This is an excerpt from the Epilogue of Jonas' Introduction to the U.S. Health Care System, Seventh Edition, detailing the Supreme Court upholding the Affordable Care Act (ACA).Jonas' Introduction to the U.S. Health Care System, 7th Edition

As Jonas’ Introduction to the U.S. Health Care System was about to go to press, a historic Supreme Court decision was handed down that had enormous impact on the Affordable Care Act (ACA) and the efforts to provide all Americans with health insurance. As we noted earlier in the Epilogue, the attorneys general of 26 states and the National Federation of Independent Businesses had asked the Supreme Court to hear a case against the ACA, particularly the individual mandate and Medicaid expansion.

The individual mandate was crucial to the law’s success. For its supporters, the main purpose of the ACA was to provide all Americans with health insurance. However, the expense of providing health insurance for all would increase an already expensive system unless the legislation had cost-containment provisions. If costs could not be controlled, any health care legislation would be unsustainable. Because other options for insuring every American were not supported by conservative legislators, the ACA addressed this problem in three ways: (1) to spread the costs of health care over all people by requiring all persons to have health insurance through the individual mandate and Medicaid expansion, (2) to seek efficiencies in the system of delivering care; and (3) to promote prevention and thereby reduce the demand for this costly service.

The case brought before the Supreme Court sought to cripple the ACA’s ability to contain costs by striking down the individual mandate and Medicaid expansion. As Karlan (2012) wrote:

The federal government’s ability to regulate economic and social life stems largely from four powers in the Constitution. Under the commerce clause, Congress can “regulate” national economic activity. Under the taxing power, it can “lay and collect Taxes.” Under the spending power, it can “provide for the common Defence and general Welfare of the United States.” And under the enforcement powers, it can enact “appropriate legislation” to enforce the 14th Amendment’s equal protection and due process clauses and the 15th Amendment’s guarantee of the right to vote regardless of race.

The Obama administration defended the individual mandate as permissible under the Commerce Clause. During the period of March 26–28, 2012, the Supreme Court considered this case National Federation of Independent Businesses et al. v. Sebelius, Secretary of Health and Human Services, et al. In a 5 to 4 decision, the Court upheld the constitutionality of the ACA in a decision that was awaited anxiously by both sides. However, in a surprise to most observers, the Court did not justify its ruling with the Commerce Clause. Rather, the authority of the federal government to impose taxes was the basis of the Court’s ruling, and the Chief Justice, a highly conservative justice known for favoring limited government, wrote the decision. Roberts wrote in a split-the-difference decision, “The federal government does not have the power to order people to buy health insurance. The federal government does have the power to impose a tax on those without health insurance.” Chief Justice John Roberts Jr. sided with Justices Ruth Bader Ginzberg, Stephen Breyer, Sonja Sotomayor, and Eleanor Kagan to form the majority opinion. As a result of the Supreme Court decision, the ACA will continue to be implemented.

The decision was another episode in the curious, complicated, and long tale of America’s attempt to achieve universal access to health care, as all developed nations of the world have done. However, the Supreme Court victory for the ACA is not the end of the story. The elections in November 2012 may deliver a Republican president and legislative majority that will repeal the ACA. Republican presidential candidate, Mitt Romney, has pledged to overturn it if elected, as have most current leaders of the Republican party, even though the ACA is virtually the same as the legislation that Mr. Romney enacted as governor of Massachusetts and the Heritage Foundation recommended as a means of keeping government out of health care. Indeed, the
Supreme Court decision has galvanized conservative political action to prevent re-election of President Obama, maintain a Republic majority in the House of Representatives, and create a Republican majority in the Senate.

Further, the Supreme Court decision, although it allows the present survival of the ACA on the basis of the federal government’s taxing authority, may have established legal precedent for future threats to federal programs that have been justified by the Commerce Clause. As Karlan (2012) noted:

What, then, to make of the court’s landmark decision to uphold the individual mandate? Chief Justice Roberts construed the mandate not as a requirement that individuals purchase health insurance but as a choice: buy insurance or pay a tax. But the conservatives surely know that a Congress that can tax but not do much else—spend money, regulate the economy or enforce civil rights—will be hamstrung. Taxes are unpopular and nearly every Republican member of Congress has promised to oppose any additional taxes on individuals or businesses.

A Congress that can advance national priorities only through its taxing power is a Congress with little power at all. That is the real legacy of the last term. The Supreme Court has given Americans who care about economic and social justice a reason to worry this Fourth of July. The court’s guns have been loaded; it only remains to be seen whether it fires them.

Our original ending to the new Epilogue still holds. Health policy in the United States is still pulled taut between those who want government to take an active role in assuring equal rights and opportunities for Americans and those who believe that equalities will occur naturally, with little government action, as an offshoot of private enterprise. The most recent Supreme Court decision does nothing to resolve this basic tension in American society.

Tell us what you think below--should the Supreme Court have upheld the law, or overturned it?