Saturday, June 30, 2012

The Patient Protection and Affordable Care Act

Every so often an issue comes along that involves all three branches of the federal government.  For the past three years that issue has been the Affordable Care Act (ACA).  President Obama made health care reform the central promise of his campaign in 2008 and followed through on that commitment in 2009 and 2010.  Congress considered and debated ways to provide health insurance to more Americans for the better part of a year beginning in March 2009 and culminating with the passage of the ACA in December of 2009 after an extremely contentious process in the Senate.  Things moved back to the House in March 2010 when the House agreed to the Senate bill, provided the Senate would adopt some 'fix' measures that House Democratic moderates insisted upon.  The President signed the ACA on March 23, 2010.  Using a process known as reconciliation both chambers then took up the 'fix' package and passed it in short order.  The president signed the changes into law on March 30, 2010.  Then the legal battles began.

For more than two years, observers waited for the ACA to make it's way to the U.S. Supreme Court.  Arguments centered around two key provisions:  1)  Could Congress mandate that all Americans obtain a minimum standard of health insurance coverage or pay a fine and; 2) Could the government withhold all Medicaid funds from states if they did not expand their Medicaid rolls to 133% of the Federal Poverty Level?  On Thursday, the Court ruled yes and no to the first question and no to the second question.  Huh?

As Inigo Montoya said to the Man in Black (Princess Bride), "le' me sum up."  On the first question a majority of the Court said that Congress could not use its power to regulate commerce to require Americans to buy health insurance.  This was a big win for conservatives, even if they fail to see it because of their hatred of Barack Obama and his signature initiative.  The ruling places further restrictions upon Congress use of the commerce clause, continuing a pattern of Court decisions that have been issued since Lopez v. United States (1995).  In that case, the Court struck down the Gun Free School Zones Act, which banned the possession of a gun within certain distances of a school.  Further limitations on Congress' commerce clause power came in Printz v. United States (1997), and a series of other cases.  In that sense, the ruling in the ACA case was perfectly consistent with a conservative understanding of the constitution.  At the same time, however, a majority of the Court agreed that Congress could impose a tax on consumers who fail to acquire minimally acceptable health insurance, thus upholding the ACA.

On the second question, the Court by a 7-2 majority ruled that the federal government may not punish a state by withholding all Medicaid funds if it fails to increase Medicaid coverage to all citizens within 133% of FPL.  This is yet another win for the conservatives and federalism.  Ultimately, coercion is the only power the federal government has over states in areas not involving civil rights and/or equal protection.  The government has long used this power of coercion to bring states into line with federal mandates.  It may not be able to do so any longer.  Practically, it remains to be seen what the impact of the ruling will be but it is conceivable that states may be able to lower the drinking age if they wish without fear of losing federal highway funds, ignore the provisions of No Child Left Behind without jeopardizing federal education assistance, and a plethora of other issues.  If this reading of the ruling pans out, conservatives may get what they want:  50 states with 50 separate sets of laws and a much weaker federal government.

In what may have been one of the most politically calculated decisions in the history of the Court, Chief Justice John Roberts, in the mold of the Great Chief Justice John Marshall, awarded victory to both liberals and conservatives in one case while deferring to the elected branches on the question of policy wisdom, and maintained the independent integrity of the U.S. Supreme Court.  To be sure, opponents of 'Obamacare' won't see it this way due to their partisan and ideological blinders.  But from an institutionalist's view, it was by all accounts a brilliant political maneuver.

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