The two issues considered by the court were:
1. Does the constitution allow the government to withhold Medicaid funding from states which do not choose to participate in expanding Medicaid to citizens who sit below 133% of the poverty line?
2. Can the government require citizens to buy health insurance?
There was lively discussion. Chief Justice Roberts argued that it is not constitutional for the government to take away Medicaid funding as a way of forcing states to comply with Medicaid expansion. Justice Ginsberg felt that this could be construed as amending the Medicaid program and was within Congresses legislative prerogative. Eventually they agreed that Congress definitely had the right to share costs with states for Medicaid expansion, as provided in the law, but could not constitutionally withhold funding from states that chose not to participate. This change would not invalidate the ACA.
The argument about the "individual mandate" to buy health insurance was livelier. All of the justices seemed to understand the issue: everyone needs health care at some time, they don't know when, and because it is so expensive, the uninsured rarely can pay their bills. Since someone has to pay their bills, providers such as hospitals do, passing the cost off to paying customers by way of their insurance, thus raising the cost of health insurance. If the uninsured only get emergency care when they are sick rather than getting preventive and primary care which cost less, the cost of health care is higher. We all pay for health care, no matter how you look at it, and the ACA's individual mandate is just a way to more equitably distribute the costs. Requiring healthy people to buy insurance before they get sick will likely keep them from costing so much, plus will allow the insurance companies to continue functioning in the black since they won't be insuring only the sick. Other provisions of the ACA do require the insurance companies to provide affordable coverage to everyone, and if there were no new healthy folks in the pool, their profits might fall to the point that they couldn't economically survive. (I'm not entirely sure that would be a bad thing in the long run, but it is not the intention of the ACA to kill the health insurance companies.) Justice Ginsberg noted that the government would have been within its rights and precedents to enact a single payer system, a "tax and spend" solution, but they decided to support the current system instead.
The question that was raised, however, was whether the government, under the commerce clause, has the right to require people to buy health insurance. This clause was originally enacted because states often acted with respect to commerce in ways that were beneficial to the states but not to the country. The clause gives the federal government the right to "regulate commerce." Since running up huge medical bills, thus driving up insurance costs and bankrupting hospitals and those who purchase health insurance is certainly commerce, enacting something to alleviate this problem could definitely be viewed as "regulating commerce." Several justices felt, though, that allowing the federal government to require people to buy something that the don't want is a dangerous expansion of federal powers. The justices then looked at it another way. If an individual does not buy health insurance, he or she is required to pay a certain amount of money as a penalty and as a way of defraying the costs of the burden they place on the health care system by not buying health insurance. This amount of money is to be payed along with income taxes. It can be viewed, then, as a tax, and the federal government can levy taxes. The individual mandate stands, then but can be more accurately read as "you can either buy affordable health insurance in a timely manner or pay a tax and not be insured."
It is definitely worth reading some of the judicial opinions, especially those of Justices Ginsberg and Roberts, just because they are so smart and express themselves so well. They manage to be conversational and engaging while presenting elegant logic. They also have this sort of sparring match going on. I would love to watch them having dinner together.
I'm glad this is over. The ACA is not perfect, and the solution to our health care problems is not in it, but it is a powerful incentive to move in a direction that will eventually be beneficial. In fact it is already beneficial. The fact that the whole country is watching health care, and we all know it, is profoundly motivating for us to get our acts together and make the changes that are totally obviously needing to be made.
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