NEJM: PPACA extends the gov't's reach in healthcare decision-making

The Supreme Court’s Patient Protection and Affordable Care Act (PPACA) decision, ruling the individual mandate constitutional under Congress’ taxing power and forced Medicaid expansion unconstitutional under Congress’ spending power, expands the federal government’s ability to regulate individual behavior while testing its ability to shape national policy through conditions attached to federal dollars sent to states, according to a July 18 New England Journal of Medicine article.  

“The broad significance of this case can be found in the justices’ views of the proper roles of the state and federal governments and not just in what they ruled about the PPACA themselves,” wrote the Boston University School of Public Health’s Wendy K. Mariner, JD, MPH, Leonard H. Glantz, JD, and George J. Annas, JD, MPH.

In the months leading up to the Supreme Court’s ruling, the mandate’s opponents argued that, if found constitutional according to Congress’ ability to regulate interstate commerce through the commerce clause, then Congress would possess the implied power to force individual purchases of other items, such as broccoli. This argument seems to have influenced Chief Justice John Roberts’ majority opinion upholding the law. “The framers gave Congress the power to regulate commerce, not compel it,” he wrote.

While Roberts joined Justices Ruth Bader Ginsburg, Stephen Breyer, Sonia Sotomayer and Elena Kagan in ruling the mandate constitutional, the latter four believed the unique market for healthcare allowed Congress to compel the purchase of health insurance through the commerce clause. Roberts, on the other hand, believed the PPACA’s wording of the future fine paid for noncompliance as a “penalty” did not differentiate it from a tax and allowed the mandate to stand under Congress’ taxing power.

However, allowing the mandate to stand under Congress’ taxing power as opposed to through the commerce clause still implies Congress’ ability to compel inactive consumers to purchase a product.

“The Court permits the federal government to influence individuals by taxing them for not having health insurance,” Mariner and her colleagues wrote. “This is now a constitutional way to regulate people who are doing nothing. It is also precisely the type of expansion of federal power that the chief justice said would redefine the relationship of the federal government to individuals.”

While the article’s authors seem to believe the court’s decision expands federal power over individuals, they seem to believe it decreases federal power over states. The most “unsettling,” “unexpected” result of the Supreme Court decision disallowed a PPACA provision that would deny all federal Medicaid funding to states that did not expand the program to include a new category of eligible recipients.

Congress’ spending authority allows it to indirectly guide national policy where it is not specifically allowed by the Constitution. For instance, Congress cannot set a national minimum drinking age, but it can withhold full federal highway funding to states that set a minimum drinking age below 21. A federal court never limited the federal government’s ability to attach conditions to federal funding until the PPACA decision, which found the law’s Medicaid expansion requirement “coercive.”

“It is remarkable that the court could conclude that states have no choice but to accept the new Medicaid conditions with their Medicaid funding,” the article’s authors wrote. “Although federal funding provides an incentive for states to participate in a federal program, it is hardly a ‘gun to the head,’ as the chief justice called it... Because so many federally funded health, education and housing programs depend on the use of the conditional spending power, this ruling may encourage opponents of these programs to challenge new conditions in court.”

The Supreme Court’s PPACA decision creates far reaching implications for future formulations of power balances between individuals and the federal government and states and the federal government, but it does not actually chisel the PPACA’s contents into law for the long term.

“The immediate effect is to return the constitutionally blessed PPACA to the political realm,” the authors concluded. “It is now up to Congress, the individual states and especially the next president to determine the fate of the PPACA. Because the case was decided by the vote of a single justice, however, the fate of federal involvement in healthcare may also depend on the views of the next justice appointed to the court.”