By voting to uphold the Patient Protection and Affordable Care Act, Chief Justice John G. Roberts Jr.erased concerns that the Supreme Court had become captive to a political rather than a legal agenda. As he promised to do during his confirmation hearings, Chief Justice Roberts in his decision released today crafted a narrow ruling that showed due deference to the other branches of government. In fact, his view of the most controversial element of the law, the so-called individual mandate — a requirement that individuals purchase health insurance or pay a penalty — cut through the political spin of Democrats in Congress and President Barack Obama. They had refused to call the penalty a tax, out of an effort to avoid breaking the president's promise not to raise taxes on the middle class. But Chief Justice Roberts said that's what the provision amounts to, and under Congress' broad powers to levy taxes, it stands.
The implications for the nation's health care system and for the American people are enormous. Had Chief Justice Roberts sided instead with the court's conservative wing, the entire act would have been thrown out — and with it, protections for Americans with chronic diseases and pre-existing conditions, the expansion of health insurance to millions who now lack it, and provisions to control the spiraling cost of health care in the United States. A rejection of the model for universal health care embodied in the Affordable Care Act would have left little other option besides a single-payer system, which is for the foreseeable future a political impossibility.
The 5-4 decision is not a complete validation of the Affordable Care Act. It narrows a provision related to the expansion of Medicaid, which is the law's mechanism for expanding health insurance to the very poor. In many states, Medicaid eligibility for childless adults is extremely limited, but the Affordable Care Act called for states to expand it to all those who fall below 133 percent of the federal poverty level, or about $14,500 for an individual. The court ruled that the penalty for states that refuse to do so — a loss of existing federal Medicaid funds — was unconstitutional. Although that element of the decision leaves open the possibility that access to health care for the poor will vary significantly among the states, it corrects something of a perversion in the original law: The penalty for failing to expand Medicaid sufficiently was to take health care away from the very poor.
Speculation before the decision centered on whether the conservative majority on the court would reject the notion that the individual mandate was authorized by the Commerce Clause and, in the process, overturn precedents for Congress' ability to regulate the economy dating to the New Deal. Without that mandate, insurance companies would not be able to cover pre-existing conditions or provide many other benefits without raising premiums drastically. Interestingly, a majority of justices did conclude that the mandate was not a permissible regulation of interstate commerce — which, at first glance, would seem to present a real limitation on Congress' ability to address problems that the states can't handle on their own. After all, granting greater deference to Congress' authority to levy taxes is of little use in an era when approximately half of Congress has signed a pledge never to raise taxes under any circumstances.
But the way Chief Justice Roberts (who was joined in his opinion by Associate Justices Stephen G. Breyer, Ruth Bader Ginsburg, Elena Kagan and Sonia Sotomayor) construed the issue should limit its impact as a precedent. He drew a distinction between regulating an existing commercial activity and bringing one into existence through an act of Congress. That is, can Congress force people to engage in economic activity, or can it merely regulate those already participating in it? That was a novel issue presented by this case, and there aren't a lot of other obvious instances in which it would come into play.