, the Court said current Medicaid funding cannot be revoked, but new funding can be withheld.
“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,” Chief Justice Roberts wrote in his opinion. Roberts, who was appointed by President George W. Bush, cast the deciding vote to uphold the ACA.
For, the world-famous neurosurgeon and director of pediatric neurosurgery at Johns Hopkins Children’s Center in Baltimore, Maryland, the outcome of today’s decision doesn’t change much. “The impetus behind the bill was the fact that we had these escalating costs and people who weren’t adequately covered … even though we spend twice as much per capita on healthcare as anybody else in the world,” said Carson.
He supports the concept of health-care reform, but doesn’t think the ACA was done right and compared the effort to hiring pundits to rebuild a bridge instead of hiring structural engineers. “It was done by politicians and special interest groups as opposed to by people who actually know what the problem is and know how to deal with it,” said Carson. “We got what could be expected in that situation.”
Escalating beaurocracy and a lack of comprehensive electronic medical records make the practice of medicine more difficult than it once was, Carson said. In his new book, America the Beautiful: Rediscovering What Made This Nation Great, he includes a chapter on health-care reform. He suggests using “health stamps” to incentivize the uninsured to use clinics rather than emergency rooms for their primary care. This would lead not only to cost savings, but to better care for patients with chronic illnesses, Carson said.
He also advocates Tort reform to rein in the costs of medical malpractice suits. “We’re the country in the world that has the biggest problem with that. Is it because we have the worst doctors? Of course not. It’s because of special interest groups. The Trial Lawyers Association. We will not deal with them. Every time it has come up before Congress, the House has passed it, but the Senate will not vote on it, because there are some filibustering senators who are in the hip pocket of the Trial Lawyers Association,” said Carson.
Finally, Carson said we have to come to grips with the fact that insurers make money by denying people care. “That’s a basic inherent conflict of interest. We have to find a way to deal with that,” he said.
Some Christians, especially the self-employed and small business workers, are participating in medical cost sharing ministries like Medi-Share because they can’t afford the high cost of individual health insurance plans. Today’s ruling won’t have a direct impact on them, said Tony Meggs, the president and CEO of Medi-Share’s parent organization, Christian Care Ministry.
As part of an alliance of three cost sharing organizations, Medi-Share lobbied for and won an exemption from the individual mandate for its members. “We’re grateful that Congress, both left and right, saw healthcare sharing ministries like ours and the other two ministries as being part of the solution,” said Meggs.
His organization’s 19-year history of paying every eligible bill (approaching $700 million to date) and its focus on wellness and preventative care helped convince legislators that cost-sharing ministry members deserved an exemption, he said.
“They understand that they need to bend the cost curve in some way in getting people to make better choices in terms of how they live their lives. From a diet and exercise perspective, those are things that Congress was interested in, and so I think it was a combination of [that and] the fact that we’ve been here for a long time. This is how we help people. It’s credible. We’re not scamming people,” said Meggs.
Medi-Share’s steady growth “accelerated” after the ACA was enacted, Meggs said, and he expects that growth to continue because he says there is about a 40 percent cost difference between an individual health insurance plan and a monthly Medi-Share contribution.
There are differences, however. Medi-Share participants must sign a statement of faith and agree not to abuse drugs or alcohol or engage in extra-marital sex, Meggs said. Medical problems resulting from violations of these agreements are not generally “shared,” nor are mental health problems or some pre-existing conditions. Additionally, insurance companies are contractually obligated to pay for eligible services, but “sharing” medical expenses is voluntary for Medi-Share members. “There’s no guarantee. There’s no contract. Our program is strictly voluntary, but what I can tell you is that over a 19 year history, a 100 percent of every eligible bill that we’ve ever published has been shared,” said Meggs
How will today’s ruling impact your family’s health decisions?