Supreme Court: Mandate Stands

— WASHINGTON -- The Supreme Court has upheld the constitutionality of Obama's landmark Affordable Care Act (ACA).

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Reactions to ACA Ruling Largely Predictable14:29 p.m. ET
Romney Says 'Repeal & Replace ACA'12:49 p.m. ET
Roberts Swing Vote on ACA12:28 p.m. ET
Supreme Court Upholds Healthcare Law10:48 a.m. ET

10:16 a.m. ET
WASHINGTON -- The Supreme Court ruled today that the Affordable Care Act's requirement that everyone have health insurance is constitutional. Rulings on whether other parts of the law can stand are expected shortly.

Updated: 10:27 a.m. ET
By a 5 to 4 vote, the Supreme Court has ruled that the Affordable Care Act -- including the individual mandate requiring everyone to have health insurance -- is constitutional.

Supreme Court Upholds Healthcare Law

Updated: 10:48 a.m. ET
WASHINGTON -- In a big win for the Obama administration, the Supreme Court has ruled that the landmark Affordable Care Act (ACA) is constitutional.

By a 5-4 vote, the court ruled that the law's controversial individual mandate -- which requires nearly everyone to have health insurance -- is constitutional. "The individual mandate may be upheld as within Congress's power under the Taxing Clause," Chief Justice John Roberts said.

The much-anticipated 193-page ruling was handed down Thursday morning.

The court notably took a stance that no lower court did: that the law's requirement that everyone have insurance is a tax. Both the Obama administration and the 26 states suing the federal government argued that the mandate is a penalty, not a tax.

Even though the mandate is a tax, the court decided that an old tax law called the Anti-Injunction Act does not apply. If law had applied, the court wouldn't have been able to rule on the law until 2015.

The court also, for the most part, upheld the ACA's expansion of Medicaid to cover nearly all people under age 65 with household incomes at or below 133% of the federal poverty level. That provision is set to go into effect in 2014.

However, the court struck down the provision that gives the Secretary of Health and Human Services the authority to penalize states for not complying with the Medicaid expansion, something that many states considered too onerous.

Roberts Swing Vote on ACA

Updated: 12:28 p.m. ET
WASHINGTON -- Almost as big a story as the win for the Obama administration on the Affordable Care Act (ACA) is the fact that conservative Chief Justice John Roberts cast the deciding vote.

The much-anticipated 193-page ruling was handed down Thursday morning. In addition to Roberts, Justices Ruth Bader Ginsburg, Stephen Breyer, Sonya Sotomayor, and Elena Kagan voted in favor of the mandate. Justices Antonin Scalia, Anthony Kennedy, Clarence Thomas, and Samuel Alito dissented.

The court notably took a stance that no lower court has taken -- that the law's requirement that everyone have insurance is a tax. Both the Obama administration and the 26 states suing the federal government argued that the mandate is a penalty, not a tax.

The Obama administration's argument hinged on the Commerce Clause, which allows the government to regulate commerce between the states. The administration argued that U.S. citizens can never truly stay out of the commerce of healthcare because, at some point, everyone is going to need medical treatment. Thus, not purchasing insurance affects the stream of commerce because if a person doesn't have health insurance and must get medical care, others might absorb the cost of the care in the form of higher premiums.

Opponents argued that the federal government cannot penalize citizens for not participating in commerce.

The scene in the courtroom played out like a boxing match: first, the mandate appeared to be down as Chief Justice John Roberts eviscerated the argument that it was constitutional under the Commerce clause.

"Congress has never before attempted to use the Commerce Clause to regulate inactivity, and nothing in the Constitution suggests it can," he said. "Congress already enjoys vast power to regulate what we do. Accepting this theory would allow Congress to regulate what we do not do. The distinction between doing something and doing nothing would not be lost on the framers [of the Constitution] and there is no reason to depart from it now."

But then the outlook for the mandate grew brighter as the Chief Justice said that the mandate's imposition of a penalty on those who did not purchase insurance was acceptable under Congress' power to levy a tax, as specified by the Constitution.

"This payment certainly looks like a tax," he said. "It is applied to taxpayers and must be included when they file their [tax] returns ... The amount of the payment also suggests it is a tax. The payment is calibrated to taxpayers' income and is never higher than the cost of buying insurance."

The Chief Justice noted that while Congress cannot regulate inactivity under the Commerce clause, there is nothing stopping it from taxing inactivity.

Roberts explained that under the Supreme Court's own precedent, "if there are two possible interpretations [of a law] and one interpretation violates the Constitution, we should adopt the other one allowing it to be upheld," so the mandate is upheld under the taxation argument.

Even though the mandate is being considered a tax, the court decided not to apply a tax law called the Anti-Injunction Act, which would have forced the justices to put off a ruling on the law until after 2014, when the penalties would actually have gone in to effect and there would presumably been some people who would have had to pay them.

The court also upheld the ACA's expansion of Medicaid to cover nearly all people under age 65 with household incomes at or below 133% of the federal poverty level. That provision is also set to go into effect in 2014.

However, the court struck down the provision that gives the Secretary of Health and Human Services (HHS) the authority to penalize states financially -- by withholding federal Medicaid matching funds -- for not complying with the Medicaid expansion, something that many states considered too onerous.

"The threatened loss of over 10% of a states' overall budget is economic dragooning that leaves the states with no real option but to acquiesce in the Medicaid expansion," Roberts wrote.

He went on to say that the "constitutional violation is fully remedied" by preventing the HHS secretary from being able to withdraw existing Medicaid funds for "failure to comply with the requirements set out in the expansion."

Leaving the financial penalty in would be "a gun to the head," Roberts said from the bench.

Justices Ruth Bader Ginsburg and Sonya Sotomayor dissented from the other justices on that issue. They thought the secretary could withhold funds from states who don't want to participate in the Medicaid expansion.

"Congress can and often does expand programs, adding new conditions states must meet before receiving funds," Justice Ginsburg said from the bench.

In a dissenting opinion arguing that the ACA should be struck down entirely, Justice Kennedy noted that striking down the Medicaid expansion while leaving the mandate intact will create problems.

The ability of states to refuse to accept the Medicaid expansion may be an illusion, he said, "because, even if a state elects not to accept the expansion, its citizens are still subject to the individual mandate. ... But now in the states the cost of the insurance that must be purchased may well be far higher, for insurance companies have no Medicaid expansion to help defray the cost of insuring unhealthy individuals at unprofitable rates."

Less than an hour after the decision was handed down, House Majority Leader Eric Cantor reportedly said the House would vote on a full repeal of the ACA on July 11.

Romney Says 'Repeal & Replace ACA'

Updated: 12:49 p.m. ET
WASHINGTON -- "If we want to get rid of Obamacare, we are going to have to replace President Obama," Republican presidential candidate Mitt Romney said Thursday following the Supreme Court decision that lets the Affordable Care Act stand.

Reactions to ACA Ruling Largely Predictable

Updated: 14:29 p.m. ET
WASHINGTON -- President Obama and Republican presidential candidate Mitt Romney wasted no time responding to Thursday's Supreme Court ruling that largely upheld the Affordable Care Act (ACA).

Romney was first to publicly respond. He blasted the Supreme Court decision and vowed to overturn the law if voters elect him to the White House in November. "If we want to get rid of Obamacare, we are going to have to replace President Obama," Romney said

"What the court did not do on its last day, I will do on my first day as President of the United States," he said, speaking from near the U.S. Capitol. "That is, I will act to repeal Obamacare."

However, Romney said he would keep some "essential" parts of the law, including preventing insurers from denying coverage on the basis of a preexisting medical condition.

The court, Romney emphasized, "did not say [ACA] is good law, or good policy."

When Obama spoke shortly after, from the White House, he called the ruling a "victory for people all over this country."

Obama said it is clear that he didn't push for healthcare reform "because it was good politics; I did it because I believed it was good for the country."

He highlighted the parts of the law that the administration has touted since the beginning: that insurance will be more secure and affordable, insurers won't be allowed to charge sky-high premiums, or deny coverage for the sick.

"What we won't do is go back and refight the battles of 2 years ago," he said.

But part of the battle will be fought again, at least symbolically. House Majority Leader Eric Cantor (R-Va.) announced just hours after the Supreme Court decision that the House would vote on July 11 to repeal the entire ACA.

That move was not greeted with open arms by the Democrats. "Take Yes for an answer, and let's move forward," was the response of House Minority Leader Nancy Pelosi (D-Calif.).

Pelosi said she contacted the widow of Ted Kennedy, who was a longtime champion for healthcare reform until his death in 2009.

"Now he can rest in peace," Pelosi said. "His dream for American families has become a reality."

At a Republican press conference later on Thursday, Rep. Nan Hayworth (R-N.Y.), an ophthalmologist, said that her colleagues tell her that "they are very concerned about their ability to deliver the care their patients deserve ... under the terms of this law."

"We're here to honor the goals of [the ACA]," including affordable care for all Americans, "but this is the wrong law," she continued. "We are here to put patients at the center of healthcare, not the federal government."

House Speaker John Boehner (R-Ohio) said at the press conference that the court's decision "underscores the urgency of repealing this harmful law in its entirely. Americans want a step-by-step approach to healthcare reform that [ensures] they'll get the care they need from the doctor they choose, at a lower cost."

Physician groups were largely pleased with the high court's ruling -- or at least that there was a ruling.

Jeremy Lazarus, MD, president of the American Medical Association, a group which has supported the ACA from the beginning, said the group is pleased with the court's ruling.

"The expanded healthcare coverage upheld by the Supreme Court will allow patients to see their doctors earlier rather than waiting for treatment until they are sicker and care is more expensive," Lazarus said in a statement. "The decision upholds funding for important research on the effectiveness of drugs and treatments and protects expanded coverage for prevention and wellness care, which has already benefited about 54 million Americans."

The American College of Physicians (ACP), which never took a firm position on the ACA, said that the individual mandate, combined with the ACA's subsidies to help low-income people buy insurance, the Medicaid expansion, and insurance industry changes, will "expand coverage to nearly all Americans."

"We are pleased that the Supreme Court's ruling resolves the legal questions so that these and other reforms can go forward," ACP president David Bronson, MD, said in a statement.

"We hope that a day will come when the debate will no longer be polarized between repeal on one hand, or keeping the law exactly as it is on the other, but on preserving all of the good things that it does while making needed improvements," Bronson said.

American Heart Association CEO Nancy Brown said the law will "benefit America's heart health for decades to come."

"Questions about the Affordable Care Act's constitutionality have overshadowed the law's progress," she said in a statement. "With this ruling, that uncertainty has finally been put to rest."