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Health Reform in Court: What’s it All About?

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Wellness related image Photo: Getty Images

As I’m sure you know, several states and others have sued to try to stop the health reform law from taking full effect. If you’re not a lawyer, it’s hard to follow exactly what’s going on, so I thought I’d give you a quick summary of the status of the major cases.

The main argument against the law is that the Constitution does not allow the federal government to require people to buy insurance. Starting in 2014, under the health reform law, everybody is required to have insurance or pay a penalty. There will be expanded Medicaid to help low income consumers, and subsidies to help the middle class afford to buy insurance. The penalty for not buying insurance is only $95 in the first year.

The theory behind the requirement to buy insurance, called the “individual mandate", is that when you open the insurance market to people with pre-existing conditions, you have to make sure all of those people are balanced out by young, healthy people. If only sick people race to buy insurance as soon as they can, premiums will go through the roof because the market will be dominated by the most expensive consumers-- people with pre-existing conditions. So to try to get as many of those young, healthy people into the market to balance out that cost and keep premiums balanced, you have an individual mandate.

The challenge to the law is that the federal government can’t make you buy something – anything. Under the Commerce Clause of the Constitution, the federal government has the right to regulate things in commerce. There is a limit, though, to federal authority. Things that are not in commerce – private things – cannot be regulated by the federal government. Instead, those things can be and are regulated by the states.

But where, exactly, that line is drawn has been the subject of Supreme Court case law for a very long time. Child labor? Yup, the feds can regulate. Gun-free school zones? Nope, the feds cannot regulate because nothing was crossing state lines and schools are generally locally regulated. But none of those cases tells us for sure what the answer is here. Many constitutional scholars think this should be an easy case, that Congress clearly has the power to regulate health care financing since it will be tax dollars that pays for care for the uninsured. And really, they say, the law isn’t requiring people to buy something; it’s just making decisions about how we as a country will finance health care--for example, public or private, state or federal.

In the federal court system, there are three levels of courts: District courts, which are the trial courts; Circuit courts, which are the Courts of Appeals; and the Supreme Court. District courts in various states have ruled on the challenges to the health reform law, some saying it’s fine and some saying it’s not. So now the cases are at the Courts of Appeals. There were two District court cases in the Fourth Circuit that split, one in favor and one against. The Sixth Circuit already has ruled that the law is constitutional. But the big case brought by 26 states is in the Eleventh Circuit. Decisions should come from these courts in the coming months. Conventional wisdom is that the cases will then go to the Supreme Court. I figure this controversy will be at a fevered pitch during the 2012 Presidential campaign.

Interestingly, Massachusetts, which is the only state that has universal health care, including an individual mandate, has filed a brief in support of the law. Based on their experience, the individual mandate is a critical element of the success of their plan. Without that, their system would not be working as well as it is. Unfortunately, there are a lot of people who don’t want it to work. And that’s a shame because without it, we are right back where we started, with skyrocketing premiums, 50 million uninsureds, and people who are suffering terribly. For me, the answer is clear.

Edited by Alison Stanton

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