The current issue of New England Journal of Medicine includes a perspective on the legal challenges to the Affordable Care Act (ACA). Rosenbaum and Gruber convincingly argue that the ACA should survive these pending cases.
the fight is over whether the individual mandate to purchase health insurance (or pay a tax) is about regulating individuals’ economic conduct or regulating their noneconomic status. Depending on which characterization of the facts prevails, the individual mandate either falls within or lies outside Congress’s power to act.
The constitution and judicial precedent grant congress wide authority to regulate economic behavior via the Commerce Clause, but limited power to regulate other behaviors. They discuss a 2005 decision in Gonzalez v. Raich in which the US Supreme Court declared growing marijuana an economic activity, given the "established and lucrative interstate market." They contrast this case with two involving gun possession on school grounds and domestic violence. Both conditions had secondary economic consequences, but were deemed to primarily involve other behaviors. Gun possession and domestic violence were thus outside the realm of Congress.
So how can the ACA be seen through these lenses? The plaintiffs frame the ACA as "a law about status (being uninsured) rather than about economic activity." The US government argues that the law is economic in nature:
the U.S. Department of Justice argues that the ACA is a quintessential economic regulatory effort because it addresses the when and how of paying for health care (a market commodity that almost all Americans will purchase at some point, either because they plan to or because of an unforeseen event). In its argument, the Justice Department lays out the congressional findings that undergird the ACA, which highlight the economic imperative of health care reform in order to save a health care system that is fundamentally failing the tens of millions of Americans who are either uninsured or faced with purchasing insurance in a dysfunctional insurance market.
They then review some facts about US healthcare:
- Accounts for 17.5% of US GDP
- Uninsured consume $50 billion in uncompensated care which must be passed on to insured people
- Medical debt is a leading cause of bankruptcy in the US
- Lack of health insurance can reduce worker productivity
- Fear of loss of insurance keeps many workers tied to jobs they dislike
The authors conclude, correctly, that the ACA, at its heart, is an economic law:
In the end, the ACA is all about altering individual economic conduct, and its importance lies in the way it changes the when and how of health care purchasing. By ensuring access to affordable coverage for most Americans, the law seeks to rationalize our economic behavior while providing the regulatory and subsidization tools to make this rationalization possible. To characterize the ACA as a law aimed at anything other than individual economic conduct is to fundamentally miss the point of the legislation.
This article presents an understandable and succinct summary of one of the major judicial issues facing the ACA. I recommend you click a link (here it is again) and read the entire piece.
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