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Q&A: 10 things you need to know about the PPACA ruling

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Q. Who wrote the majority opinion?

A. Chief Justice John Roberts.

Roberts wrote the core opinion delivering the view of the court that a federal law restricting tax suits, the Anti-Injunction Act, does not bar consideration of a major suit challenging the constitutionality of the Patient Protection and Affordable Care Act of 2010 (PPACA), NFIB vs. Sebelius.

In the majority opinion, Roberts also writes that neither the Commerce Clause nor the Necessary and Proper Clause of the Constitution allow Congress to impose an individual health insurance ownership mandate; that the individual mandate is a tax; and that the Taxing Clause of the Constitution does permit Congress to impose the individual mandate penalty payment requirement.

Roberts was joined by two other justices, Stephen Breyer and Elena Kagan, in a section of the opinion on the PPACA Medicaid expansion provisions.

For exclusive, ongoing coverage of the PPACA verdict and its impact on the industry, visit

Q. What did the court say about the individual health insurance ownership mandate?

A. The Commerce Clause of the U.S. Constitution does not give Congress the authority to make individuals buy commercial products, but the Constitution does give Congress the authority to “lay and collect Taxes” on individuals who fail to buy commercial products.

 Q. What does the Supreme Court think the PPACA individual health insurance “shared responsibility payment” is?

A. A tax.

“Although the payment will raise considerable revenue, it is plainly designed to expand health insurance coverage,” Roberts says. “But taxes that seek to influence conduct are nothing new. Some of our earliest federal taxes sought to deter the purchase of imported manufactured goods in order to foster the growth of domestic industry. … Today, federal and state taxes can compose more than half the retail price of cigarettes, not just to raise more money, but to encourage people to quit smoking. And we have upheld such obviously regulatory measures as taxes on selling marijuana and sawed-off shotguns.”

Q. Does taxing a type of inactivity make that inactivity illegal?

A. No. 

“While the individual mandate clearly aims to induce the purchase of health insurance, it need not be read to declare that failing to do so is unlawful,” Roberts says. “Neither the Act nor any other law attaches negative legal consequences to not buying health insurance, beyond requiring a payment to the IRS. The Government agrees with that reading, confirming that if someone chooses to pay rather than obtain health insurance, they have fully complied with the law.”

Q. If taxing inactivity made the inactivity illegal, how many outlaws would PPACA create?

A. 4 million.  

“It is estimated that four million people each year will choose to pay the IRS rather than buy insurance…” Roberts says. “We would expect Congress to be troubled by that prospect if such conduct were unlawful. That Congress apparently regards such extensive failure to comply with the mandate as tolerable suggests that Congress did not think it was creating four million outlaws.”

Q.  How can Congress put pressure on states to expand Medicaid?

A. Congress can put strings on how states use new money but can’t change the rules governing use of existing Medicaid funding.

“Nothing in our opinion precludes Congress from offering funds under the Affordable Care Act to expand the availability of health care, and requiring that States accepting such funds comply with the conditions on their use,” Roberts says. “What Congress is not free to do is to penalize States that choose not to participate in that new program by taking away their existing Medicaid funding.”

Q. We heard talk about how the court could have killed all of PPACA if it had found one part to be invalid. Why didn’t the restrictions on the PPACA Medicaid provisions kill all of PPACA?

A. The Roberts court believes it must leave a law intact unless it is evident that Congress would have wanted the whole law to die if the portion that was killed died. 

“We have no way of knowing how many States will accept the terms of the [PPACA Medicaid funding] expansion, but we do not believe Congress would have wanted the whole Act to fall, simply because some may choose not to participate,” Roberts says. “The other reforms Congress enacted, after all, will remain ‘fully operative as a law,’ … and will still function in a way consistent with Congress’ basic objectives in enacting the statute,’ … Confident that Congress would not have intended anything different, we conclude that the rest of the Act need not fall in light of our constitutional holding.”

Q. What does the Supreme Court majority actually think about PPACA?

A. The court expressed no opinion about the wisdom of PPACA. 

“The Framers created a Federal Government of limited powers, and assigned to this Court the duty of enforcing those limits,” Roberts says. “The Court does so today. But the Court does not express any opinion on the wisdom of the Affordable Care Act. Under the Constitution, that judgment is reserved to the people.”

Q. What do the four justices who opposed the ruling say in their joint dissenting opinion?

A. The majority opinion amounts to “vast judicial overreaching,” the dissenters say.

“The Court today decides to save a statute Congress did not write,” the dissenters write. “It rules that what the statute declares to be a requirement with a penalty is instead an option subject to a tax. And it changes the intentionally coercive sanction of a total cut-off of Medicaid funds to a supposedly noncoercive cut-off of only the incremental funds that the Act makes available…. It leaves the public and the States to expend vast sums of money on requirements that may or may not survive the necessary congressional revision.”

Q. How many times do the majority, concurring and dissenting opinions refer to “broccoli”?

A. 12. 

For more on the PPACA verdict and its impact on the industry, see:

 Industry Offers Mixed Reaction to PPACA Decision

Could HHS Be Default Healthcare Regulator in Half the Country?

PPACA Decision: The PDF, with Interesting Parts Highlighted


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