Landmark decision on healthcare
The federal health care law that already has expanded access to care and provided billions of dollars in benefits to Americans has survived its own complicated surgery at the hands of the Supreme Court.
Chief Justice John Roberts was the key vote for the majority in the 5-4 decision, which otherwise split along the court's familiar ideological fault line. And the decision itself was split regarding the key issues. The court rejected two of the administration's three principal arguments but the majority ultimately found that the key provision in question - the "individual mandate" - fell within Congress' constitutional authority.
The mandate requires people to purchase health insurance or pay a penalty for not doing so.
Most of the attention had focused on the Constitution's commerce clause, which gives Congress the power to regulate interstate commerce. The court found that Congress has the power to regulate existing commerce but not to compel people to engage in commerce by buying health insurance.
But, the majority found that Congress, as argued by the administration, has an undisputed ability to levy taxes.
"The Affordable Care Act's requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax. Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness," Chief Justice Roberts wrote.
Conservatives should embrace the ruling because it constitutes the "judicial restraint" that they favor. It confines itself to the constitutionality of the law rather than its policy implications which, as the chief justice noted, are the purview of the elected officials of the other branches.
The individual mandate also is a conservative idea. It long ago was promoted by conservative politicians and think tanks because they knew that it was the only way that insurers could cover costs for vastly expanded health care coverage.
In 2006, when he was governor of Massachusetts, Mitt Romney effusively praised that state's legislature for including an individual mandate in its health care law.
Medicaid provision killed
One of the key provisions of the law authorized the federal government to withhold all federal Medicaid funds from states that did not agree to expand Medicaid coverage - one of the law's key devices to expand coverage.
The court found, however, that the measure was unconstitutionally coercive. Federal authorities could offer additional funds for the additional coverage but could not withhold funds that were authorized for existing coverage.
Under the law the federal government would cover 100 percent of the expanded coverage until 2016 and then reduce that to 90 percent.
Many states, including Pennsylvania, are not likely to approve expanded Medicaid coverage, which will weaken the law's ability to expand coverage, even with the individual mandate.
So there is much more work to do to broaden access to and financial responsibility for health care. But that was true even before the Supreme Court case, because the law is but the first major step toward transformation of the nation's health care system.
Opponents say they will switch their focus to repealing the law. But doing so would eliminate its benefits that already have become standard: a ban on denied coverage due to pre-existing conditions; coverage of 6.6 million young people under their parents' policies to age 26; elimination of the Medicare drug plan "doughnut hole," saving $3.7 billion a year for older Americans; insurance premium rebates to 13 million subscribers by companies that spent excessively on administration rather than care; the end of lifetime coverage caps for legitimate illnesses; and mandatory coverage of preventive care measures that improve health and save money over the long term.
The ruling is a landmark decision on the scope and limits of congressional power, possibly the most significant since the 1930s rulings on FDR's New Deal legislation.
It's also a landmark that will help lead the United States to a less-fragmented, more accessible modern health care system.