The United States Supreme Court decision in National Federation of Independent Business v. Sebelius, upheld the Affordable Care Act. The case promotes health equity in all policies. A 5-4 majority of the Court upheld the individual mandate under the taxing power. A different 5-4 majority struck down the mandate under the Commerce Clause. In essence, the Court held Congress does not have the power to require people to buy insurance under the Commerce Clause, but does have the power to tax people who do not buy insurance. This ruling clears the way for the ACA to advance long-standing efforts to reduce racial and ethnic disparities in access to healthcare, and to broaden access to healthcare for millions of Americans.
In addition, a 7-2 majority limited Medicaid expansion. States can opt out of the expansion. The United States cannot threaten a state with loss of existing Medicaid funding if the state declines to comply with expansion.
Chief Justice Roberts was the swing vote on the individual mandate and wrote the majority opinion. Justices Ginsburg, Breyer, Kagan, and Sotomayor joined Chief Justice Roberts in the 5-4 majority on the individual mandate under the taxing power.
Chief Justice Roberts with Justices Breyer and Kagan voted to limit Medicaid expansion. With the four dissenting justices, that results in a 7-2 majority to limit expansion. Justices Ginsburg and Sotomayor voted to uphold Medicaid expansion.
Four justices would have struck down the Act including Medicaid expansion under both the tax power and the Commerce Clause (Scalia, Kennedy, Alito and Thomas).
Under the 5-4 taxing power and 7-2 Medicaid majorities, the other parts of the Act remain in effect. This includes the provisions on guaranteed issue, community rating, no rescinding coverage, no lifetime limits, preventive care at no cost, state exchanges, employer mandate, pre-existing condition coverage, coverage for young adults, Medicare prescription drug discounts, tax credits for individuals, tax credits for small businesses, and community health centers.
The case is almost 200 pages long. There are four opinions. The attached ACA vote count breaks down the different opinions and the individual votes. The chart is subject to change based on continued review of the various opinions.
Click here for the LCHE report on Latino Policy Priorities for an Effective & Equitable Health Benefit Exchange in California.
Robert Garcia, Founding Director and Counsel, The City Project, and LCHC Board Member