Supreme surprise

The U.S. Supreme Court on Thursday surprised nearly everyone by upholding the central element of the Affordable Care Act dubbed Obamacare by opponents — the individual mandate that requires everyone in the country to obtain health insurance. The way the high court reached that decision, however, makes the ruling less sweeping than it might have been, and the court majority invalidated one other element of the law.

The result is that health care reform will continue to take effect in stages, but some states may be emboldened to refuse to implement changes to the Medicaid program. Fortunately, Oregon, which already is pursuing its own Medicaid reforms with the blessing of the Obama administration, will not be one of them.

Opponents have denounced the individual mandate as an attack on individual freedom by an overzealous federal government. In fact, unless the country adopts a single-payer, universal health care model, the mandate is the only way to make needed reforms work, extend coverage to more Americans and bring down the cost of health care overall.

Without the individual mandate, insurers could not be required to cover everyone because healthy Americans would simply wait to buy insurance until they got sick.

Most observers expected the court's ruling to center on the Commerce Clause of the Constitution, which grants Congress the power to regulate commerce among the states. Never before, opponents said, has the Commerce Clause been used to require individuals to engage in commerce — something they argued was unconstitutional.

The court agreed with that reasoning, but found the individual mandate constitutional anyway because Congress has the power to levy taxes. The fine that Obamacare will impose on those who refuse to buy insurance is a kind of tax, the court said, and therefore is constitutional.

Opponents of President Obama immediately pointed to his statement in a 2009 interview that the individual mandate was "absolutely not a tax increase." If the mandate is constitutional because it is a tax, they argued, the president must have lied.

Except that he didn't.

If Congress ordered everyone in America to pay a new tax to support health care reform, that would be a tax increase. But the penalty for not buying health insurance will apply only to those who refuse to obtain it. They can avoid paying the penalty — just as a smoker can avoid paying tobacco taxes by quitting. There is nothing new about government influencing behavior through tax policy — and nothing wrong with it, either.

The court did strike down one element of Obamacare, ruling that Congress could not punish states that refuse to expand their Medicaid programs by removing all existing Medicaid payments. This means some states may indeed refuse, denying their low-income residents the benefits of expanded coverage.

In Oregon, lawmakers have already put in motion plans to expand the Oregon Health Plan — and spend less money in the process — by creating Coordinated Care Organizations to more efficiently use Medicaid dollars.

The future of Obamacare now depends largely on the outcome of the November elections. Congressional Republicans have vowed to try to repeal the legislation if they maintain their majority in the House, and Mitt Romney says he will repeal the law if he's elected president.

Chief Justice John Roberts, writing for the court majority, essentially said the future of Obamacare is up to the voters:

"Members of this court are vested with the authority to interpret the law; we possess neither the expertise nor the prerogative to make policy judgments," Roberts wrote. "It is not our job to protect the people from the consequences of their political choices."

Voters should examine those consequences carefully, and realize that they are a good thing for the country.

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