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    Challenging Health Care Reform

    Your Guide to the U.S. Supreme Court Hearings.

    On March 26-28, the Supreme Court will hear several challenges to the health care reform law, also known as the Affordable Care Act. To make its decisions - with a ruling expected in June - the court will focus on four key issues. Click on each icon to learn about the questions and what each outcome may be.

    Can we be required to buy health insurance?

    The centerpiece of the health care reform law is the individual mandate. It requires that all people have health insurance in 2014, either through their employer, the government, or on their own. Those who don't will face penalties, unless they fall below a certain income level.

    The mandate is needed to provide health care for all. Bringing healthy people into the market will keep medical and insurance costs down.

    The mandate is unconstitutional. Congress does not have the power to force us to buy insurance

    What the court will consider:

    Under the commerce clause of the Constitution, Congress has the power to regulate industries, such as health care, that affect people in multiple states. But does that power give Congress the legal authority to require an individual to buy a private product or service, or levy a fine for not doing so?

    Could the court delay its decision?

    Yes. It gets back to the penalty for not buying insurance. Here's why: If you do not purchase health insurance in 2014, you would pay a penalty when you file federal income taxes. Does this make the penalty a tax?

    What the court will consider:

    A law called the Anti-Injunction Act says a tax can't be legally challenged until it is paid. If the court decides the penalty is a tax, it would have to delay its decision until someone is actually forced to pay the tax.

    Can the entire law be overturned?

    Yes. But if the court decides that the mandate is constitutional, then the law stays in place. If the court rules that the mandate is unconstitutional, it must then decide whether the rest of the law's multiple provisions can stand on their own. In other words, should the mandate be separated from the rest of the law?

    Mandate Cannot Be Separated

    If the court makes this ruling, several things could happen:
    • Changes from the law would be stopped and provisions already in place eliminated, overturning the law.
    • The court could throw out parts of the law dependent on the mandate, but not the entire law.
    • The court could send it back to the lower courts to determine what parts of the law should stay or go.

    Mandate Can Be Separated

    If the court makes this ruling, several things could happen:
    • Other parts of the law would stay in effect or go into effect as planned.
    • Policy makers would look for other ways to encourage people to buy insurance.
    • The insurance industry could fight back, saying it cannot provide affordable health care coverage without the mandates.

    Can states be forced to insure the poor?

    The health reform law will require millions of additional Americans to be covered under Medicaid. This group includes those under 65 below a certain income level (currently $14,484 for an individual). States that do not participate in the Medicaid expansion risk losing federal Medicaid funds.

    Congress is allowed to attach conditions to its funding as part of the "Spending Clause" law.

    Because Medicaid funds are so important to the states, forcing states to increase their coverage in order to get these funds is "coercive" and should not be allowed.

    What the court will consider:

    If the court finds this part of the law constitutional, it will continue as planned.

    If the court finds it unconstitutional, several outcomes could occur:

    • It would open the door for states to sue in other areas attached to federal funding, such as civil rights, education, and national security.
    • The courts would have to decide whether the Medicaid expansion can be separated from the rest of the law.
    • Expansion of health coverage to the poor would not happen.


    1. The Henry J. Kaiser Health Foundation, "A Guide to the Supreme Court's Review of the 2010 Health Care Reform Law."
    2. Commonwealth: "Supreme Court Leaves the Doors Open with Health Care Lawsuit Order."
    3. Bob Laszewski, healthcare consultant, Health Policy and Strategy Associates, Inc.
    4. Herring, B. New England Journal of Medicine, March 10, 2011.

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