Is Universal Constitutional? Exploring the Implications of the Affordable Care Act Cases
In September 2009, President Barack Obama stood before Congress and ambitiously declared an endeavor to revolutionize healthcare: “We know we must reform this system. The question is how” [1]. Within a year, the Patient Protection and Affordable Care Act (PPACA) would attempt to resolve this query by fundamentally reimagining the nation’s medical infrastructure. The PPACA established and mandated a standard minimum for care, regulated health coverage practices and entities, and expanded public Medicare and Medicaid programs. The statute further established a legislative precedent that has been resoundingly evoked by the healthcare policy platforms of candidates such as Bernie Sanders and Joe Biden over a decade later. At the same time, the PPACA has proven remarkably controversial, drawing criticism for its emphatic incentivization of public healthcare at the state level and mandation of coverage at the individual level. As evidenced by the dozens of consequential lawsuits brought before the Roberts Court as a result of the PPACA, the future of universal healthcare remains legally contentious [2].
The Patient Protection and Affordable Care Act Cases were a conglomeration of three major lawsuits that went before the Supreme Court in the last decade, and which are typically cited collectively: National Federation of Independent Business v. Sebelius (2012), Department of Health and Human Services v. Florida (2012), and Florida v. Department of Health and Human Services (2012)[3]. In conjunction, the cases primarily challenged two main facets of the PPACA: the Medicaid expansion and the individual mandate. More specifically, the cases questioned the constitutionality of the PPACA’s revisions to public health insurance policy, since it encouraged growth by threatening to suspend state healthcare funding. Plaintiffs further argued that the individual mandate, which required that individuals maintain a minimum healthcare plan, overstepped congressional authority. The suits were collectively tried under National Federation of Independent Business v. Sebelius. These expansive lawsuits were brought collectively by 26 states, the National Federation of Independent Business, and petitioners Kaj Ahburg and Mary Brown [4].
The plaintiffs in these cases first argued that the Maintenance of Minimum Essential Coverage clause in the PPACA—which imposed a specific “minimum essential coverage” unto individuals and employers—unjustly overstepped congressional authority under the Commerce Clause. Under the infamous individual mandate, the PPACA demanded that applicable individuals sustain healthcare at all times justifying this requirement as a manifestation of the Commerce Clause: “[healthcare] is commercial and economic in nature, and substantially affects interstate commerce” [5]. Under such reasoning, the PPACA compelled applicable individuals to maintain health care coverage or incur a monetary penalty. Ahlburg challenged the individual mandate on the grounds that he was wealthy enough to cover his own medical expenses, thus annulling the necessity of constant insurance. Brown held that the PPACA had forced her to divert funds from her ailing business, asserting that the government could not infringe upon her choice to opt into health insurance. In short, these plaintiffs claimed that the decision to maintain health coverage was beyond governmental jurisdiction and the imposition infringed on their liberty as such.
The plaintiffs also challenged the PPACA’s Medicaid extensions, which were intended to improve public medical insurance by widening coverage access, granting Medicaid eligibility to adults with incomes up to 133% of the federal poverty level and facilitating child enrollment by streamlining protocol. In order to encourage these policies, however, the PPACA declared that states could potentially lose federal funding for both existing and novel programs if the terms of the new Medicaid program were violated, strongly incentivizing acquiescence to the expansion. To the plaintiffs in the Patient Protection and Affordable Care Act Cases, this method of expansion constituted coercion.
The Roberts Court was clear in its intention to preserve the PPACA. Justice Ginsburg aptly noted: “When a court confronts an unconstitutional statute, its endeavor must be to conserve, not destroy, the legislation” [6]. The Roberts Court thus monumentally upheld congressional authority over the individual mandate by clarifying that the PPACA imposed a fee but never classified coverage as compulsory; if the penalty fee were construed as a tax, the individual mandate would fall under the Congress’s authority via the Taxing Clause [7]. Conversely, the Court deemed the Medicaid expansion an impermissible assumption of Congressional authority under the Commerce Clause, despite the pervasive scope of the clause. Since it forced inactive individuals into commerce related activities, the Maintenance of Minimum Essential Coverage Clause was ruled beyond Congress’s enumerated powers [8]. As such, the Court ruled in favor of the plaintiffs on the Medicaid expansion issue, judging the use of federal power to coerce states into compliance unconstitutional.
This ruling is pivotal with respect to both the PPACA itself and to the viability of universal healthcare. The Roberts Court decision critically redefined the application of the PPACA, rendering the Medicaid expansion clause effectively optional and slightly decreasing the power of the federal government over healthcare [9]. On a broader scale, the 2012 ruling established a standard for healthcare policy that fundamentally informed the principle of universal coverage. On the one hand, vindication of the individual mandate represented a major step in federal healthcare jurisdiction, granting Congress an unprecedented national medical insurance authority. On the other hand, the Court’s rejection of the PPACA’s endeavor to consolidate state Medicaid policies via federal legislation presents a hurdle to nationalized universal healthcare. In considering the contemporary debate over healthcare, it is therefore essential to consider not solely moral and economic restraints, but also legal feasibility. At the moment, a universal healthcare system would still demand a novel legal approach at both the state and federal levels.
[1] Obama, Barack. “Obama's Health Care Speech to Congress.” The New York Times, The New York Times, 9 Sept. 2009, www.nytimes.com/2009/09/10/us/politics/10obama.text.html. [2]“Patient Protection and Affordable Care Act.” Home - Supreme Court of the United States, Supreme Court of the United States, www.supremecourt.gov/docket/ppaaca.aspx.
[3]“National Federation of Independent Business Et Al. v. Sebelius, Secretary of Health and Human Services, Et Al.” Supreme Court of the United States, Oct. 2011, https://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf.
[4]Maltby, Emily, et al. “Hurdle for Health-Law Suit.” The Wall Street Journal, Dow Jones & Company, 5 Dec. 2011, www.wsj.com/articles/SB10001424052970204397704577074351071536684.
[5]“Compilation of Patient Protection and Affordable Care Act.” Office of the Legislative Counsel, 1 May 2010, https://www.hhs.gov/sites/default/files/ppacacon.pdf.
[6]“National Federation of Independent Business Et Al. v. Sebelius, Secretary of Health and Human Services, Et Al.” Supreme Court of the United States, Oct. 2011, https://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf.
[7]Haberkorn, Jennifer. “Supreme Court Upholds Individual Mandate.” POLITICO, 28 June 2012, www.politico.com/story/2012/06/supreme-court-health-care-ruling-077935.
[8]“National Federation of Independent Business Et Al. v. Sebelius, Secretary of Health and Human Services, Et Al.” Supreme Court of the United States, Oct. 2011, https://www.supremecourt.gov/opinions/11pdf/11-393c3a2.pdf.
[9]“Status of State Action on the Medicaid Expansion Decision.” The Henry J. Kaiser Family Foundation, 20 Sept. 2019, www.kff.org/health-reform/state-indicator/state-activity-around-expanding-medicaid-under-the-affordable-care-act/?currentTimeframe=0&sortModel=%7B%22colId%22%3A%22Location%22%2C%22sort%22%3A%22asc%22%7D.