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Massachusetts Medical Society




The U.S. Supreme Court decision to uphold most of the Affordable Care Act (ACA), including the insurance-coverage requirement, allows historic reforms in the health care system to move forward. Because the justices were split four to four on whether the ACA was constitutional, Chief Justice John Roberts was able to write the lead opinion that commanded five votes for whatever outcome he determined was constitutional. The chief justice's leadership in upholding almost all of the ACA was unanticipated, as was much of his legal reasoning. It was widely assumed that the interpretation of the Commerce Clause by the Court would determine whether the Constitution authorized Congress to require individuals to purchase a product from private companies, something Congress had never done before and, therefore, something the Court had never considered.3,4 It was not surprising that the chief justice found no Commerce Clause authority for the individual mandate. The surprise was that he saved the individual mandate by determining that it was a constitutional tax. The chief justice received support for each of these conclusions from two different four-justice groups, sometimes referred to as the liberal and conservative wings of the Court. Perhaps most unexpected, seven justices voted to limit the power of the federal government to impose conditions on federal funding allocated to the states.


From The New England Journal of Medicine, Wendy K. Mariner, Leonard H. Glantz, and George J. Annas, Reframing Federalism — The Affordable Care Act (and Broccoli) in the Supreme Court, Volume 367, Page 1154 Copyright © (2012) Massachusetts Medical Society. Reprinted with permission.



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