Let's try and keep this debate intelligent and civil. It's not so hard. Can someone explain to me what the difference would be between being required to pay health insurance and the commercial activity (buying car insurance) most of us are already required to engage in? Also, what is the difference between being required to pay for health insurance and being required to pay for the Medicare we will all receive when we hit 65?
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Supreme Court Review of the Health Care Reform Law
by Gregory D. Curfman, M.D., Brendan S. Abel, B.A., and Renée M. Landers, J.D.
N Engl J Med 2012; 366:977-979
Later this month, the U.S. Supreme Court will examine the constitutionality of the Affordable Care Act (ACA), potentially producing a landmark decision. For most cases, the Supreme Court allocates 1 hour for oral argument — 30 minutes for each side. For the health care reform case, the Court has scheduled 6 hours for oral argument — the most time devoted to a case in more than 45 years. These arguments will take place on March 26, 27, and 28, and the Court's ruling will probably be announced in June.
Setting the foundation for the largest expansion of health care coverage since Medicare was established in 1965, the ACA will reach approximately 32 million of the 50 million Americans who are now uninsured. It will do so in two ways.
First, beginning in 2014, the ACA's “individual mandate” requires most citizens and legal residents whose income is above the threshold for filing federal income taxes to maintain health insurance or pay a financial penalty — with exemptions for those who cannot afford coverage, have incomes below 100% of the federal poverty level, or lacked coverage for less than 3 months of the year.
Individuals with incomes between 100% and 400% of the poverty level will qualify for income-based federal subsidies. The individual mandate, when fully implemented in 2016, is expected to add 16 million people to the rolls of the insured.
The ACA also authorizes the creation of mostly state-administered insurance exchanges through which individuals and small businesses may purchase insurance policies. States have considerable latitude in specifying minimal essential benefits that must be covered by all insurance policies offered. Among other requirements, under the ACA, insurance companies may not deny coverage or charge higher premiums on the basis of preexisting medical conditions, are limited in their ability to rescind policies, and may not place annual caps on coverage.
Second, the ACA extends Medicaid eligibility to all citizens and certain legal residents with incomes of up to 133% of the poverty level, making an additional 16 million people eligible for
the federal–state program. States not complying with the expansion risk losing all federal Medicaid funds. The federal government will pay 100% of Medicaid coverage for the newly eligible for the first 2 years and gradually reduce its contribution to 90% in 2020.
Challenges to both of these ACA provisions will require the Court to apply the principle of federalism, which recognizes the division of power between the federal and state governments. The U.S. Constitution assigns enumerated powers to the federal government, reserving the rest “to the
states respectively, or to the people.” The justices will determine whether, in crafting the ACA, Congress exceeded its powers.
Numerous lawsuits have been filed against the ACA, but the Supreme Court selected for review the case brought by 26 states and the National Federation of Independent Business (Florida v. HHS). In that case, the U.S. Court of Appeals for the 11th Circuit ruled that the individual mandate was unconstitutional but that the other insurance reforms in the ACA could stand. It further ruled that the Medicaid expansion was constitutional. In reviewing the case, the Supreme Court will address four questions.
First,the Court will determine whether the Tax Anti-Injunction Act (AIA), which dates back to the 1800s, precludes review of the ACA until after 2014. The AIA provides that the legality of a tax cannot be challenged until the tax has been assessed. If, as some contend, the individual mandate's financial penalty is a tax under the AIA, no tax will be assessed until 2014 and a legal
challenge now is premature. Others argue that the penalty is not a tax intended to raise revenue but a financial incentive to comply with the mandate.
If the Court determines that the AIA makes review premature, it may conclude that it should not decide the substantive challenges to the ACA. If the Court determines that review is appropriate, it
will next consider whether Congress has the authority to require most U.S. citizens to purchase health insurance or pay a penalty. The government argues that it has such authority under the Constitution's Commerce Clause, which the Supreme Court has interpreted as providing Congress wide latitude to regulate activity that, when viewed cumulatively, has a substantial effect on interstate commerce.
Americans spend an estimated $2.5 trillion annually on health care, which is indisputably a part of interstate commerce. The government will also argue that Congress derives authority to mandate health insurance coverage from its constitutional power to make laws that are “necessary and proper” for executing other powers.
Challengers argue, however, that the mandate to purchase a product from a private entity is
unprecedented and constitutes an intrusion on individual liberty. If this mandate is upheld, what else might the government force individuals to buy? They further claim that regulating “inactivity,” the decision not to obtain health insurance, is outside Congress's power to regulate interstate commerce.
Third, if the Supreme Court rules the mandate unconstitutional, it will determine whether the rest of the ACA must also be overturned or whether the mandate is “severable” from the rest of the law. ACA opponents argue that the whole law must be overturned if the Court invalidates the mandate, in part because the mandate is “inextricably intertwined” with the law's other elements. The
government argues that only two other portions of the law would also have to fall if the mandate is invalidated: the requirements that insurers cover people with preexisting conditions and not charge them higher premiums. Without a mandate, these requirements would become infeasible. Some authorities argue that Congress, not the Court, should decide these questions.
Finally, the Court will consider whether the ACA's Medicaid expansion is constitutional and whether states can be required to comply with it in order to remain eligible for federal Medicaid funds. The principal point of contention here is whether the ACA requirements “commandeer” or “coerce” state functions in a way that exceeds federal authority. Although the lower federal courts have consistently rejected this argument, the Supreme Court has opted to review it. The government will argue that states operate Medicaid programs voluntarily, contributing their own funds in order to receive federal funding, and that Congress has broad power under the Constitution's Taxing and Spending Clause to require state compliance as a condition of receiving federal funding.
However the Supreme Court rules, the implications for health care in the United States will be profound. At one extreme, the Court could strike down the entire ACA, implicitly endorsing a more limited role for the federal government in the regulation of health care and other areas. At the other extreme, the entire law could be upheld. Intermediate rulings, such as striking the mandate but upholding the Medicaid expansion, are of course also possible.
If the Court upholds the ACA, the number of people with health insurance coverage will swell by as many as 32 million. This result would put pressure on providers to deliver more care. Currently,
only about two thirds of physicians accept Medicaid patients, so the burden of serving the newly eligible populations would fall disproportionately on these physicians. The ACA begins to address this problem with workforce-development provisions. In addition, at least in the short run, health care costs would probably increase, though the ACA contains some cost-control measures.
The Supreme Court's decision in this case could have a significant effect on the presidential election, since the ACA, President Barack Obama's signature legislative accomplishment, is already a hot-button issue. Public opinion, which favors some parts of the law but not others, makes the political calculus complicated. With all these factors in play, 2012 is shaping up to be a momentous year for U.S. health care.
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