We will be performing site maintenance on AAOS.org on February 8th from 7:00 PM – 9:00 PM CST which may cause sitewide downtime. We apologize for the inconvenience.

Chief Justice John Roberts, who cast the deciding vote upholding the constitutionality of the PPACA, looks on as then president-elect Barack Obama signs the visitors’ book at the Supreme Court. Official White House Photo by Pete Souza


Published 8/1/2012
Madeleine Lovette

Court Upholds Healthcare Reform Law

Madeleine Lovette

On June 28, 2012, the Supreme Court of the United States upheld the constitutionality of the Patient Protection and Affordable Care Act (PPACA). The 5–4 decision came as a shock to many, particularly since it was Chief Justice John Roberts who cast the deciding vote.

Before the decision was announced, former Supreme Court clerks, experienced attorneys, and numerous Supreme Court scholars had all supposed that the Court would strike down the law’s central provision, the individual mandate. Many also anticipated that the mandatory Medicaid coverage expansion would be overturned as well.

Under the individual mandate, most Americans are required to buy health insurance by 2014 or pay a penalty. The Medicaid expansion upheld by the Court requires all states to expand their Medicaid programs to cover individuals younger than age 65 with incomes at or below 138 percent of the federal poverty line. A provision that gave the Secretary of Health and Human Services the authority to withhold funds from states that do not comply with the Medicaid expansion was struck down.

What Court watchers found most fascinating, however, was the way the Court came to its decision. The Obama administration had argued that Congress had the authority to mandate the purchase of health insurance under the commerce clause, which gives Congress the right to regulate interstate traffic. Five justices—the Chief Justice and Justices Kennedy, Scalia, Thomas, and Alito—rejected that argument.

However, rather than striking the provision from the law, Chief Justice Roberts saved the insurance mandate by arguing in his opinion that a penalty assessed for failure to purchase insurance was a tax and thus valid under Congress’s authority to ‘lay and collect’ taxes. Justices Ginsburg, Breyer, Sotomayor and Kagan agreed with this judgment.

Immediate fallout
The Court’s decision immediately ignited controversy since both President Obama and administration officials had denied that the mandate is a tax. The Court’s decision to uphold the mandatory Medicaid expansion by making it optional to states also came under scrutiny in the wake of the ruling. Thus far, at least 15 governors have decided not to expand or are leaning toward not expanding their Medicaid programs, leaving thousands of Americans in insurance limbo. In addition, reports that Justice Roberts had originally planned to strike down the individual mandate have been leaked to the press, adding more fuel to the political debate.

The decision also altered Americans’ public perception of the Court. According to two Rasmussen polls, one taken before and one taken after the Supreme Court decision, the number of individuals who believe that the Court is doing a poor job has risen by 11 percentage points. In addition, the Rasmussen polls revealed that the number of individuals who believe that the justices pursue their own political agenda rather than remain impartial has also risen.

Voters’ response
There is no question that the court’s landmark decision, coupled with a ‘flip-flopping’ Chief Justice, caused a political and media firestorm. But is this storm just hot air, or will the Court’s decision really affect voters’ decisions in November?

A CNN/ORC International poll released on July 2, 2012, shows that the Court’s decision did not necessarily change voters’ minds about the Presidential candidates, but it did affect voter enthusiasm. The poll found that enthusiasm among registered voters identifying themselves as Democrats rose more than 10 percentage points to 59 percent following the healthcare ruling. Enthusiasm among registered voters identifying themselves as Republicans remained constant at 51 percent.

Campaign narratives
The ruling has been characterized by many political analysts as a win for the Obama administration. According to the CNN/ORC poll mentioned above, voters now place more confidence in Obama’s handling of health care than they do in Romney’s potential to handle the issue (51 percent to 44 percent).

But the law, at least in its entirety, remains unpopular among the American public. According to a Kaiser Family Foundation poll taken days after the ruling, 41 percent of Americans favor the law, with an equal number opposed to it.

This presents both Republicans and Democrats with an opportunity to spin the ruling in their favor during the upcoming elections, thus affecting the campaign narratives of the Presidential candidates.

President Obama hopes that as voters reap the benefits of PPACA, its popularity will grow. He will continue to emphasize the patient protections in the law such as providing free preventive care, closing the Medicare donut hole, eliminating preexisting conditions, and allowing young adults to be covered under their parents’ insurance plans. It remains to be seen whether he will attempt to defend and explain other, less popular provisions in the law. Political analysts see the ruling as an opportunity for the president to put this debate aside and focus on the economy.

Mr. Romney’s campaign narrative about the reform law has only intensified since the ruling, appealing to the law’s opponents that he is now their only hope for repeal. Within hours of the Court’s decision, he raised approximately $200,000 in campaign funds. Mr. Romney has also taken full advantage of the Court’s interpretation of the individual mandate penalty as a tax to depict President Obama as a tax-and-spend liberal, even though the tax would only affect a small percentage of Americans.

But whether hinging his campaign on repealing healthcare reform will ensure Mr. Romney a win in November is unclear. At least one poll, performed by The Kaiser Family Foundation, found that more than half of Americans (56 percent) want the law’s detractors to stop trying to block its implementation and move on to other national problems.

Madeleine Lovette is the AAOS communications specialist in the office of government relations. She can be reached at lovette@aaos.org

Additional Resources: