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Advocates hail Supreme Court’s health decision

Paul Kleyman | 7/3/2012, 8:40 a.m.

Initial reactions to the U.S. Supreme Court’s general upholding of the health care reform law last week ranged from praise to criticism. The American Public Health Association’s (APHA) heralded the decision, while conservative groups such as the Association of American Physicians and Surgeons decried it as “a victory for those who want the Federal government to micromanage your life and medical care.”

Buzzing beneath the first bluster of reactions, though, advocates for uninsured or underinsured Americans are raising concerns about the impact — if any — of limitations on the high court’s decision.


Chief Justice’s surprise swing vote

First, here’s what the court decided: The 200-plus-page judgment breaks down into two major parts. In a 5-4 majority opinion written by conservative stalwart Chief Justice John Roberts, who became the surprise swing vote, the court upheld the law’s provision mandating that individuals have insurance or pay a penalty.

“The Affordable Care Act’s [ACA] requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax,” the decision states.  

Roberts thus accepted the Obama administration’s secondary argument that compelling people to buy insurance or be penalized was not tantamount, as dissenting Justice Antonin Scalia argued, to compelling citizens to buy broccoli for their health. Instead, says the majority, the penalty for not purchasing health insurance is no different from any other federal tax permitted by the U.S. Constitution.

The Chief Justice, however, sided with his four conservative colleagues on the administration’s primary argument calling on them to uphold the individual mandate under the commerce clause of the Constitution as federally protected interstate commerce.

This highly controversial part of the decision by the conservative justices throws into question 70 years of Supreme Court decisions affirming the government’s right to regulate interstate trade on such concerns as product safety, the clean air act, and some worry, the 1964 Civil Rights Act. Seemingly obscure to most Americans, it was hotly argued by the White House and public advocates. But on this issue the five conservatives prevailed.

Even though, as ACA advocates asserted, factors determining health care costs are national and don’t stop at a state’s borders, health insurance, usually regulated by states, is a states-rights matter not subject to federal control. This part of the decision — although not in the headlines now — is likely to have a huge ripple effect on issues unrelated to health care.

Vote limiting Medicaid expansion

The court’s decision may well trigger long-term problems for lower-income, uninsured people in some states. The court voted that the federal government can expand the Medicaid program when the full law goes into effect in 2014. But if state political leaders don’t want the new program and its rules for covering people adequately, the United States government cannot threaten to withhold payments they already receive or existing Medicaid services.

Although the ACA will now move ahead with the aim of covering about 31 million uninsured people, about 17 million are supposed to be covered under state-run Medicaid plans.