WASHINGTON – The US Supreme Court Thursday upheld President Obama’s national health care law, including its requirement that most Americans obtain insurance, handing the president a major victory and setting battle lines on the contentious issue for the 2012 election.
The 5-to-4 ruling — with conservative Chief Justice John G. Roberts Jr. the unexpected swing vote — reaffirms the most ambitious and controversial undertaking of Obama’s first term: attempting to guarantee that most of the 45 million Americans without insurance will get better access to medical care.
Demonstrators supporting the health care law exploded in cheers outside the Supreme Court as news of the ruling emerged Thursday morning, and supporters and advocates celebrated across the country.
“I was jumping around school today,” said cancer patient Gail O’Brien, a 53-year-old New Hampshire mother and preschool teacher in summer camp who enrolled in a high-risk insurance pool set up by the law. “If you saw me, you would have thought I was crazy. It’s the best news.”
But even as Obama and Democrats rejoiced, determined Republicans in Congress vowed to redouble their efforts to legislatively repeal the measure.
“The court’s ruling doesn’t mark the end of the debate. It marks a fresh start on the road to repeal,’’ declared Senate minority leader Mitch McConnell of Kentucky.
To have a realistic chance of repeal, opponents in November will have to eject Obama from the White House and replace him with presumptive GOP nominee Mitt Romney, seize a majority in the Senate, and retain their majority in the House.
The justices specifically rejected an endorsement of broad new government powers under the constitution. Instead, ruling more narrowly, they said Congress acted within its authority to impose an “individual mandate’’ as a form of taxing power. Under the law, individuals who fail to obtain insurance will be required to pay a tax penalty. The requirement begins in 2014.
Chief Justice Roberts, an appointee of President George W. Bush, often has sided with the court’s conservatives in close cases, but this time he sided with the more liberal wing. There is some irony in the turn of events. As a US senator in 2005, Obama voted against Roberts’s confirmation. Now Roberts has handed Obama one of the biggest victories of his political life.
The president’s win was not altogether complete. The court struck down the ability of the federal government to deny Medicaid funds to states that refuse to participate in a massive expansion of the Medicaid program. Expanding Medicaid is supposed to extend coverage to 17 million people, representing more than half of the 30 million the law is supposed to help. But the court said the government could not strip states of Medicaid subsidies if they choose not to participate, calling it an excessively coercive intrusion on state autonomy.
The effect of that element, said specialists, is to make the Medicaid expansion optional for individual states. Twenty-six states participated in the Supreme Court challenge to the health care law, so a refusal to participate could be widespread.
“They pulled a few teeth in terms of the degree in which the law can assure Medicaid expansion at the state level,” said Donald Berwick, Obama’s former chief of Medicaid and Medicare and former head of the Cambridge-based Institute for Healthcare Improvement. “That is basically going to confront the states with a choice: do you want to leave people uncovered or take advantage of federal dollars? I would suspect most states are going to come to their senses and not leave poor people high and dry.”
Polls have shown a majority of Americans have not supported the benefits or costs of the complex law; a narrow majority continues to favor its total repeal. Even Obama has not campaigned aggressively on its passage in his 2012 reelection bid.
After the court ruling Thursday, the president defended the controversial individual mandate for the first time in weeks, explaining that when the uninsured seek care in emergency rooms or wait until they are sick to buy coverage, everyone else pays higher premiums. He also ticked off popular provisions that bar insurance companies from denying coverage for preexisting conditions and that require insurers to cover children in family plans until they are 26 years old. He sought to discourage another crippling, partisan tussle in Congress.
“What the country can’t afford to do is refight the political battles of two years ago, or go back to the way things were,” he said. “With today’s announcement, it’s time for us to move forward.”
Romney left little doubt that he would continue to attack the health law. “Obamacare was bad policy yesterday; it’s bad policy today,’’ Romney said. His attempts to find fault with the law will be complicated, however, by the fact that his health law in Massachusetts served as a model for the national plan. Romney has argued that what was good for Massachusetts is not suitable for the nation.
Stephen Ryan, head of the government strategies group in the Washington-based law firm of McDermott Will & Emery, said Roberts saved the court from being seen as a politicized body, a risk created by such decisions in the past 12 years as Bush v. Gore, which determined the winner of the 2000 presidential race, and Citizens United, which permitted unlimited political spending by corporations.
“This is the move of a great pol,” Ryan said. “He in effect has taken his branch of government out of being seen as having dumped something ugly in the punch bowl.”
The political costs of the 2010 health care bill have been extremely high to both the president and Democrats in Congress. It generated a conservative backlash that helped to spawn the Tea Party movement and helped Republicans win back the House in the 2010 midterm elections. The negative reaction also helped Massachusetts Republican Scott Brown seize the seat long held by Senator Edward M. Kennedy, who spent most of his career advocating for expanded health coverage and was a crucial backer of the Obama effort until his death in August 2009.
Suitably for a historic case, the justices said in their opinions that it turned on basic questions of federal power and checks and balances of the American system of government. Roberts, writing for the majority, began with a civics lesson about judicial restraint. It could be seen as a response to critics who have accused the court under his leadership of driving a conservative agenda.
“We do not consider whether the [health care] act embodies sound policies. That judgment is entrusted to the nation’s elected leaders,’’ said the court’s majority opinion. “We ask only whether Congress has the power under the Constitution to enact the challenged provisions.’’
And the court, it said, found that Congress did act within its power. Joining Roberts in the majority were Ruth Bader Ginsburg, Sonia Sotomayor, Elena Kagan, and Stephen G. Breyer.
But the four dissenting justices – Anthony Kennedy, Antonin Scalia, Samuel Alito, and Clarence Thomas – strongly disputed the majority’s reasoning. They said the court, by allowing the government to compel certain behavior, was authorizing an expansion of federal power without precedent. They said the entire law should have been thrown out.
“The act before us here exceeds federal power both in mandating the purchase of health insurance and in denying nonconsenting states all Medicaid funding,” the dissenting opinion said.
“The values that should have determined our course today are caution, minimalism, and the understanding that the federal government is one of limited powers. But the court’s ruling undermines those values at every turn,’’ they said. “In the name of restraint, it overreaches. In the name of constitutional avoidance, it creates new constitutional questions. In the name of cooperative federalism, it undermines state sovereignty.’’
The ruling did give conservatives a consolation prize. The majority rejected the government’s argument that the interstate commerce clause of the Constitution allows Congress to force consumers to take action in the health care marketplace. The court ruled that would have been an expansion of raw federal power that is prohibited by the Constitution. Instead, it upheld the individual mandate based on another argument the administration presented: the taxing powers of Congress. People who do not buy insurance under the mandate are subject to a penalty, payable to the IRS, which is not a novel concept.
Conservatives criticized the court’s maneuver, pointing out that Congress never called the mandate-and-penalty combination a form of tax, instead referring to it as a “penalty” and a “shared responsibility payment” to be collected by the IRS.