WASHINGTON – The U.S. Supreme Court on Thursday upheld most of President Obama's signature health care reform law, including its controversial requirement that all Americans buy medical insurance, thereby throwing the hugely divisive issue back to the people in the November election.
After a 5-4 court majority led by Chief Justice John G. Roberts Jr. upheld most provisions of the law, President Obama said the court had ensured that health care in America would be more available and more affordable.
"Whatever the politics, today's decision was a victory for people all over this country whose lives will be more secure because of this law and the Supreme Court's decision to uphold it," the president said.
Meanwhile, Obama's presumptive rival in the November election, Republican Mitt Romney, vowed to work to repeal the health reform legislation.
"Obamacare was bad policy yesterday; it's bad policy today," Romney said. "Obamacare was bad law yesterday; it's bad law ?today."
Repeal will be difficult, though, unless Republicans were to elect Romney and gain a supermajority of 60 members in the U.S. Senate, which is far beyond what most Washington political pundits say is likely in this year's election.
That being the case, Thursday's court decision is likely to have long-lasting impact.
The court said that the "individual mandate" requiring people to buy health insurance is constitutional even though the clause of the Constitution giving the federal government the right to regulate interstate commerce does not give Congress the power to force the American people to buy a product they may not want.
The mandate stands because the court majority said Congress' taxing power gives lawmakers the right to impose a penalty upon those who do not buy health insurance.
"It is reasonable to construe what Congress has done as increasing taxes on those who have a certain amount of income, but choose to go without health insurance," wrote Roberts, who joined the court's four liberals in upholding most of the health law. "Such legislation is within Congress's power to tax."
At the same time, the justices overturned a provision of the 2010 health law that forces states to expand their Medicaid programs or else lose all their Medicaid funding. The Medicaid expansion can go forward, but without states having to face that draconian penalty, the court said.
"Congress has no authority to order the states to regulate according to its instructions," Roberts wrote.
Just as the health care law has divided the American public for nearly three years, it divided the court as well, with the court's most conservative members arguing that the decision opens the door to an expansion of federal power.
"The values that should have determined our course today are caution, minimalism and the understanding that the federal government is one of limited powers," Justices Anthony Kennedy, Antonin Scalia, Clarence Thomas and Samuel Alito said in a joint dissent. "But the court's ruling undermines those values at every turn."
While upending the Medicaid expansion, the court left the rest of the health law standing.
And it dismissed out of hand the contention that the high court debate on the health care issue was premature.
Those decisions are likely to be overshadowed, though, by a landmark ruling that endorses a broad reading of the congressional power to tax.
Many legal experts thought the future of the individual mandate hinged on the Constitution's Commerce Clause, which gives Congress the right to regulate interstate commerce. The Commerce Clause issue dominated the March oral arguments in the health care cases, while the tax issue received comparatively little attention.
But in Thursday's ruling, the taxing power came front and center – while the court put new limits on the scope of the Commerce Clause.
The tax in question is the penalty Americans will have to pay if they ?don't have health insurance starting in 2014.
The Obama administration has resisted calling that penalty a tax, but to the court majority, that's clearly what it is.
"Although the payment will raise considerable revenue, it is plainly designed to expand health insurance coverage," Roberts wrote. "But taxes that seek to influence conduct are nothing new."
As for the Commerce Clause, though, the court majority said it's not broad enough to allow Congress to force Americans to buy a product – in effect creating commerce rather than regulating it.
"The power to regulate commerce presupposes the existence of commercial activity to be regulated," Roberts wrote. "If the power to ‘regulate' something included the power to create it, many of the provisions in the Constitution would be superfluous."
Far apart from the legal arguments, the ruling will have profound implications on health care in America.
The Patient Protection and Affordable Care Act, which was passed by a narrow congressional majority in March 2010, remakes the health care system based on the so-called "individual mandate," which now – with the Supreme Court's approval – will force the nation's 30 million uninsured by acquire health insurance by 2014.
By forcing younger, healthy people into the health care system, Congress bet that insurance companies would be able to afford what otherwise would be costly mandates.
Most notably, the bill prevents insurers from discriminating against people on the basis of pre-existing medical conditions. And it forces every state to create a health insurance "exchange": essentially a regulated marketplace where consumers could compare plans and shop for insurance.
Those provisions of the bill will now go forward, as will provisions allowing people to keep their children on their health policies until the age of 26 and creating a series of incentives aimed at encouraging businesses to offer health insurance.
And the money-raiser behind so much of the bill, the individual mandate, remains, despite criticism of it from four of the nine justices at the oral arguments on the health care cases in March.
Experts predicted much higher health care costs if the Supreme Court had upended the individual mandate. The nonpartisan Congressional Budget Office, for example, predicted the cost of health insurance could increase between 15 and 20 percent if young people were not forced to buy policies while insurance companies were forced to sell policies to the sick and the aging.
Nevertheless, polls have showed the individual mandate to be deeply unpopular – meaning the battle over the health law is likely to continue in political circles.
In the highest court of the land, though, the matter is settled, albeit divisively.
In addition to the stinging dissent from Kennedy and the court's three most conservative justices, the court's four liberals joined together to say they would have upheld the individual mandate under the Commerce Clause, as well as the Medicaid expansion.
Justice Ruth Bader Ginsburg wrote in a dissent that the majority's ruling on those matters would have consequences far beyond health care.
"In the end," she said, "the Affordable Care Act survives largely unscathed. But the court's commerce and spending clause jurisprudence has been set awry."
Most immediately, though, the high court let stand what is most likely the most broad-ranging federal health law in history.
And it did so, Roberts said, out of deference to the power of Congress to levy taxes and set policy.
"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," the chief justice wrote. "Those ?decisions are entrusted to our nation's elected leaders, who can be thrown out ?of office if the people disagree with them."?