Challenging the Affordable Care Act: Consequences and Concerns

The fate of the Obama administration’s signature health care legislation, the Affordable Care Act (ACA), hangs in the balance as the Supreme Court deliberates upon its fate. The court is due to deliver its opinion of this comprehensive health care package this month.1 The individual mandate, which requires every individual to either buy health insurance or pay a fine, lies at the heart of the controversy.

The decision may forever memorialize the ACA case as a landmark decision for federalism, ruling on the boundaries and scope of Congress’s actions. Alternatively, the decision could result in an anticlimactic technicality. On the grounds of the Anti-Injunction Act (AIA), the Court may take the easy way out by ruling that the penalty for the individual mandate functions as a tax, and that its constitutionality can only be challenged once the tax is in effect in 2014.2 However, if the Court decides that this gateway issue is not applicable, they must directly confront the central conflicts of the ACA.

Challengers have framed the ACA as an overreach of federal power that violates state sovereignty, both through the individual mandate and the expansion of Medicaid. Although Medicaid has been expanded several times in the last 46 years and never deemed unconstitutional, the states deem this expansion as “unduly coercive.”3 Another central question is if inactivity, or refusing to buy health insurance, can be regulated as interstate commerce. The challengers argued that the individual mandate sets a precedent for a dangerous slippery slope. If health care insurance can be mandated by the federal government, then why not the consumption of broccoli or burial insurance?4 While the slippery slope arguments strike distinctly of a strict adherence to formalism, and appear to disregard the context of the mandates in question and their relative impacts, it brings to the fore the question of the extent of federal power and how to impose appropriate limits.

After 6 hours of oral arguments in March, the Court is only one or two weeks away from releasing its decision. One of the main questions remains — if the individual mandate is struck down, will the remainder of the ACA remain or fall as well? The challengers contend that the entire bill should be thrown out as unconstitutional; anything less would strike as legislating from the bench by cherry-picking provisions. A popular sentiment in the public is to strike down the mandate while maintaining consumer protections, such as stopping discrimination of individuals with pre-existing conditions. However, the consumer protections afforded by the ACA are only affordable if offset by the individual mandate, making the popular half of the act inoperable without the other. In fact, even the federal government, represented by Edward Kneedler, argued that the popular pre-existing condition protection would have to be removed if the individual mandate was rejected, as it would cause insurance prices to rapidly spiral up. The rest of the act however, he argued, should be kept in place.5

Should the ACA be struck down, it will have extreme and reverberating implications. Although the individual mandate comes into play starting from 2014, several provisions have already been implemented as of 2010. Among them, the ACA has eliminated co-pays for preventative services, allowed children to stay on their parents’ insurance until the age of 26, and stopped the denial of insurance to children with pre-existing conditions. However, one of the largest victims will be the Pre-Existing Condition Insurance Plan (PCIP) which covers critically ill patients who have been denied insurance by other companies because of pre-existing conditions. The program is meant to act as a temporary stopgap until the ACA comes into full effect in 2014 and insurers will be required to accept all applicants. The PCIP has offered life-saving healthcare to patients with cancer, AIDS, and other critical illnesses.6 The Obama administration fully expects that the ACA will be upheld and has not made any contingency plans in case it is overturned.7

The political implications of the decision are also guaranteed to be momentous.  A favorable outcome may simultaneously reaffirm the Obama administration’s success in passing a comprehensive health care package while reenergizing the Republicans for the general election. Yet given Mitt Romney’s complex relationship with health care reform, especially in his home state of Massachusetts where he signed a similar individual mandate into law, the amount of political leverage he can gain from the Court’s decision is questionable and remains to be seen. In fact the GOP may be put on the defensive if the entire act is struck down, along with its widely popular provisions. It will be torn between attempting to mitigate the effects of an overturn of health care reform legislation and keeping consistent with calls from its base to entirely repeal ‘Obamacare.’8 On the other hand, an overturning of the legislation would be a harsh blow to the Obama administration, depriving Obama of his signature achievement before the upcoming election. Yet, the decision may simultaneously deflate the Republicans if the Court throws out the ACA and resolves ‘Obamacare’ by itself.

Regardless of the direction or the scope of the decision, the ruling on the ACA will have an enormous impact – legally, physically, and politically. All that remains is to wait and see what the health-related future of this country holds.


  1. Carlson, Kathleen. “Ready to React to ‘Obamacare’ Ruling.” Nashville Ledger Newspaper. Last modified May 17, 2012. Accessed on May 19, 2012.
  2. Jones, David K. “The Fate of Health Care Reform — What to Expect in 2012.” The New England Journal of Medicine. Last modified January 26, 2012. Accessed on May 19, 2012.
  3. Goldman, T.R. “Health Reform Gets Its Day In Court–The Supreme One.” Health Affairs 31, no. 1 (2012): 8-11. Accessed on May 19, 2012.
  4. Sacks, Mike. “Supreme Court Health Care Law: Justices Come Down Hard On The Mandate.” The Huffington Post., Last modified March 27, 2012. Accessed on May 19, 2012.
  5. Simon, Ammon. “Summary of the Supreme Court Health-Care Oral Arguments – By Ammon Simon – Bench Memos – National Review Online.” National Review Online. Last modified March 23, 2012. Accessed on May 19, 2012.
  6. “Fate of ‘uninsurables’ Hinges on Supreme Court.” New York Daily News. Last modified May 18, 2012. Accessed on May 19, 2012.
  7. Lavelle, Janet. “Millions Await Supreme Court Ruling on Health Law.” U-T San Diego. Last modified May 2, 2012. Accessed on May 19, 2012.
  8. Beautler, Brian. “Why An Adverse Supreme Court ‘Obamacare’ Ruling Puts Republicans In A Tough Spot.” TPM. Last modified May 17, 2012. Accessed on May 19, 2012.
  9. Image credit (Creative Commons): kenudigit. “US Supreme Court Court Room.” Flickr. Last modified October 4, 2010.

Arifeen Rahman recently graduated from Saint Francis High School in Mountain View, California. Follow The Triple Helix Online on Twitter and join us on Facebook.