Second Day Commentary
The Supreme Court upheld the health care reform law on Thursday in a ruling in which conservative Chief Justice John Roberts sided with the liberal wing of the Court and cited ways to keep the controversial law within constitutional bounds. The ruling saves President Obama’s major domestic policy initiative, but probably won’t stop the political debate over the sweeping Affordable Care Act.
The 5-4 ruling lets stand the individual mandate, requiring that just about everyone carry health insurance or pay a fine. But the ruling calls the fine a tax, allowing the law to escape arguments that it exceeds the authority of the Commerce Clause of the constitution. Not all the justices agreed. "In our view, the entire Act before us is invalid in its entirety,” conservative justice Anthony Kennedy writes in his dissent.
The ruling, written by Roberts himself, also addresses the law’s controversial requirement that states expand Medicaid coverage to millions more. It says the federal government may ask the state to do so and can even provide the cash, but it cannot withhold its share of Medicaid funds to coerce them to do it.
"Nothing in our opinion precludes Congress from offering funds under the ACA to expand the availability of health care, and requiring that states accepting such funds comply with the conditions on their use,” the ruling declares. “What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding." The Medicaid expansion is expected to cover 17 million of the estimated 30 million people who will get insurance under the law.
Whether states will opt out of the Medicaid expansion is now the question. But, even after the decision, opting out won't be a painless choice. Those decisions will carry substantial stakes. Many of the conservative states most likely to opt out of the Medicaid expansion are also among the states with the largest number of uninsured. Under the bill, the federal government will pay all of the cost for the coverage expansion during its first three years (2014-2016), and then taper down to a permanent 90 percent contribution by 2020.
Even without the threat of a complete funding loss, it may not be easy for governors to explain why they would walk away from a deal that commits Washington to paying 90 cents on the dollar for expanding coverage to the uninsured in their state.
The reality is that the Court’s decision, as historic as it is, does not guarantee the survival of the law that is the signature accomplishment of Obama’s first term in office. For even after this decision, the health care law still is far from the permanent reform he envisioned when he hailed its passage as answering “the call of history.
Polling shows that individual components are popular. But, as indicated in an ABC News/Washington Post Poll released on Wednesday, that doesn’t mean people like the overall bill any better. In fact, the survey, conducted June 20-24, shows that 52 percent dislike it.