Approximately 49 million nonelderly Americans are uninsured. Of those, approximately 20 percent have the financial means to buy health insurance but decide not to and instead rely on emergency care when necessary; the rest desire insurance but are denied coverage or cannot afford it. Even though uninsured, some individuals in the latter group receive medical services, resulting in approximately $43 billion worth of uncompensated care costs. These costs are recouped through higher charges for health care services, thereby producing a cost-shifting effect that results in higher premiums for those who are insured. This cost shift is...

On November 14, 2011 the United States Supreme Court agreed to hear oral arguments on issues that have arisen as a result of more than two dozen legal challenges to the Affordable Care Act (ACA) that were filed upon or immediately following the March 2010 enactment of the health reform law. The Court will consider four constitutional issues related to the ACA: (1) whether Congress has the power under Article I of the Constitution to enact the coverage requirement; (2) if the coverage requirement is found unconstitutional, whether it is severable from the remainder of the ACA; (3) whether the ACA’s requirement that states expand Medicaid eligibility or risk losing federal funds is unduly coercive in violation of the Tenth Amendment; and (4) whether the individual coverage requirement is a tax for purposes of the Anti-Injunction Act, meaning that plaintiffs seeking to challenge the requirement must wait until it takes effect in 2014. Oral arguments are set for March 26-28, 2012, and a decision is expected by the end of the Court’s term in late June of 2012.

On September 28, 2011, the United States Justice Department (DOJ) asked the United States Supreme Court to review the decision of the court of appeals for the Eleventh Circuit striking down as unconstitutional what the DOJ terms the law’s “minimum coverage provision.” In seeking Supreme Court intervention, the DOJ sought review on two matters: first, whether Congress exceeded its Commerce Clause powers, as enhanced by the Necessary and Proper Clause; and second, whether the Anti-Injunction Act bars the challenges from proceeding in the first place.

Since the enactment of the Affordable Care Act (ACA), at least 27 lawsuits have been filed challenging the constitutionality of various provisions of the law. While nearly half of the lawsuits have been dismissed on procedural grounds, three district courts have found provisions challenged to be constitutional, and three have found them to be unconstitutional. Previous HealthReform GPS Implementation briefs/updates have discussed these lower court decisions. Following appeals of each of these rulings, the United States Courts of Appeals in the Fourth, Sixth, and Eleventh Circuits have now issued decisions as well. Most importantly, the appellate decisions continue to reflect a split in judicial opinion regarding the constitutionality of the Affordable Care Act’s individual mandate. Other important issues addressed by the appellate rulings concerned the constitutionality of the ACA Medicaid expansion and the question of whether the trial court in the Virginia cases (Liberty University v. Geithner and Commonwealth of Virginia v. Sebelius) had the authority to hear the cases at all.

This is an updated version of a brief originally published on November 15, 2010. Shortly after President Obama signed the Patient Protection and Affordable Care Act (ACA)^[1] into law, opponents of the law filed a series of legal challenges in federal court. This health reform implementation brief provides an overview of the legal challenges by identifying and providing summaries of the two major cases filed by states and select claims, not raised by the states, from other cases.