The Constitutionality of Health Care Reform


Ok, now that I’ve scared the poop out of your butts, why don’t we have a little chat about the case that recently came before the Supreme Court calling the Patient Protection and Affordable Care Act’s (PPACA, prounounced pee-pah-cah if you want to sound cool) constitutionality into question. “But Matt,” you may say, “how are you qualified to talk about this extraordinarily complicated issue? For goodness sake, you said the word poop in your last sentence!”

Well my friend, I happen to have taken not one, but two classes on health care reform. Plus, as a college student, I am required to hold a strong opinion on every issue ever raised. Luckily for all of you, I’ve read up on the topic. And as to the poop thing, those of us who’ve read PPACA (well, parts of it anyway) know that Congressmen love to throw toilet humor into their laws. It’s in there, you just have to know where to look. Most importantly though, I’m not going to go into the minutia and I’m certainly not going to pretend I’m a lawyer. But by the end of this post, you’re going to have some idea what’s going on. At least, enough to impress the ladies, or your grandparents, or whoever else is claiming Obamacare is ruining this country from the inside out.

First off, a little background. The case itself is called U.S. Department of Health and Human Services v. Florida. It’s no surprise that the biggest case in front of SCOTUS (Supreme Court of the US, pronounce it sco-tuss if you want to sound cool) since Gore v. Bush once again involves Florida. They aren’t alone though. 13 other states are in on the case, along with the National Federation of Independent Businesses and four individuals. Their main point of contention is the individual mandate, which is a requirement that all U.S. citizens obtain health insurance. That’s what the big hubbub is about. And guess what. The individual mandate will affect about 2% of Americans, according to the Urban Institute. That’s it. 2%.  The Court will be answering four questions, which is very convenient for bloggers trying to simplify things.

Question 1: Can we even do this now? Can’t we just do this later?

First thing’s first, the Court had to decide whether or not it was even appropriate to hear the case yet. Under the Anti-Injunction Act, a law passed in 1867, no one can sue to stop a tax until the tax has already started collecting money. Since the individual mandate, which we will get to in a minute, is the major piece of PPACA under fire, and it doesn’t begin taxing/penalizing people until 2015, this one seems obvious. Both sides agree, but not in the way you might expect. They both say that the Anti-Injunction Act doesn’t apply. The states say that the individual mandate is not a tax, but a penalty, and therefore not subject to the law. The Obama Administration argues that the individual mandate doesn’t quite fit the definition of a tax affected by the Anti-Injunction Act. SCOTUS, in a blatant attempt to put off their work until later,  conscripted a lawyer to fight for their right to do this some other time. Because they have a lot going on right now and Con Air just started on TBS. But seriously, its actually standard practice to hear the merits of the other side an argument when both of the contenders are together on it.

Question 2: Is the individual mandate constitutional?

This is the big one. Does the federal government have the ability to compel people into buying health insurance?

First off, it’s important to understand why the individual mandate is included at all in PPACA. The people this is aimed at are the ones who don’t buy health insurance because they are healthy. Healthy people don’t need health insurance because healthy people don’t need doctors. Sick people need health insurance because they have to go to the doctor a lot and doctors are expensive. Before PPACA, insurance companies could and would avoid the sick people because they cost more to cover. PPACA outlawed that practice, which is good for people with asthma and cancer, but bad for insurance companies’ bottom lines. To compensate, the individual mandate attempts to add more healthy people into the pool of insured people. Healthy people don’t need doctors and so they don’t cost a lot. You think allowing people under the age of 26 to stay on their parent’s insurance was just to help young people? You should know by now that politicians only pretend to care about young people. That was to make it easier for insurance companies to keep young, healthy people on their roles. Just like the individual mandate.

Why is it such a big deal? Well it’s not often that the government compels people to buy something. Under the Commerce Clause of the Constitution, the government has the ability to regulate economic activity. Proponents of PPACA claim that the individual mandate falls under the Commerce Clause. Failing to purchase health care affects others, they say, when the uninsured gets hit by a bus and expects care at the local emergency room. These events drive up costs for the insured, and thus requiring people to buy health insurance is a necessary and proper way to regulate the industry. Their opponents argue that this is an unprecedented overreach of government power. They say that if the government can force a person to buy health insurance, it can force them to buy other things as well. The example that often comes up is broccoli. Not sure why broccoli, but my guess is that Americans generally and Supreme Court justices specifically hate broccoli with the passion of a four-year-old.

Question 3: Can reform go on without the individual mandate?

As you should realize by now, the individual mandate is pretty crucial to the effectiveness of health care reform. If you don’t, read the last two paragraphs again. And this time really try hard. The third question before the Court asks whether they should strike down the whole bill if the individual mandate is ruled unconstitutional. Insurers would crumble if they were forced to take on every sick person who wanted coverage without a guarantee of an influx of healthy souls to suck on. Yes, it’s weird to pity the health insurers only a few years after using them as a club to beat health care reform through Congress, but it’s always been said that the Supreme Court makes for strange bedfellows. (Well, I guess that’s only been said since Thomas got on the Court.)

But anyway, the Obama administration argued that if the individual mandate gets shut down, only the insurance provisions (ie: requirement that insurers take people with pre-existing conditions) should too. Everything else though, Medicare reforms, payment reforms, etc. should stay. The States think the whole thing should fall if the mandate does, as the whole bill was an attempt at universal health coverage, and without the individual mandate that becomes impossible. I have a sneaking suspicion they really just don’t like the whole bill, but I can’t prove it. Once again, the Court called in an independent lawyer to make a third argument, this time that if the individual mandate is ruled unconstitutional, everything else should stay, including insurance provisions. Because why not?

Question 4: What about the Medicaid expansion? Is that ok?

PPACA, in addition to creating the individual mandate, also expanded Medicaid to people earning up to 138% of the Federal Poverty Line. In 2012 that means families of four making up to $31,809 or individuals making up to $15,414 would be eligible for Medicaid coverage. In total, Medicaid will be covering 16 million more people if PPACA survives. The States argued that the Medicaid expansion was coercive, as if they refused to comply the Federal Government would pull all funding for Medicaid. The Obama administration argued right back saying something like “Hey, that’s always been the case and it’s never been a problem before. Plus, we’re paying for 90% of the expansion, so what are you complaining about?” In response the lawyer from the states kind of shrugged his shoulders and then when the Justices weren’t looking stuck his tongue out at the lawyer for the government. Maybe. I wasn’t there, but I heard that from someone.

So how did it all turn out?

Well, we don’t know yet. And we won’t until June. A lot of pundits say that the Obama lawyers did a terrible job and that the Court is poised to strike down the law. They always use the word “poised.” But we’ll find out in June. I suggest that you don’t think about this until the decision comes down. That way it will be a big surprise! And surprises are fun!


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