By April 09, 2013 at 7:24 PM on April 09, 2013 at 7:15 PM, updated
Ohio House Republicans are acting with gross irresponsibility in rejecting Republican Gov. John Kasich's bid to expand Medicaid coverage for poor Ohioans. Even more perplexing is the lack of vocal opposition from some Cleveland-area GOP lawmakers for a decision that -- if it stands -- will gravely damage Greater Cleveland.
Anti-expansion Republicans portray their position as a matter of principle. But their stance is the poisoned fruit of childish partisanship and craven self-interest: They fear primary-election challenges from other Republicans who think that expanding Medicaid in Ohio represents a form of collusion with President Barack Obama, whom they loathe.
For that seamy reason, the Ohio House's GOP caucus, led by Medina's William Batchelder, would deny adequate medical care to hundreds of thousands of Ohioans (many in Greater Cleveland) and reject billions of dollars from the U.S. Treasury. It's mindless and it's pathetic.
Rejecting Medicaid expansion will damage Ohio from Lake Erie to the Ohio River. It will further imperil community hospitals already squeezed by the cost of caring for uninsured patients. It will especially damage Greater Cleveland, which has some of Ohio's greatest concentrations of poverty -- and a nexus of high-tech biomedical companies, including world-renowned hospitals that help shoulder the costs of caring for the uninsured, a burden Medicaid expansion would lighten.
Medicaid expansion also is a smart economic strategy that will underwrite jobs, keep Ohioans' tax dollars in Ohio, improve the health and productivity of our citizens and reduce state outlays for prison health care.
Among those who would benefit are working Ohioans without health insurance who live at or below 138 percent of the poverty level. These men and women, who play by the rules, are the very Ohioans Republicans claim to respect.
What Ohio House Republicans have really decided is that unpaid emergency room charges -- and all other such unpaid medical costs -- will be paid not with help from taxpayers in all 50 states but instead by jacking up the health-insurance premiums or employer-sponsored health plan costs of Ohioans who do have coverage. If that's fair to Ohio employers, the word "fair" has no meaning at the Statehouse.
The House Finance-Appropriations Committee now will affirm or reject House Republicans' refusal of Medicaid expansion. Among the committee's members are Reps. Marlene Anielski of Independence and Mike Dovilla of Berea, both Republicans. Also with a key voice within the House GOP caucus, although she's not on the committee, is Westlake's Nan Baker.
Baker, Anielski and Dovilla have a clear choice. They can stand with the blind partisanship of some of their GOP colleagues. Or they can stand with Greater Clevelanders by fighting for Medicaid expansion.
Byon March 16, 2013
As a former Ohio Supreme Court justice busily and happily transitioning into my new work on mental health and veterans' issues, I wasn't paying much attention to the discussion about Medicaid expansion. Like Gov. John Kasich and many others, I had issues with Obamacare. Then a friend asked me to "look at the facts" of Medicaid expansion. That triggered 23 years of judicial training, learning how to put aside personal biases and feeling and judge a matter on evidence alone.
This is what I learned:
Medicaid is health insurance for Ohio's most vulnerable citizens -- those earning up to 138 percent of the federal poverty level, or about $15,856 for an individual and $32,499 for a family of four. About 366,000 Ohioans will be covered by the Medicaid expansion for an estimated total cost of $2.6 billion over the biennium.
That cost will be paid entirely by the federal government through 2016, ratcheting down to 90 percent afterward. Ohio can opt out of the expansion if the rules change later.
Rejecting the federal expansion money would send federal money back to Washington and to other states to pay for their Medicaid expansions. Yet Ohio receives billions of dollars every year from the federal government for roads and bridges, education and research grants, and we don't for one minute consider sending that money back to the federal government. After all, we pay good money to the federal government in the form of taxes, and we deserve to get some of it back. How is Medicaid expansion any different?
Besides, state and local governments, employers and taxpayers already pay for the health care of uninsured Ohioans. Our Department of Rehabilitation and Corrections will save $27 million over the biennium on inpatient hospital costs to prisoners under the expansion. In addition, the community behavioral health system will save approximately $105 million over the biennium on services that shift to Medicaid. For example, of the 8,000 individuals in Lucas County now requiring behavioral health services, 7,000 -- or 88 percent -- would be covered by Medicaid, saving $4.6 million and freeing up much-needed local funding for other county needs.
Today, health care for 1.5 million uninsured Ohioans is borne by Ohio's hospitals, employers and 10 million other taxpayers. Hospitals are required to provide medically necessary care, at no cost, to low-income and uninsured individuals. Hospitals make up their losses by charging others more or eliminating services or programs. As a result, the average privately insured individual pays approximately $1,000 per year for costs incurred by uninsured individuals.
Preventive health care for uninsured individuals is virtually nonexistent. They often wait to seek medical treatment -- hoping the condition resolves itself -- until their situation worsens, requiring care in the emergency department. This is a costly scenario for both the individual and the hospital. In 2010, Ohio hospitals provided $1.1 billion in total charity care and incurred $645 million in bad debt.
The Affordable Care Act reduced reimbursement to hospitals that provide a high volume of care to low-income and uninsured individuals with the expectation that the additional Medicaid funds associated with the expansion would offset the loss. The U.S. Supreme Court ruled that the Medicaid expansion is optional for states, but if a state rejects it, its hospitals will still feel the impact of the reimbursement cuts.
My analysis: Why would we turn down these federal funds and instead use local dollars to pay for needs that already exist? Our federal income-tax dollars will go to other states and we still have to come up with the local dollars.
I have used my health insurance many times, including for surgery that I otherwise would never have been able to afford. But so many people have no such insurance. I am particularly concerned about those with serious mental illnesses. I saw many of them in my courtroom, and I know firsthand the ill effects of a lack of insurance and a poorly funded community behavioral health system.
Individuals who do not get needed physical and behavioral health treatment and their families struggle. Extending Medicaid to Ohio's lowest-income uninsured is the right thing to do for them and for all Ohioans.
Evelyn Lundberg Stratton, a former Ohio Supreme Court justice, is a health care adviser and attorney with Vorys, Sater, Seymour and Pease LLP.
Published on Friday, August 17, 2012 by Common Dreams
by Donna Smith
It was a slow and torturous death, my American dream. And for millions of others, I am guessing it is the same. Nothing this current round of politicos is planning to do can restore it. Just like there is nothing to being a little bit pregnant, there is nothing anyone can do to breathe life back into what once seemed possible. Now I just hang on waiting to die.
This piece is not about who will or will not be our president or vice president, as after voting in every election since the 1970s, I am pretty sure what I need and want isn’t coming from any of them.
The Columbus Dispatch Op Ed, Wednesday August 8, 2012
By Kevin Horrigan, The St. Louis Post-Dispatch
“Perhaps not surprisingly in a country where health-care reform is so controversial, it was the high-profile presence of the NHS that stunned many American writers. … Certainly the U.S. equivalent, which would be dancing health insurance corporate executives, was hard to imagine.”
— Paul Harris, in The Guardian , July 28
?Hah, hah, hah. Very funny. It’s not hard at all to imagine what the “U.S. equivalent” to your Olympic Opening Ceremony’s salute to Britain’s National Health Service would look like. I’m already working on it.
Sure, “dancing health-insurance corporate executives” will be part of it. If you’d made that much money last year, you’d want to dance, too.
Picture this: It’s night in Florida. We’re in a darkened Raymond James Stadium in Tampa, jammed with 66,000 delegates to the Republican National Convention and their guests. A spotlight illuminates the stage. The seven top health-care CEOs, carrying canes and dressed in white top hats and tails, prance on stage as the Mormon Tabernacle Choir sings Puttin’ on the Ritz.
Pretty nice, huh?
The spotlight widens to show 94 primary-care doctors, in multi-colored scrub suits, forming a ring around David Cordani, the CEO of Cigna Health Care, bowing and scraping to honor the fact that at $19.1 million, Cordani made more in 2011 than all 94 of them combined.
The orchestra breaks into Gershwin’s It Ain’t Necessarily So as the stadium floor is lighted, revealing 400 actual health-insurance bureaucrats wearing telephone headsets and sitting at small desks. They shake their heads back and forth in our “Salute to Rescission.”
The crowd erupts, because fans know that if Republicans repeal the Affordable Care Act, God will be in his heaven, all will be right with the world and insurance companies once again will be allowed to retroactively cancel coverage when someone needs it.
Lights around the stadium’s upper tier are forming a large donut, signifying the “Medicare donut hole” that will return once “Obamacare” is eliminated, thus ensuring that drugs for anything between basic coverage and catastrophe are not covered. The orchestra swings into Live and Let Die.
Cannons in the end zones fire clouds of pills into the sky. As they fall to the floor, out of the stadium tunnels limp thousands of senior citizens who are allowed to scrounge for the pills. Then, it’s time for our….
Tribute to the ER! Giant video boards flash the image of former President George W. Bush uttering these immortal words in 2007: “I mean, people have access to health care in America. After all, you just go to an emergency room.”
The theme from the TV show ER comes up as sirens wail, ambulances tear around the stadium floor, disgorging patients into the busy “emergency department” on center stage, already jammed with insured adults and children who have no primary-care doctors.
Our ER “treats” them and sends them on their way with big weights (symbolizing hospital bills) strapped to their backs, which they then pass to the people in the crowd — who are delighted to get them!
On wires stretched across the top of the stadium a huge number “17.6” sparkles in lights. It represents the percentage of the gross domestic product devoted to health care — 8 percent higher than the Brits. The music swells into Creed’s Can You Take Me Higher?
The crowd sings along, waving 66,000 foam “We’re No. 1” fingers, signaling America’s status as the nation with the most expensive health care in the world — 2.4 times more expensive than the silly Brits.
KA-BOOM! go the fireworks. We crane our heads skyward to see a giant figure “37,” symbolizing the World Health Organization’s ranking of the American health-care system.
The big finale: With the crowd’s attention diverted skyward, volunteers from health-insurance companies have erected cardboard cutouts of men, women, children and babies around the floor of the stadium. There are so many of them — 45,000 — that they loop around the field in a squiggly line almost a mile long.
They represent the 45,000 Americans whose lack of health insurance contributes to their premature death each year, according to a 2009 study by the Harvard Medical School. Now riding into the stadium atop Rafalca, his wife’s Olympic dressage horse, is Mitt Romney, who will be nominated for president on the following night.
He guides the mare’s nose to the first cardboard figure. A simple nudge and, like dominoes, they topple over in spectacular sequence. The crowd goes wild.
Kevin Horrigan writes for the St. Louis Post-Dispatch.
By Bill Moyers, Moyers & Company
04 Aug 12
BILL MOYERS: I read a news story this week that sent me on a nostalgic trip down memory lane. This past Monday, July 30th was the 47th anniversary of Medicare, and to celebrate it, the "Raging Grannies," as they’re known, gathered outside the county office building in Rochester, New York to protest rumored cuts to their Medicare coverage.
RAGING GRANNIES: This old grey granny now needs a test or two -
BILL MOYERS: They praised Medicare in song as "the best deal we have in the country," and even called for expanding it Medicare into universal health care for everyone.
It seems the Republican Speaker of the House, John Boehner, was coming up from Washington to raise funds for Republican congressional candidate Maggie Brooks. The "Raging Grannies" wanted to make certain Ms. Brooks didn’t sign on to the GOP budget which includes cuts to Medicare.
For myself, the "Raging Grannies" channeled a familiar voice, the Texas twang of my boss back in 1965, Lyndon Baines Johnson. I was a White House assistant at the time and had been working with the President and others on the team trying to get Medicare through Congress. Even with overwhelming Democratic majorities in the House and Senate, it was one tough fight. Others had tried before us.
In his 1948 State of the Union message, President Harry Truman said:
HARRY TRUMAN: This great Nation cannot afford to allow its citizens to suffer needlessly from the lack of proper medical care. Our ultimate aim must be a comprehensive insurance system to protect all our people equally against insecurity and ill health.
BILL MOYERS: But every time Harry Truman proposed legislation to do just that, Congress refused to budge. In the 1960s, John F. Kennedy took up the cause:
JOHN F. KENNEDY: Our working men and women, instead of being forced to ask for help from public charity, once they are old and ill, should start contributing now to their own retirement health program through the Social Security System…
BILL MOYERS: But his proposal failed in the Senate by just two votes.
On the other side, actor Ronald Reagan, still in private life, had signed on as the American Medical Association’s hired spokesman in their campaign against Medicare. Doctors’ wives organized thousands of small meetings in homes around the country, where guests listened to a phonograph record of Reagan deploring the evils of "socialized medicine":
RONALD REAGAN: Behind it will come other Federal programs that will invade every area of freedom as we have known it in this country […] until one day, as Norman Thomas said […] you and I are going to spend our sunset years telling our children and our children’s children what it once was like in America when men were free.
BILL MOYERS: But now, it was Lyndon Johnson’s turn. Tragically thrust into the White House by Kennedy’s assassination, LBJ, the son of Franklin Roosevelt’s New Deal and Harry Truman’s Fair Deal, vowed to finish what they had started. He pushed us relentlessly to get it done. Here he is talking to his Vice President, Hubert Humphrey, in early March of 1965:
LYNDON JOHNSON: They are bogged down. The House had nothing this week, all -damn week. Now that’s where you and Moyers and Larry O’Brien have got to find something for them. And the Senate had nothing […] so we just wasted three weeks […] Now we are here in the first week in March, and we have just got to get these things passed […] I want that program carried. And I’ll put every Cabinet officer behind you. I’ll put every banker behind you. I’ll put every organization we got behind you […] I’ll put the labor unions behind you."
BILL MOYERS: About all he had left was the White House kitchen sink, and pretty soon he threw that behind us, too.
Later that March he called me to talk about a retroactive increase in Social Security payments that we were supporting. I had argued for it as a stimulus to the economy. LBJ said okay, but reminded me that social security and Medicare were about a lot more than economics:
LYNDON JOHNSON: My inclination would be […] that it ought to be retroactive as far back as you can get it […] because none of them ever get enough. That they are entitled to it. That that's an obligation of ours. It's just like your mother writing you and saying she wants $20, and I'd always sent mine a $100 when she did. I never did it because I thought it was going to be good for the economy of Austin. I always did it because I thought she was entitled to it. And I think that's a much better reason and a much better cause and I think it can be defended on a hell of a lot better basis […] We do know that it affects the economy […] But that's not the basis to go to the Hill, or the justification. We've just got to say that by God you can't treat grandma this way. She's entitled to it and we promised it to her.
BILL MOYERS: LBJ kept that promise. He pushed and drove and cajoled and traded, until Congress finally said yes. And so it was that 47 years ago, we traveled to Independence, Missouri, the hometown of Harry Truman, and there with the former president at his side, LBJ signed Medicare into law. Turning to Truman, whom he called "the real daddy of Medicare, " Johnson signed him up as its first beneficiary. Harry Truman was 81.
All this was high drama, touched with history, sentimentality, politics, and compromise. A whole lot of compromise. The bill wasn’t all LBJ wanted. It was, in fact, deeply flawed. There were too few cost controls, as some principled conservatives warned, who were then rudely ignored. Co-pays and deductibles remain a problem. And we didn’t anticipate the impact of new technology, or the impact of a burgeoning population.
In fact, even as he signed the bill we still weren’t sure what all was in it. As LBJ himself once told me, never watch hogs slaughtered before breakfast and never, never, never show young children how legislation gets enacted.
But Lyndon Johnson had warned: "We will face a new challenge and that will be what to do within our economy to adjust ourselves to a life span and a work span for the average man or woman of 100 years."
That longevity, and the cost, are what we must now reckon with. As the historian Robert Dallek has written, Medicare and Medicaid, the similar program for the very poor, "…did not solve the problem of care at reasonable cost for all Americans", but "the benefits to the elderly and the indigent…are indisputable." And there’s no going back, current efforts notwithstanding. A new study in the journal Health Affairs finds that Medicare beneficiaries age 65 and older are more satisfied with their health insurance, have better access to care, and are less likely to have problems paying medical bills than working-age adults who get insurance through employers or purchase coverage on their own.
So sing on, Raging Grannies, sing on. The surest way to save so popular and efficient a health care system is to make it available to everyone.
RAGING GRANNIES: Everybody in and nobody out, single-payer Medicare for all.
August 7th, 2012
By Donna Smith
My tweet yesterday said I’d write about the three pieces of mail I received from my insurance company, Aetna, this week. All three confirmed it. In their eyes and in every manner of decision they make, I am either a medical loss if a claim must be paid or I am a profit if they can deny me.
If only we had Medicare for all for life…
July 4, 2012
Michael Moore, ACA, and the Single Payer Solution
By Chuck Pennacchio
Michael Moore's SiCKO reunion visit, coupled with Single Payer state-based convention, show the way to transform the Affordable Care Act's enabling provisions into Medicare for All.
Filmmaker and citizen activist Michael Moore (SiCKO, Bowling for Columbine, Roger and Me, Capitalism: A Love Story) graced Philadelphia last Saturday for a five-year reunion of SiCKO's release, the third-highest grossing documentary ever that revealed the tragedy of under-insurance in the United States. Also assembled were seven of the film's health insurance industry victims (including our own Donna Smith), and two industry whistle-blowers who continue to expose the medical-industrial-complex's profit-first methods of maximum money-making.
In addition to the emotional sagas of PREVENTABLE suffering that continue to this day - 9/11 rescue worker with oxygen tank, parentless teen, widowed spouse, morphing cancers, running battles with insurance companies, medical bankruptcies - Wendell Potter (author of "Deadly Spin") shared his crisis-of-conscience journey to 'industry whistle-blower,' beginning with his former company, CIGNA, assigning him, stealthily, to sneak-preview "SiCKO" in Sacramento and plan the public relations attacks on the movie.
Michael Moore then used story, movie-making insights, and outrage over right-wing bullying and Obama-enabling to illustrate, on the one hand, SiCKO's educational and motivational benefit and, on the other hand, the watered-down Affordable Care Act that the Supreme Court validated last week. At the same time, Michael (and Wendell) chastised single payer activists inclined to look past the significance of corporatist Chief Justice Roberts siding with the Court's more liberal members, and permitting ACA's implementation (minus the force of withholding Medicaid funding for states that refuse to accept ACA minimal health standards).
During a pre-event reception at Healthcare-NOW's William Way Center auditorium, the 300-person public event at Plays and Players Theater (sans air-conditioning on a sticky night!) near Rittenhouse Square, and the day following at our 22-member, 'One Payer States' all-day conference, speaker after speaker, discussant after discussant, emphasized the opportunity presented by ACA's continuing implementation. We need to celebrate (Moore), exploit (Michael Lighty, CA Nurses), understand our challenges, challengers, and potential allies (Brigitte Marti, Dr Carol Ritter, Mark Dudzic, Pennacchio), strategize (Potter), and organize (Francesca Lo Basso, Smith).
Specifically, our best opportunity for translating ACA passage and SCOTUS ruling into universal healthcare isembedded in the national legislation itself. That is, ACA contains provisions for state-based healthcare innovation and funding waivers (can you say "Single Payer six times straight"...six times?), already endorsed by President Obama, embraced by numerous Republicans at all levels of government, and led by Independent Senator Bernie Sanders (VT) and Democratic Representative Jim McDermott (WA) in the United States Congress.
So now it's on us, to build on the week's and weekend's successes, energy, inspiration, and more, to turn ACA into state-based Improved Medicare for All as the next step to achieving true, universal single payer healthcare for each and every person in America. Every body in, no body out.
Onward to the Proven Single Payer Solution.
Co-Founder, One Payer States Network
Submitter’s Website: www.healthcare4allpa.org
Chuck Pennacchio, PhD, Executive Director, Healthcare for All Pennsylvania, and History Program Director, The University of the Arts in Philadelphia. BA in history and political science from University of California, and MA and PhD in diplomatic history from University of Colorado. Organizer of 40 years on issues of healthcare, environment, economic justice, war and peace. Former aide to Senators Alan Cranston (CA), Tom Harkin (IA), Tim Wirth (CO), Paul Simon (IL), and Military Personnel Caseworker to Congressman Ronald V. Dellums. Pennsylvania candidate for US Senate in 2006.
New York Times
June 28, 2012
Supreme Court Upholds Health Care Law, 5-4, in Victory for Obama
By ADAM LIPTAK
WASHINGTON — The Supreme Court on Thursday upheld President Obama’s health care overhaul law, saying its requirement that most Americans obtain insurance or pay a penalty was authorized by Congress’s power to levy taxes. The vote was 5 to 4, with Chief Justice John G. Roberts Jr. joining the court’s four more liberal members.
The decision was a victory for Mr. Obama and Congressional Democrats, affirming the central legislative achievement of Mr. Obama’s presidency.
“The Affordable Care Act’s requirement that certain individuals pay a financial penalty for not obtaining health insurance may reasonably be characterized as a tax,” Chief Justice Roberts wrote in the majority opinion. “Because the Constitution permits such a tax, it is not our role to forbid it, or to pass upon its wisdom or fairness.”
At the same time, the court rejected the argument that the administration had pressed most vigorously in support of the law, that its individual mandate was justified by Congress’s power to regulate interstate commerce. The vote was again 5 to 4, but in this instance Chief Justice Roberts and the court’s four more conservative members were in agreement.
The court also substantially limited the law’s expansion of Medicaid, the joint federal-state program that provides health care to poor and disabled people. Seven justices agreed that Congress had exceeded its constitutional authority by coercing states into participating in the expansion by threatening them with the loss of existing federal payments.
Justice Anthony M. Kennedy, who had been thought to be the administration’s best hope to provide a fifth vote to uphold the law, joined three more conservative members in an unusual jointly written dissent that said the court should have struck down the entire law. The majority’s approach, he said from the bench, “amounts to a vast judicial overreaching.”
The court’s ruling was the most significant federalism decision since the New Deal and the most closely watched case since Bush v. Gore in 2000. It was a crucial milestone for the law, the Patient Protection and Affordable Care Act of 2010, allowing almost all — and perhaps, in the end, all — of its far-reaching changes to roll forward.
Mr. Obama welcomed the court’s decision on the health care law, which has inspired fierce protests, legal challenges and vows of repeal since it was passed. “Whatever the politics, today’s decision was a victory for people all over this country whose lives are more secure because of this law,” he said at the White House.
Republicans, though, used the occasion to attack it again.
“Obamacare was bad policy yesterday; it’s bad policy today,” Mitt Romney, the presumptive Republican presidential nominee, said in remarks near the Capitol. “Obamacare was bad law yesterday; it’s bad law today.” He, like Congressional Republicans, renewed his pledge to undo the law.
The historic decision, coming after three days of lively oral arguments in March and in the midst of a presidential campaign, drew intense attention across the nation. Outside the court, more than 1,000 people gathered — packing the sidewalk, playing music, chanting slogans — and a loud cheer went up as word spread that the law had been largely upheld. Chants of “Yes we can!” rang out, but the ruling also provoked disappointment among Tea Party supporters.
In Loudoun County, Va., Angela Laws, 58, the owner of a cleaning service, said she and her fiancé were relieved at the news. “We laughed, and we shouted with joy and hugged each other,” she said, explaining that she had been unable to get insurance because of her diabetes and back problems until a provision in the health care law went into effect.
After months of uncertainty about the law’s fate, the court’s ruling provides some clarity — and perhaps an alert — to states, insurers, employers and consumers about what they are required to do by 2014, when much of the law comes into force.
The Obama administration had argued that the mandate was necessary because it allowed other provisions of the law to function: those overhauling the way insurance is sold and those preventing sick people from being denied or charged extra for insurance. The mandate’s supporters had said it was necessary to ensure that not only sick people but also healthy individuals would sign up for coverage, keeping insurance premiums more affordable.
Conservatives took comfort from two parts of the decision: the new limits it placed on federal regulation of commerce and on the conditions the federal government may impose on money it gives the states.
Five justices accepted the argument that had been at the heart of the challenges brought by 26 states and other plaintiffs: that the federal government is not permitted to force individuals not engaged in commercial activities to buy services they do not want. That was a stunning victory for a theory pressed by a small band of conservative and libertarian lawyers. Most members of the legal academy view the theory as misguided,if not frivolous.
“To an economist, perhaps, there is no difference between activity and inactivity; both have measurable economic effects on commerce,” Chief Justice Roberts wrote. “But the distinction between doing something and doing nothing would not have been lost on the framers, who were practical statesmen, not metaphysical philosophers.”
Justice Ruth Bader Ginsburg, in an opinion joined by Justices Stephen G. Breyer, Sonia Sotomayor and Elena Kagan, dissented on this point, calling the view “stunningly retrogressive.” She wondered why Chief Justice Roberts had seen fit to address it at all in light of his vote to uphold the mandate under the tax power.
Akhil Reed Amar, a Yale law professor and a champion of the health care law, said that it was “important to look at the dark cloud behind the silver lining.”
“Federal power has more restrictions on it,” he said, referring to the new limits on regulating commerce. “Going forward, there may even be laws on the books that have to be re-examined.”
The restrictions placed on the Medicaid expansion may also have significant ripple effects. A splintered group of justices effectively revised the law to allow states to choose between participating in the expansion while receiving additional payments or forgoing the expansion and retaining the existing payments. The law had called for an all-or-nothing choice.
The expansion had been designed to provide coverage to 17 million Americans. While some states have indicated that they will participate in the expansion, others may be resistant, leaving more people outside the safety net than the Obama administration had intended.
Although the decision did not turn on it, the back-and-forth between Justice Ginsburg’s opinion for the four liberals and the joint opinion by the four conservatives — Justice Kennedy and Justices Antonin Scalia, Clarence Thomas and Samuel A. Alito Jr. — revisited the by-now-familiar arguments. Broccoli made a dozen appearances.
“Although an individual might buy a car or a crown of broccoli one day, there is no certainty she will ever do so,” Justice Ginsburg wrote. “And if she eventually wants a car or has a craving for broccoli, she will be obliged to pay at the counter before receiving the vehicle or nourishment. She will get no free ride or food, at the expense of another consumer forced to pay an inflated price.”
The conservative dissenters responded that “one day the failure of some of the public to purchase American cars may endanger the existence of domestic automobile manufacturers; or the failure of some to eat broccoli may be found to deprive them of a newly discovered cancer-fighting chemical which only that food contains, producing health care costs that are a burden on the rest of us.”
All of the justices agreed that their review of the health care law was not barred by the Anti-Injunction Act, which allows suits over some sorts of taxes only after they become due. That could have delayed the health care challenge to 2015. The conservative dissenters said that the majority could not have it both ways by calling the mandate a tax for some purposes but not others.
“That carries verbal wizardry too far, deep into the forbidden land of sophists,” they said.
As a general matter, Chief Justice Roberts wrote that the decision in the case, National Federation of Independent Business v. Sebelius, No. 11-393, offered no endorsement of the law’s wisdom.
Some decisions, the chief justice said, “are entrusted to our nation’s elected leaders, who can be thrown out of office if the people disagree with them.”
Justice Ginsburg, speaking to a crowded courtroom that sat rapt for the better part of an hour, drew a different conclusion.
“In the end,” she said, “the Affordable Care Act survives largely unscathed.”
Reporting was contributed by John H. Cushman Jr., Robert Pear, John Schwartz, Ethan Bronner and Sabrina Tavernise.