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An Oncology Perspective on the Supreme Court’s Pending Decision Regarding the Affordable Care Act

An Oncology Perspective on the Supreme Court’s Pending Decision Regarding the Affordable Care Act


Beginning on March 26, 2012, the Supreme Court of the United States heard oral arguments regarding challenges to the recent federal health care reform legislation. The Court scheduled this unusually lengthy series of arguments to last for three days—a reflection of both the high stakes and the complexity of the legal issues involved. Whatever the Court ultimately decides, the outcome will have significant political and legal implications, as well as momentous practical consequences for virtually all stakeholders in the US health care system. In this article we provide a summary of the questions under consideration by the Supreme Court regarding the health care reform legislation, and we explore how the pending decision on this high-profile matter may impact the oncology community.

Steven K. Stranne, MD, JD1

The law faced obstacles from the outset. Congress engaged in a debate that was protracted and heated, even by its own standards. Due to razor-thin margins of support and an unexpected shift in party control of a single Senate seat partway through the legislative process, Congress enacted the reforms through two separate bills. The two laws, the Patient Protection and Affordable Care Act[1] and the Health Care and Education Reconciliation Act of 2010,[2] have become known collectively as the Affordable Care Act (ACA). Soon after President Obama signed the legislation into law in March 2010, opponents of the ACA began to challenge (and the Obama administration began to defend) the law’s validity in multiple federal courts throughout the United States. Following conflicting opinions issued by federal appellate courts in different parts of the country,[3,4] the Supreme Court agreed to hear the case. The Court is expected to issue its opinion in June.

Issues Before the Court

Matthew G. Halgren

As the justices discuss, draft, and negotiate their opinions, it is important to remember what some commentators in the press or otherwise seem to forget: the Court is not charged with deciding whether the ACA is good health care policy. Rather, the justices are contemplating whether the ACA falls within or outside the powers granted to Congress by the US Constitution, and there are a variety of considerations they must weigh as they form their conclusions.

General considerations

The Constitution delegates certain powers to the federal government while reserving all unspecified powers to the states or the people. If Congress passes a law falling outside its enumerated powers, the law can be challenged on the grounds that the federal government overstepped its authority. Most of the constitutional objections to the ACA have rested on this doctrine.

Due to the emphasis on precedent in our legal system, Supreme Court justices typically think about how other potential cases and scenarios would fare under the legal rationales on which they base their rulings. When deciding whether to allow a particular law to stand, the justices reflect on what other laws they might be required to uphold or strike down in order to consistently apply the Constitution. While considering the ACA, the justices may try to avoid hampering the Court’s ability to consider unforeseen questions that may implicate similar constitutional principles. They might seek to achieve this goal and build internal consensus by writing a narrow opinion resting upon a unique aspect of the case at hand, such as the nature of the health insurance market in the United States. However the justices navigate through the present case, they will certainly be keeping in mind whether and how their reasoning may be applied in the future.

Specific questions

The Court heard arguments on whether Congress has exceeded its powers with respect to two specific provisions of the ACA. One of these provisions is the law’s requirement that individuals maintain a minimum level of health insurance, which is often referred to as the “minimum coverage requirement” or the “individual mandate.” The other contested provision is the law’s expansion of eligibility and financial support for the Medicaid program, through which the federal government provides grants to state governments to help fund health insurance for the poor.

In defense of the law, the Obama administration contended that two powers delegated to Congress each provide sufficient authority for the minimum coverage requirement. Immediately preceding the minimum coverage requirement in the text of the ACA itself, Congress offered its own lengthy justification of why the Commerce Clause, which is a provision in the Constitution that delegates to Congress the power of regulating commerce among the states, authorizes this individual mandate. Although the precise meaning of the Commerce Clause is a subject of frequent debate, several justices noted that its powers do have limits. For example, Justice Antonin Scalia asked, “If the government can do this, what else can it not do?” and he wondered aloud whether the ACA’s supporters thought the government could force individuals to purchase broccoli. Seizing upon an aspect of the ACA that may make it unique, Justice Ruth Bader Ginsburg, later in the arguments, countered, “But the problem is … as much as they say, ‘Well, we are not in the market,’ ... [the uninsured] haven’t been able to meet the bill for cancer, and the rest of us end up paying because these people are getting cost-free health care.”[5]

In addition to the Commerce Clause, the administration argued, the Constitution’s Taxing and Spending Clause also gives Congress authority to enact the minimum coverage requirement and collect a penalty for noncompliance via federal income tax returns. The law’s opponents maintained that neither power could be invoked in this case.

The arguments in favor of the ACA’s Medicaid expansion relied on the Taxing and Spending Clause and also on the Appropriations Clause, both of which are generally regarded as giving Congress significant discretion in dictating how federal funds are spent. However, the Court has previously indicated that Congress may not use its spending power to unduly coerce the states. The ACA’s opponents argued that the Medicaid expansion is unconstitutionally coercive because it attaches new terms (ie, the requirement to cover more people) to substantial existing funds (ie, the grants the federal government already gives to the states for the original Medicaid program and its various pre-ACA expansions). Due to the size of the Medicaid program, the argument goes, the states have no real alternative but to continue participating in Medicaid under the ACA’s terms. The justices discussed many sides of this issue during the oral arguments. For example, Justice Elena Kagan stated, “It’s just a boatload of federal money for you to take and spend on poor people’s health care. It doesn’t sound coercive to me.” Meanwhile, Chief Justice John Roberts observed, “I don’t think you can deny that it’s a significant authority that we are giving the federal government to say, ‘You can take away everything if the States don’t buy into the next program.’”[6]

In addition to these two central questions, the Court also heard arguments on “severability,” addressing whether it must invalidate all or part of the ACA’s remaining provisions if it finds Congress exceeded its authority when enacting either of the provisions discussed above. In other words, the severability discussion concerns whether the Court would strike only the provision in question, only the provision in question plus some closely related provisions, or the entire ACA. The arguments on this issue mainly addressed the minimum coverage requirement and focused on the degree to which certain provisions of the ACA are linked with that provision and what Congress would have intended to occur if the provision were found unconstitutional. Congress often makes its intent regarding severability explicit, but it did not do so in the ACA.

It is also worth mentioning that the Court began its marathon of arguments by considering whether the Anti-Injunction Act of 1867 bars the Court from ruling on the constitutionality of the minimum coverage requirement before its tax-related penalties will first be levied in 2015. The Anti-Injunction Act generally prohibits courts from hearing a challenge to a tax before the tax has been paid. It would certainly be anticlimactic to postpone a decision on the minimum coverage requirement for several years, and most analysts expect the Court will find that the Anti-Injunction Act does not apply in this case.


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